Health and Care Bill (First sitting)

Alex Norris Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Justin Madders]

Thank you. For the last minute, I am going to hand over to my colleague.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q I have a very quick question for Danny Mortimer. You have the unenviable task of negotiating with the staff and their representative unions on all sorts of issues—pay, terms and conditions, safety. When you have such negotiations, how high up on the list does a commissioning restructure come in terms of the things that our front-line staff are really after?

Danny Mortimer: We have a really constructive set of relationships in the NHS with our trade unions, on both terms and conditions and the social partnership forum, which the Minister’s colleague Helen Whately chairs and which brings trade unions and employers together.

There is an interest in how the health service organises itself, and there is an interest in how the health service and our friends in social care can better work together to relieve the pressure that our colleagues were experiencing even before the pandemic. Of course, there are other things that people are interested in as well. There are outstanding questions about long-term pay strategy, and there are other issues around working environments and support that Navina touched on. Those are really important as well.

There is a recognition, when I speak to trade union leaders and representatives, of the opportunities available through system working to improve service delivery, and therefore to help their committed members do their jobs better and relieve the pressure that they have been under for far too long.

[The Chair]

I call Dr Phillipa Whitford, the SNP spokesperson.

Health and Care Bill (Second sitting)

Alex Norris Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[The Chair]

This is the third panel. We will now hear from Simon Madden, the director of data policy at NHSX, who is appearing in person. We have until 2.30 pm for this session. Good afternoon, Mr Madden. Could I ask you to introduce yourself for the record?

Simon Madden: Good afternoon. I am Simon Madden, director of data policy, NHSX.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q46 Thank you, Simon Madden, for your attendance this afternoon. I think it would be safe to say that the roll-out of the general practice data for planning and research scheme did not go as planned earlier this year. It was remarkable that despite the limited engagement, well over 1 million people opted out. What learning do you think we can take from that exercise for the data provisions contained in part 2 of the Bill?

Simon Madden: We have obviously set out the position. The Government have set out the position in respect of GP data for planning and research, in terms of taking a pause and having a conditions-based approach, rather than a clear timeline for the commencement of that. Above all else, I think that the overriding need for trust and transparency—to build public trust in the use of health data—is vitally important, and the ways in which this is governed need to be transparent in such a way that the general public can see quite easily how their data will be used.

Indeed, I think it is a responsibility on Government and those of us in the health and care system more broadly to really promote the benefits of sharing data. It is a public good and, while putting in place sufficient safeguards and then giving the public the opportunity to opt out of that process if they are not convinced by those safeguards, it remains a public good and contributes to the broader health, if I can put it that way, of the health and care system.

[Alex Norris]

Q Do you see the process enabled by the Bill running alongside a future resumption of the GPDPR process—or a conditions-based continuation, as you put it—or would they remain two separate things that overlap?

Simon Madden: Essentially, they are separate in terms of process. The general public will not make a distinction between any things to do with their health data. Whether it is the draft data strategy that we published earlier in the year or the GP data for planning and research programme, to the general public it is about their health data.

It is incumbent on us to make sure that we have a strong narrative that reflects all aspects of health data. We need to reset the relationship between the patient—the citizen—and their health data, so that a perception does not arise that we are taking their trust for granted, because that is certainly not the case. The provisions in the Bill around data are meant, to some degree, to provide clarification where there is some confusion in the current framework about how and when data could be shared.

[Alex Norris]

Building on that point—

[The Chair]

Hang on a second. I had better give somebody from another party a chance.

--- Later in debate ---

[Edward Argar]

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

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

[Alex Norris]

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

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

[Alex Norris]

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

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

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

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

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

--- Later in debate ---

[The Chair]

I am really sorry, but we had better move on to Alex Norris.

[Alex Norris]

Q Thank you, Chair, and good afternoon to the panellists. Councillor Jamieson, I will start with you, if I may. You have mentioned on a number of occasions that you see this as enabling legislation and that, rather than prescribing to your community or the community of your members what model they should pursue, it leaves you the space to do that. I have some enthusiasm for that, but one area where that is not the case is schedule 2 to the Bill, which sets out, in schedule 1B to the National Health Service Act 2006, that the chair of the integrated care board must be

“appointed by NHS England, with the approval of the Secretary of State”.

Under paragraph 5, only NHS England can remove a chair if they are unpopular and not doing the job, and there is nothing that you can write into your local decision making to get around that. Are you comfortable with not having any say over your chair when they are appointed or whether they carry on in the job?

Cllr James Jamieson: Clearly, there are two chairs in this scenario, and one of them, as you say, is NHS appointed in effect and the other one could be anybody—it could be a councillor, a local government representative, or a local director of public health. There is a role. I think this is a difficult area, but that is the reality, because ultimately that chairman will be the person who is financially responsible for the NHS trusts in his or her area. I have some sympathy with it; if I could find a better solution, I would seek to find one.

[Alex Norris]

Q Thank you. Professor Rae, you have talked a lot about the challenges to the nation’s health at the moment and the negative direction of travel in recent years. The King’s Fund estimates that, entering the pandemic, the value of the public health grant was 15% less than in 2013. Is that a characterisation that you recognise? What does that mean we do less of than we did seven or eight years ago?

Professor Maggie Rae: I am still a fan of the fact that you need public health and local government. I started my career there and moved to the NHS; I moved back to local government; and now I am moving back to the NHS. What we need is flexibility, so professional groups can work there. I would highly recommend all my public health colleagues and public health registrars to get experience nationally, regionally and locally. That makes you a much better, capable public health practitioner. However, you cannot deny that you can do the same for half the money.

I know that when the announcement was made about public health moving into local government, I did do the rounds saying that it would be a really good thing. I have to say that some very experienced people from councils were saying to me, “Well, I know what will happen. We will get the responsibility, and then they will take the money from us.” I said, “No, no, that won’t happen because public health has always been ring-fenced.” When we were in the NHS, the public health funding was ring-fenced. I have to confess that I was naive, wasn’t I, because actually the grant was cut. I do believe that every pound you spend at the local level in that local government setting you will get back tenfold because of all the social capital you can get from it. That is the reality. If your plans are ambitious, you do not need a lot of money. Lots of the interventions on obesity, smoking and all the other things do not take a huge cost in comparison with some of the high-tech NHS ones. If you have the ambition, you need to follow it through with the necessary resources to do it.

I have been public in saying—I am probably with Councillor Jamieson—that in the ideal world, and I have been a director of adult social care, as well as a director of public health, we are not in camps with our bags of cash. We actually put all of our money together for the resources of the population. I would like to see the ICSs mandated to spend so much on prevention and health inequalities wherever the money comes from, because if we continue with what we are doing at the moment—waiting too long to intervene—none of us will be able to afford the mountain of the problem that you will build up. There is no money available in the world to do that.

There have been some early positive signs that we mean business this time with prevention and health inequalities, but we have to deliver. Having just looked at the social care paper today, I struggle to find prevention. I know from being a director of adult social care that if we do not intervene early and get people to be ageing well and healthy, we will not have the carers in the world who can look after them. Again, I make the plea for the resources. It does not take a lot—I am not asking for billions—but a small amount of resource could make a huge difference. If we continue to cut the public health grant, well, we will continue to have poor health, I think.

[Alex Norris]

Q I have a question on fluoridation. At the moment, there is broad agreement that the system does not work: local communities, through their local authorities, can try to lead the process and take it through. I know from my time on my local authority, where I was very keen to do that, that it was very, very hard to do, although not impossible. We are taking away that grassroots, ground-level approach and replacing it with a top-down, Secretary of State-led approach. That has many attractions, in the sense that it takes away from some of the parochial concerns and planning concerns about where you have pour the stuff in to make it work. At the moment, we are going from one to the other. Would you have any anxieties if, rather than moving from one to the other, we kept what we currently had and added the new model to it, so that rather than either/or, it is both?

Professor Maggie Rae: My experience is that there are some things you can legislate for—seatbelts would be the classic example, or smoke-free places—that work really well, but for most things, if you really want to get action, you need to take the public with you. Certainly, if you fluoridate the water, you will have some very direct oral health benefits. Dental decay, for example, is a classic. However, you probably will not fix every little problem you have got, because it takes more than just fluoridation. Most people’s teeth fall out because of gum disease, so you have to have a wider educational programme with the public.

I also know from my work as the director of public health at the local level and my early days work in Scotland that I could take you to lots of families where they do not drink water, so it is not that obvious to me that that is just going to fix the problem as easily as we think it will. I think you need an all-encompassing programme. While we wait for any implementation of the fluoridation, today children will be having their teeth taken out—children of four or five. That is unacceptable because, alongside that, we should be ensuring that there are the educational programmes and the supply if people cannot afford toothbrushes and toothpaste. That would be a nice easy fix for something to do.

We obviously have a huge population who have already lost their teeth, and one of the biggest problems of the elderly is pure nutrition because they simply cannot eat. It is a problem that sometimes you think legislation will fix it top-down, but I think in everything you do it is much better to see public health people as being responsible to the population. In my experience, you really have to take the population with you to have any chance of implementation, whether you have legislation from the Secretary of State or not.

[The Chair]

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

--- Later in debate ---

[Dr Whitford]

Q And that would apply also to things like sharing patient information of a certain type, and whether it was anonymised or pseudo-anonymised and so on? That would be a concern for you?

Eluned Morgan: Absolutely, and we are developing our own systems in relation to those things, of course. It is our patient information, and we should be deciding who has access to it and when.

[Alex Norris]

Q I thank you, Minister, and your officials for your time this afternoon. You mentioned correspondence with Ministers in the UK Government. Is that correspondence publicly available, or is it something you are willing to make publicly available?

Eluned Morgan: I am more than happy to send the correspondence that I have sent to Minister Argar to the Committee, so you can see it. It sets out all the issues that we are concerned with in relation to the Bill.

[Alex Norris]

Q In your conversations, have Ministers shared with you an impact assessment for the Health and Care Bill?

Eluned Morgan: I am not aware that we have seen an impact assessment. Lyn and Mari may have more to add.

Lyn Summers: No, we have not.

[Alex Norris]

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

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

[Edward Argar]

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

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

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

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

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

Health and Care Bill (Third sitting)

Alex Norris Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

Thank you. I now turn to the shadow Minister, Alex Norris.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q Thank you, Chair. Thank you to all three of you for joining us this afternoon, and thank you for everything your members have done for us in such difficult times in recent months. Collectively, you speak for tens of thousands of NHS staff and allied professionals, so a simple first question from me. Pat, you might go first: how do staff feel at the moment?

Pat Cullen: Where do I start? They feel exhausted, demoralised; they are tired to say the least, and they are very concerned about the future. Why is that? Because they do not have the workforce to deliver.

[The Chair]

Could I just remind the shadow Minister to stick within the scope of the Bill, please?

[Alex Norris]

On a point of order, Mrs Murray. How our staff are at the moment is within the scope of a Bill about the NHS, I would have thought.

[The Chair]

Okay, but can we just make sure that we stay within the scope of the Bill?

Pat Cullen: I will try and answer in relation to the Bill. All the issues that I have just spoken about in relation to that exhaustion, the tiredness and the fact that they are not able to provide the care for their patients—there are opportunities in the Bill to correct some of those things. Again, going back—I hate to harp back to it in my Northern Ireland words—but the fact is that if we ensure that accountability sits with the legislator and with the Secretary of State, to ensure that we do not find ourselves back in this place again, with 40,000 vacancies going into a pandemic or at any other emergency situation we find our nurses in, that will absolutely assist and support. However, there are opportunities for the workforce in the Bill that we do not believe are being grasped at the minute, and that is further adding to the demoralisation that they are feeling.

Professor Helen Stokes-Lampard: I will keep it succinct. I completely agree that the clinical workforce—doctors—are demoralised, and I think anxiety would be the greatest feedback that we get: anxiety and fear of the amount of risk that is being held in the system at the moment. We are in the grip of a third wave of this pandemic, which many in the media seem to have completely forgotten about. People are dying by their hundreds on a daily basis still. This is a huge challenge. It goes back to exactly the point in the Bill about workforce planning for the future, so that we never find ourselves in a similar situation again. While we cannot predict when the next pandemic will hit, we can certainly be assured that another pandemic will come. The challenges around the climate and the global problems are going to impact on our health and wellbeing hugely, and we can plan for them now if we choose to. So, fearful and anxious, but we can do something about it. We have a unique moment in time to grasp this, and this legislation is one part of that unique moment in time.

Professor Martin Marshall: You will not be surprised to hear that morale in general practice is at rock bottom. We read about it in the newspapers every day. Surveys that we have conducted of our members suggest that 60% of GPs say that their mental health has deteriorated significantly over the last year. Anxiety, depression, suicide, ideation—33% of GPs say that at least once a week they find it almost impossible—

--- Later in debate ---

[The Chair]

I am just saying from the Chair that we are here to talk about what is in the Bill and to take evidence on the Bill, so we should stay within the confines of what is in the Bill.

[Alex Norris]

Q With that in mind, given the quite challenging picture that all three of you describe there, do you have any anxieties that this is not the right time to have the Bill and that, with staff anxious, demoralised and tired, a reorganisation might add to those anxieties and concerns for the future?

Professor Martin Marshall: There could not be a worse time for general practice to introduce the Bill, but I do not think that means it should not happen. It has to happen now. The NHS is ready for it, so it has to happen. The fact that general practice does not have the capacity or capability to engage fully with the implications of the Bill will mean that the Bill will not realise its full potential.

Professor Helen Stokes-Lampard: From my point of view, there is never an ideal time to introduce legislation and, certainly, in the midst of a global pandemic is on nobody’s agenda as a good time to do anything legislatively. However, the consequences of not doing it are that the integrated care systems, which are in a really vital part of their evolution and formation, will stall and therefore are far more likely to fail. So my view and the view of the Academy of Medical Royal Colleges is that we absolutely must go ahead with this legislation in the timeframe. There is never a good time to have a baby or move house, but you still need to crack on and do these things at bad times.

Pat Cullen: Same here: never a right time. If you were to ask nurses on the ground today, carrying out patient care in frontline services, they would say that anything that might improve where things are at the minute will be a bonus. But the issue is how it plays out and whether we are listened to. The professional royal colleges do represent nurses. I am here representing 480,000 nurses today. It is really important that we get this right. There is never a right time, but it is actually a great time if we do get it right.

[Alex Norris]

Q I will just ask a final question in my last couple of minutes. Martin, notwithstanding what you said about a greater GP voice on boards, and similarly Pat regarding directors of nursing on integrated care boards, what else could we do to get the voice of the staff really heard in the plans generated by the integrated care partnerships and then executed by the boards? What mechanisms do you think are effective ways of hearing from the frontline what is happening day in, day out? Perhaps, Martin, you could go first.

Professor Martin Marshall: I cited earlier the example in Gloucestershire. It has very purposefully built a primary care subgroup of the board in order to provide that clinical expertise and that clinical sounding board to everything that goes on at board level. That seems to me to be a really good way of moving on from a single GP on the board—which will be helpful but will have limited impact—to actually making a real difference on the ground. The real change, of course, will not happen at ICS level anyway. It will happen at local level; it will happen at the place level. That is where real change in integrated care, from the patient perspective, will be enacted and will be felt.

Professor Helen Stokes-Lampard: To build on what Martin has said, there are great examples of clinical panels, which is essentially what we will be talking about. That is a model that works extremely well and which can be broadly based and covering a huge range: primary and secondary care—the whole range of specialities. But in the same way, citizen panels have become something that can be hugely helpful as well. I am very anxious that we also hear the patient voice in the decision making at community level.

There has been a covid culture of creativity. When there was less top-down insistence on following direct process at the start of the pandemic, a lot of creativity was allowed to flourish. I feel we need to capitalise on that culture of creativity. These kinds of panels are exactly the sort of output that has come and they have been hugely beneficial. And, of course, the move to greater digital working has meant that we have been able to reach people that we have not otherwise been able to get. Clinicians leaving the clinical environment to participate has become easier when they can do so remotely. There is a dividend that we should build on.

Pat Cullen: To add to that, I fundamentally believe that the patient voice must be heard in those structures beneath the board. That is how we will really influence and move forward in terms of what is required, and those voices will feed into the population needs assessment at local level. But there needs to be a nurse involved in each one of those structures that feeds right in through to the director of nursing that sits on the board, and that is how you will hold the accountability line up and down.

[Alex Norris]

Thanks, all three of you.

[The Chair]

Thank you. We now go to Minister Argar.

Health and Care Bill (Fourth sitting)

Alex Norris Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Dr Whitford]

Q In the morning sitting we heard from Professor Marshall, who was talking about your own ICS. I asked about the problem of the power imbalance between the partnership and the board, and he mentioned that you have a primary care sub-group. We have had a lot of discussion about how we gather the voices and ensure everyone is there. What led Gloucestershire to develop that? How do you feel it is working? Do you think that is a good model? How do you ensure the board listen to what the partnership come up with?

Dame Gill Morgan: It is about multi-layering of advice. We will have a primary care sub-committee partly because managing primary care, and all the things that come through GMS and the opportunities, is expert; we do not want it to be subsumed by a generalist groups. We want it to have proper focus, because if our vision of the future is right, we need better and more engaged primary care at local level that can link its services more effectively with support in the hospital and the community. That is the objective, so we will have that.

We will also have an ICB. GPs will have different views. That is one view, which is about me as a jobbing GP. I go in in the morning, and I do my work and all of those things. I need to be supported to do that, but I also need GPs in the system who are engaged in management. We are very proud of our primary care networks, which are beginning to pull together around our localities, because we are smaller and it is not a big place.

There are models where they are working with second tier local government, where they are beginning to think about housing, and they are working with the voluntary sector, so when they are talking about frailty, it is not a GP or a hospital conversation; it is a system conversation in this place. All of a sudden there are things that can be unlocked. If we leave it in any one box, as we have always done in the past—there is a box for acute, for this and for that—we do not get this. Our task is to make those boundaries semi-permeable, with the expectation that we look at the patient flowing through all those boundaries, rather than pretending that patients sit in an individual box, because they do not.

Louise Patten: Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q Thank you both for coming this afternoon. Dame Gill or Ms Patten—it is fairer to ask the question more generally—suppose the integrated care partnership itself put forward plans for the footprint. The integrated care board, under this draft legislation, has to pay due regard to that. If you disagreed with that as a board, how would you manage that? How would that be resolved? How would that manifest locally?

Dame Gill Morgan: The first thing is that you would try to make sure that you have developed a mechanism for engagement and trust, so that you do not get into those sorts of disagreements. If you get into those disagreements while you are sat around the board, you have failed to do the task of integration and partnership. That is what happens in the conversations about how we solve it. If we ever got into that sort of difficulty, it would have to be resolved at the integrated care board, and we will have local government, public health and social care on our board as full and equal partners.

[Alex Norris]

Q That is a very helpful answer, thank you. Obviously there would be old informal mechanism. From my time as chair of health and wellbeing in Nottingham, I remember that the best thing you could ever do was just phone someone up and talk about it. Beyond that, for systems that may not be advanced or relationships that may not yet be embedded, is there a good formal mechanism that we could be writing in to ensure that that existed?

Dame Gill Morgan: The more you try to write in legislation, the more it becomes the lowest common denominator and the less you unleash the innovation that you want. I would do something quite different. I would probably write something that requires the different models of ICSs to be formally evaluated over a period of time, so for the first time we could look to structural change and say, “This is what it has demonstrated, not just against the outcome measures measured by the Department of Health and suchlike, but this has been a structural change that has added benefit, or not.” If you are going to do that, it must be done from day one. I think that is more important than trying to put something about solving problems in the Bill. You will never hit the particular strange circumstances of a locality that has problems, because they are always serendipitous.

[Alex Norris]

Q Louise, with your broader advisorate hat on, what do you feel about the selection of chairs and how we could get local voices into both the selection and—hopefully never needed—removal of chairs?

Louise Patten: The selection process for chairs and the executive team has got to be about what this integrated care system requires, what sort of leadership, and what are the partners that we have got. No two ICSs are the same. In order to achieve that, it needs to be a local discussion about what it is that this system needs to make sure it has the best leadership to take it forward. That will involve discussion with local people, local stakeholders and potentially the public to sort that, because the leadership will be different in different ICSs.

[Alex Norris]

Q You said, “What does the area require?”, so you would say that local people would have as good or a better understanding of that than, say, NHS England at the centre in Whitehall.

Louise Patten: The two will have a very good idea collectively about what leadership is required: one from experience of leaders and the other very much from the grassroots level of, “If this is our system, this is what we need.” It is a combination of the two.

[Alex Norris]

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

Louise Patten: It is both/and.

[Edward Argar]

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

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

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

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

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

--- Later in debate ---

[The Chair]

I know it is fascinating, but we had better go to Mr Norris.

[Alex Norris]

Q Thank you, Chair, and good afternoon, Sir Robert.

We have spoken quite a bit in these proceedings about the relationship between the integrated care board and the integrated care partnership, the fact that the board has to pay “due regard” to the integrated partnership’s plan, and what that due regard means. You talked about that in your written evidence, and you suggested mechanisms for resolving the situation—or at least making account for a situation where the board sets aside the ICP’s plan. Could you talk a little more about that?

Sir Robert Francis: The first requirement is that there needs to be clarity about what happens in those circumstances, which I am not sure we see in the current legislation or in the guidance that NHS England has produced, which I briefly read. Our suggestion is that there should be a provision inserted into the Bill that, if there is a disagreement, and the board decides to do something that is contrary to the views put forward by the partnership, it should then be obliged to set out their reasons for that. In other words, there should be transparency, which enables accountability, if it is necessary, to be more easily handled.

That would be the major thing we would require, but there also needs to be a better understanding, as far as the public is concerned, about the relationship between the two. I have heard what has been said today, and I must say that I am not clear that the partnership is a sub-committee of the board. That is because the Bill explicitly says that the creation of the partnership is a joint matter between the board—I think, or the NHS—and the local authority. It strikes me that that is not clear.

That is important because, if there is a disagreement, local people are entitled to know why. It would be good if they could also be persuaded that whatever is happening is actually the right thing for them, but they are certainly entitled to be part of the discussion. For that to happen, there need to be reasons given. Another thing that might send a shiver through some spines is that if there is an obligation to give reasons, it might be easier for those who object to the course being taken to challenge it.

[Alex Norris]

Q Do you envisage, when setting out those reasons for disagreement, that they would be publicly available?

Sir Robert Francis: Yes.

[Alex Norris]

Q Thank you.

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

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

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

[Edward Argar]

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

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

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

Health and Care Bill (Fifth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

I beg to move amendment 21, in clause 4, page 3, line 5, at end insert—

“(d) health inequalities.”

This amendment would modify the triple aim to explicitly require NHS England to take account of health inequalities when making decisions.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 22, in clause 4, page 3, line 5, at end insert—

“(1A) In making a decision about the exercise of its functions, the health and well-being of the people of England must be NHS England’s primary consideration.”

This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.

Amendment 23, in clause 19, page 18, line 13, at end insert—

“(d) health inequalities.”

This amendment would modify the triple aim explicitly to require integrated care boards to take account of health inequalities when making decisions.

Amendment 24, in clause 19, page 18, line 13, at end insert—

“(1A) In making a decision about the exercise of its functions, the health and well-being of the people it serves must be the primary consideration of an integrated care board.”

This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.

Amendment 25, in clause 43, page 47, line 32, at end insert—

“(d) health inequalities.”

This amendment would modify the triple aim to explicitly require NHS trusts to take account of health inequalities when making decisions.

Amendment 26, in clause 43, page 47, line 32, at end insert—

“(1A) In making a decision about the exercise of its functions, the health and well-being of the people it serves must be the primary consideration of an NHS trust.”

This amendment would assert that duties to patients come above any other (e.g. organisational) considerations.

New clause 13—Secretary of State’s duty to set targets on population health and reduction of inequalities—

“(1) The Secretary of State must, at least every five years, publish a report setting targets on—

(a) the improvement of the physical and mental health of the population, and

(b) the reduction of health inequalities.

(2) The Secretary of State must publish an annual report recording progress against the targets in subsection (1).”

--- Later in debate ---

[Alex Norris]

It is a pleasure to serve with you in the Chair, Mrs Murray, and to make my first contribution to the proceedings. It will perhaps give my hon. Friend the Member for Ellesmere Port and Neston a chance to bask in his new-found responsibilities, while I pick up the cudgel with the Minister. I am afraid I do not have such luxury as he does.

This group of amendments relates to health inequalities and to the priority that we give to the health of the nation, rather than the structures that serve the health of the nation. I will go through each amendment in turn, but I want to talk about a couple of themes that cover them all.

I strongly believe that addressing health inequalities ought to be a foundational priority of any Government of the day. What could be crueller than having such a significant element of a person’s future—how long they will live, how long they will live in good health and what diseases they are likely to acquire—preordained at birth? That has always seemed cruel to me.

Government are not a passive part of that process. The decisions that are taken in this place play an active part in those inequalities. For example, the decisions taken later today and on universal credit will widen them. We should seek to use this Bill as a turning point in our battle against health inequalities in this country. This should be the Bill in which we say that the national health service, and those who need it locally, must be central to addressing health inequalities in this country and that the Government will resource them properly to do so.

It is not a moment too soon to do this. The legacy of this decade of austerity, which my hon. Friend the Member for Ellesmere Port and Neston talked about, is that for the first time in a century the increase in life expectancy has stalled. What does it say about us, the most technologically advanced generation in history, that the increase in life expectancy stalls on our watch?

Within that there is a yawning gap in healthy life expectancy between those who live in the best-off and the worst-off communities. On the basic life expectancy measure the gap is 10 years, but on healthy life expectancy, measured by the age at which people have their first disability, the gap is 18 years between communities like mine and the communities that are best off in this country. How sad that is; how sad is what it says about us.

As the 2020 Marmot review concluded,

“health is getting worse for people living in more deprived districts and regions, health inequalities are increasing and, for the population as a whole, health is declining…the country has been moving in the wrong direction.”

Again, we heard evidence about that in the evidence sessions of this Committee. We ought to use this Bill as a moment to do something about it.

These inequalities are not just about socioeconomic status; they are about race as well. Research by the King’s Fund shows that

“people from the Gypsy or Irish Traveller, Bangladeshi and Pakistani communities have the poorest health outcomes across a range of indicators.”

Covid has shone a light on both race and socioeconomic background as drivers of inequalities. We entered the pandemic thinking it would be a great leveller and that the virus would not know people’s postcode, job or ethnicity. Actually, we quickly learned that that was not the case and that someone was twice as likely to die from covid if they lived in the most deprived communities. A man from a black African background is nearly four times as likely to die of covid as I am. Those inequalities, and how they played out, whether in housing, in occupation or pre-existing health, offered a breeding ground for the virus. That is devastating for individuals, but it is worse for all of us, because it has spread and strengthened the virus. Those health inequalities are bad for everybody.

Just before I turn to my amendments, I should also say that it is strange, given that half of all health inequalities are driven by smoking, to see a Health and Care Bill that does not talk about smoking at all. I hope that when we get to part 5, where some of the public health elements are found, we might collectively do better there.

Amendment 21 seeks to address the point about inequalities by adding to the triple aim for NHS England as set out in clause 4. The triple aim for the national health service is a good thing. It shows the system and those who work in it and lead it, whatever their role, what we want them to prioritise. The three strands of that triple aim are noble: the health and wellbeing of the people of England, the quality of service provided and the efficiency and sustainability of resources. However, that is not robust enough to ensure not just due regard for health inequalities but strong action.

I will not prejudge what the Minister will say, but I suspect he may say that promoting the health and wellbeing of people in England is the aim that covers inequalities. That is an important pursuit, but it is not explicit enough. It is just about general improvement. For example, we hope the Government would expect to see a resumption in the increase in life expectancy. That would be a general improvement in the health and wellbeing of the people of England. The problem with that is that it would not address the point about healthy life expectancy. There would be general and maybe even aggregate improvements for possibly a great deal of the population, but not enough to deal with the extraordinary and growing gaps for others. I think we ought to want to do something about that.

Accepting the amendment would mean the Government would send a signal to NHS England that tackling health inequalities ought to be at the centre of its mission. A quadruple aim may not be as elegant as a triple aim, but it is important that tackling health inequalities is recognised in the Bill. I know that the Minister wants the legislation to stand the test of time. He suggested I said something from a sedentary position about multiple pieces of legislation, which I genuinely believe I did not, but we ought to say that we are here because the 2012 Act was so bad. That there have been nine years since that Act is not a strength on the Government’s part; it is a weakness that they have defended something that has not worked for a long period of time. If we want the Bill to stand the test of time, then we ought to say what we want the health service to do. By putting that in the Bill, we would do that.

Amendment 22 also addresses the triple aim and creates a hierarchy within. High-quality and sustainable services are important, but when commissioning decisions are being made at a national level, as happens with NHS England, and those decisions affect our constituents, we do not want equal weight being given to organisational considerations. The whole point of the Bill as explained on Second Reading is to move to an integrated system that is built around the health and care needs of the population, rather than around organisational boundaries. We all recognise where that butts up in our casework and the frustration that that causes for us and, more importantly, for our constituents—those who have to make multiple calls to arrange care for loved ones and so on. If that is our purpose here, we want health and wellbeing to come first. The amendment seeks to do that and says that the primary aim of the three is the health and wellbeing of the population. If that means that there is a knock-on effect on political decisions on funding, as discussed in the previous set of amendments, so be it. It will be for the Government of the day to ensure that NHS England has the resources to do that well.

I draw the Minister’s attention to the very recent precedent in the Medicines and Medical Devices Act 2021, the Bill Committee for which took place in this room or an identical one. I was a member of that Committee, as were the hon. Member for Bury St Edmunds, who is not in her place at the moment, and the hon. Member for Erewash. When we discussed the triple aim of that Bill, I moved an amendment to prioritise patient safety over all other considerations, because I thought that was an uppermost consideration. It was originally rejected in Committee, but the Government brought it back in later stages, which was the right thing to do. Rather than waiting to bring this back later, we could address it today. I would be very interested to hear the Minister’s comments on that.

Amendment 23 is a counterpart to amendment 21, but it operates at local level. Whereas amendment 21 applied to NHS England, amendment 23 applies to local integrated care boards—to say that, as part of their responsibilities, they must take inequalities into account. Of course, all the arguments that I have made for NHS England also apply here, so I will not repeat them, but this is quite a profound case at local level. From the written evidence, the hearings and the contributions from hon. Members throughout the Bill’s stages and elsewhere in this place, we can see that there is considerable anxiety that we will end up devolving fixed financial settlements down to the integrated care system level. That suits Ministers, because it means that they can devolve financial responsibility so that the Treasury can know what it is spending on a certain function, but all the tough decisions that get us to that point have to be taken at local level. I do not think that is a dystopian scenario, because that is literally what we do with social care already in local government.

The Government know that they do not resource local authorities sufficiently. As a result, social care is squeezed. What happens in those circumstances is that the systems start to worry about running out of money. The hon. Member for Central Ayrshire made a point about end-of-year capital that I recognise from my time in local government, but it works in reverse—when Christmas comes about, there is a spending freeze on everything, and the chief executive of every council in the country ends up reviewing every purchase of more than about a fiver. That is the reality for the systems, and local commissioners will be pressured to think in the interest of resourcing their system, rather than tackling health inequalities. That runs straight into the argument for amendment 24, which is a counterpart to amendment 22 and which says that the hierarchy within the triple aim ought to apply at an integrated care system footprint.

In paragraph 44 on page 18 of the explanatory notes, the Government have told us that the purpose of the triple aim duty is to

“require organisations to think about the interests of the wider system”.

I get that, but I do not think it is quite right, because the primary responsibility is to think about the interests of the wider population. It flows from there that the best way to address the health needs of the population is a system-based approach, which is the Minister’s central argument for this entire piece of legislation—so organisations have to think about each other. However, the primacy is the need of the population.

Perhaps the Minister will say it is axiomatic that health systems will prioritise the wellbeing of their community above everything else, but I do not think it is inconceivable at all that at some point in any given year—never mind at some point in the future—system leaders in one of those footprints will feel distressed about their finances and may take the wrong message, or perhaps the wrong bit of cover on a commissioning decision, about putting population wellbeing in the same tier as system sustainability, as if those two things could be co-equals and, if in tension, could be resolved either way. I do not think that is right, and I would be interested to hear the Minister’s view on that.

Amendment 25 requires health trusts to pay regard to “health inequalities”. Again, it is a counterpart to amendments 23 and 21, and it is for the same reasons as for NHS England and integrated care boards, so I will not repeat those arguments.

Amendment 26 is a counterpart to amendments 24 and 22, requiring the prioritisation of population health and wellbeing at trust level, for the same reasons that I have just mentioned. Again, I will not repeat those arguments.

--- Later in debate ---

I therefore encourage the shadow Minister not to press his amendments to the vote and commend clause 4 to the Committee.

[Alex Norris]

Turning briefly to the points made by colleagues, the hon. Member for Central Ayrshire made the same arguments I did about patient safety and the Medicines and Medical Devices Act 2021. She made very good points about the health and wellbeing amendments, and I thought she was right to say that there is a real public appetite, now in particular, to tackle inequality. I do not think the public would be surprised to see the Government enter this space.

The hon. Member for Arfon made a similar point about whether levelling up is a political slogan or a public policy programme. It is very hard at the moment to find evidence for the latter, but this would be a really good piece of evidence for it. It is not just a north and midlands versus south issue. As my hon. Friend the Member for Bristol South said, there are some constituencies, like my own, where every single super output area would be in the hardest pressed decile in the country. However, there are many more where there is a greater range—they have some of the poorest parts of the country, but they also have some of the best off. This is something that ought to be at the top of the priority list for every integrated care system in every constituency.

On new clause 13, the Minister said that five years is too rigid. He almost suggested that the Government might outperform. I will believe it when I see it, but there is no evidence from the last 11 years to suggest that that is in any way a risk. Nevertheless, if he brings this back with a two, three or four-year time period rather than five, I will be the first to join him in the Division Lobby to support it.

On amendments 21, 23 and 25, the idea of a “fourth limb” made it work conceptually—I quite like that. What I did not give much succour to was the idea that inequalities lie somewhere else on the statute book, in a way that health and wellbeing and organisational sustainability do not, and therefore it would not need that co-equivalence because it already exists. I did not agree with that point at all.

On the point about inequalities being part of the guidance, I suspect that that will not be the last time that is said in this Committee. Guidance is guidance; legislation is legislation. One of those is an awful lot more powerful and eminent than the other. My view is that if we want to send a clear signal about something, we do not take it out and stick it in the guidance.

I do not give much succour to the point about elevating one of the triple aims either. The Minister said that that would undermine the triple aims. He talked again about the interest of the wider system, but I think all of us are more interested in the wider population. One of those clearly comes before the other. The needs of the one flow into how to organise the system. To organise a system that is supposed to come together in the interests of population health, I would really like to think that population health is more important than the system. I am not sure about the idea that, as a result, worse decisions would be made, and I would be interested in hearing an example. I have to say that that point did not resonate with me.

I am conscious of the reply from the Minister and, indeed, of the time, so I will not press new clause 13 and amendments 22 to 26. However, I do wish to push amendment 21, because if we are talking about NHS England—that totem of healthcare in our country—I really think we ought to send the signal that health inequality should be one of its priorities.

Question put, That the amendment be made.

Health and Care Bill (Sixth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Karin Smyth (Bristol South) (Lab)]

Further to those points about clarity around the exercising of powers, the move to give NHS England that power is entirely sensible. The medical, dental, ophthalmic and pharmaceutical services have had a lower profile in our constituencies over the last few years, as I think we would all agree. It is important to give them the profile they need to be integrated into the system, because they have certainly not been so far.

The evolution of delegating that power to CCGs came late in the day, and remains muddled around the commissioning of primary care services. Therefore, while allowing the delegation of function is entirely sensible, it is not clear, as my hon. Friend the Member for Ellesmere Port and Neston has said, when or how that delegation will be sought. I think the Minister was referring to the involvement of the Secretary of State, but I am not sure in what circumstances the Secretary of State would be doing that, and why this would not be when NHS England, or NHS England regions, decides that the ICB is of a maturity to accept commissioning responsibilities.

One assumes that NHS England believes that at the moment some of those putative organisations are mature enough already; will some of them start doing that on day one, six months in or a year in? How will we know and how will they be resourced to do it? Is it a transfer of power? How NHS England and the local ICB, without representatives of medical, dental, ophthalmic and pharmaceutical bodies, will be taking that on board is all very opaque.

[Alex Norris (Nottingham North) (Lab/Co-op)]

My hon. Friend has a local Mayor, but my community does not. If someone lives in Greater Manchester there is a Mayor, but in other places there may not be. We have a very asymmetric model of local devolution. Does she agree that an asymmetric model of devolution, where some ICBs had certain powers and others did not, would be undesirable and may create more confusion than it solves?

--- Later in debate ---

Division 4

Ayes: 4

Noes: 9

[Alex Norris]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Edward Timpson]

I am grateful to the hon. Gentleman for giving way, and I understand his desire to try to push the agenda of some very important parts of our healthcare system, including mental health. Is he cognisant of the evidence that we heard from Dame Gill Morgan, who has already set up an ICS and who has perhaps done some of the testing for us on what works best? She said:

“In our case, we will have mental health and social care around the table, not because we are told to but because we could not imagine how we could do our work at a local level without having those people feeling that they are full partners and sitting around the table.”––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 133, Q186.]

Does the hon. Gentleman think it is important that we listen and learn from the experience to date in order to ensure that—to use the hon. Gentleman’s football analogy—we do not have too many people on the pitch? The analogy falls down, because it is possible to have only 11 on a football pitch. The danger is that we end up with too many people, which is unworkable and unmanageable.

[Alex Norris]

I am grateful for that intervention—I am going to stop at 10. That evidence actually supports the point the I am making. When we heard that evidence, the witness said that it was automatic to them, but of course we would want someone from a mental health background and someone from a social care background. I completely agree. What I am saying is that if that is so clear and obvious, which I believe it is, why on earth would we not put it in the Bill? It was clear and obvious enough that we wanted to have someone on behalf of local authorities, and that we wanted someone on behalf of primary care. If it is clear and obvious in those cases, it is clear and obvious in these, too. That was my reasoning, and it was obviously echoed in the evidence submitted by the Royal College of Psychiatrists and the Mental Health Foundation. That is the first thing I want to say about the amendment.

The second relates to a director of public health drawn from that patch. Goodness me—as my hon. Friend the Member for Ellesmere Port and Neston said this morning, if anyone has proven themselves under fire over the last 18 months, it is our incredible DPHs. With a unique combination of knowledge, training, local insight and cross-system relationships, they have done an extraordinary job for us in pulling together our approach to the pandemic. We should be using that to pull together our approach to all sorts of big issues that we face in our local communities.

The DPHs are the human embodiment of our communities’ joint strategic needs assessment. They bring that to life, and they could bring that to the table. If we want our system leaders to go beyond their organisational concerns when they go into their integrated care board meeting, who better than the person who develops the insight into system need? The DPH is exactly the right person. They also provide an invaluable director-level connection to all the departments of the local authority that have such a profound impact on the wider determinants of health—housing, leisure and planning. What a wealth of knowledge, and what connections, they would bring to the table.

Thirdly, the amendment provides for a designated social care representative. The stated aim of the Bill is to drive integration and to foster collaboration between health and care partners. I really want that to be the case, rather than this being just a reorganisation Bill. It is a 135-clause Bill, and two of the clauses are about social care, so it is not unreasonable to say that perhaps there is an imbalance. Rather like the much-hyped social care reform and funding plan that the Government are discussing downstairs at the moment, the clauses in the Bill neither reform nor, in the main part, fund social care. Again, social care is left trailing behind. It has been battered for 11 years and, as a result, we see rationed care, dreadful terms and conditions for staff, and services that are just not fit for what they were supposed do. If the Bill really is about fostering collaboration, social care ought to be explicitly represented.

I am conscious that there is a nominated local authority representative under paragraph 7(2)(c) of schedule 2, but that person will already have quite a lot on their plate. They will have to represent the broader views of the entire local government family. Nottingham and Nottinghamshire is probably one of the simpler planning footprints in the country, but it is still 11 counties, and representing all those views at once is very difficult. It is too much—and not credible—to represent not only 11 council chief executives, but 11 directors of adult social care and children’s social care, as well as all the other functions of the local authority. A social care lead, who convenes the social care leads in the given geography, would give the ICBs the specialist knowledge and insight to create and foster the environment for a true partnership between health and care.

Fourthly and penultimately, amendment 32 would replace the staff voice through recognised trade unions. As has already been mentioned, our health and social care services are well served with amazing staff. They are our experts. They are the people who feel things on the frontline and who know, when they go, “Here we go—here’s a new initiative”, whether it is practical and rooted in real-world experience. They have that very direct experience of population health and how it is changing over time.

The staff are the ones telling us about the fractures in the health and care system that make their jobs harder—the fractures we are supposed to be dealing with. They were the ones—boy, should we have listened to them then!—who told the Government very clearly what the impact of the 2012 reforms would be on the system and about the greater fracturing of the system. They were not listened to then, but they should have been and they should be now.

Prior to coming here, I was a union organiser. I know one thing for sure: senior management always think they can speak for the staff, but I am afraid they generally cannot. That is not a criticism; their lives at work are very different. The health and care family is better served when all aspects are covered, rather than some speaking for others. If we are going to develop really significant plans at these boards, the discussion would be incredibly enriched if the voice of the frontline was there, to sense-check things, to highlight things that are working already and the workarounds that staff develop as time goes on, and to assist on planning as well. There is an awful lot they could contribute.

Finally, and crucially, let us have a representative of the patient voice. The whole reason why any of us come to this place is that we want to give communities a voice. We think that is important. The key way we do that is to listen to people. If we do not, we do not do very well for very long.

We want our communities to have brilliant health and care services, but sometimes we make it harder for them to tell us what they want. We have tremendous mechanisms for finding out. The evidence of Sir Robert Francis from Healthwatch was particularly pertinent on not just using numbers, but the wealth of qualitative information. Let us have someone who is an expert by experience and who can draw on and bring that with them, and speak for thousands of other experts by experience. We must believe that they have as much to contribute as senior leaders. Not only would they bring insight, but it would give legitimacy to decision making, which is something that we have real concerns about, as we have said on discussion on multiple groups of amendments.

Those are the extra five members we are suggesting. If anyone listening at home is keeping score, that means five members—the chair, the chief executive, the acute lead, the primary care lead and the mental health lead—who owe their employment fundamentally to the NHS, and five—the local authority lead, the DPH, the social care representative, the staff representative and the patient representative—who do not.

If the Bill is about integrating and not about a restructure and reorganisation that involves the big acutes taking on the rest of the system, that might be quite an elegant balance. Of course, local systems could seek to augment that, which would be a matter for them, but this would be a very solid foundation, which I think enriches the board. I look forward to the Minister’s response.

[Dr Whitford]

I, too, rise to support the amendment. This is probably one of the most important amendments so far. In the witness discussion, we came back time and again to which voices would be on the ICB and would be able to influence. I agree that, with all the talk of parity of esteem, it seems incredible that there would not be a voice representing the importance of mental health on the board. Similarly, with the talk of moving to population health and wellbeing, there is a need for directors of public health to agree policy and to feed in information about the underlying health inequalities, life expectancy and so on in the local population. Not to have a social care voice when what the Government say is that they are trying to integrate the NHS with social care seems quite bizarre.

The NHS and social care are both services delivered by people for people and having both the workforce and staff voice, and the patient voice, is therefore important. On the staff voice, the “Learning from Scotland’s NHS” report from the Nuffield Trust highlights that the success of both the Scottish patient safety programme and the Scottish quality improvement standards was driven by the fact that frontline staff were involved as drivers, champions and developers from the word go. These programmes have been able to run over years, building on experience that is then shared with other sectors and specialities. It is important to get this part of the Bill right, or else priority will not be given to integration, population health or wellbeing. Of all the things that have been discussed so far in Committee, and through the witness statements, this amendment is one of the most important.

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[Edward Argar]

I think that all add value, but equally, in some circumstances, we see different local arrangements; in some localities, some people fulfil more than one role or sit in different places.

The hon. Gentleman asked me to cover his specific point about the guidance before I conclude: the guidance will not prescribe additional roles in the same way that legislation prescribes or mandates, but it does seek to set out best practice, highlighting what would be deemed to be best practice—drawing on experiences such as Dame Gill’s, I suspect. We would expect that ICBs would pay due heed to that guidance, alongside their de minimis legal and statutory obligations.

If in time, when those ICBs are up and running, it becomes clear that that approach needs strengthening and that we need to add further requirements, regulation-making powers in schedule 2 will allow the Secretary of State to do so at a later point. We believe that it is right to start at this de minimis point in the Bill. It reflects our view, which I have articulated throughout, that we must not attempt to over-legislate at this stage on the composition of ICBs, letting them evolve as effective local entities, to reflect local needs. It may not fully reassure the hon. Gentleman, but there is a mechanism whereby further changes could be made in future, although we do not believe that will be necessary.

The amendment takes a different approach, which is essentially more prescriptive and less permissive. I do not dispute the sincerity of that approach, but it comes down to a matter of where we feel the appropriate balance should be struck. I fear that, although the shadow Minister and I are quite close to one another in our region of the east midlands, we are slightly more distant in respect of the amendment, but I am grateful to him for affording the Committee the ability to debate a key point of principle in the approach to the Bill.

[Alex Norris]

I am grateful to the hon. Member for Central Ayrshire for her contribution and for sponsoring our amendment. She spoke about the way staff have not only improved patient safety and the quality improvement programmes, but made them stand the test of time. We are sometimes in danger—the Bill is a good example—of building things that do not stand the test of time and keep being changed, and she went through all the various situations. If we pass any test, it should be that one. The amendment is certainly one way of improving our chances on that.

I am grateful to the Minister for his comments, too. I understand the de minimis point, but I still cannot envisage a scenario in which we would not want a mental health rep on the board. I live in undoubtedly the best place in England—in Nottingham—but we still have mental health problems and need mental health leaders. If we need mental health reps, and we certainly do, I think that everybody probably does.

The Minister’s response did not quite address the point about balance. The balance of the five members is four NHS and one non-NHS. The whole business maxim is no mergers, only takeovers. If the provision is really about integration and partners coming together on an equal footing to improve the population’s health, everything that we have heard so far does not fit with that. What we have heard so far is about organising this round with the terms of reference that NHS England wants, and if local communities and local authorities wish to be part of that and know their role within it, that is absolutely fine. I think we should aspire to do better, so I will press the amendment to a Division.

Question put, That the amendment be made.

--- Later in debate ---

Division 5

Ayes: 5

Noes: 9

[Alex Norris]

I beg to move amendment 30, in schedule 2, page 120, line 26 at end insert—

“(2A) The constitution must prohibit representatives of GP practices with active Alternative Provider Medical Services contracts from becoming members.”

This amendment would mean that the only GPs able to participate in integrated care boards would be those whose practices are on the standard General Medical Services (GMS) contract.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 33, in schedule 2, page 120, line 26, at end insert—

“(2B) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care boards.”

This amendment prevents private providers of healthcare services from becoming members of integrated care boards.

Amendment 27, in clause 20, page 29, line 9, at end insert—

“(4) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care partnerships.”

This amendment prevents private providers of healthcare services from becoming members of Integrated Care Partnerships.

[Alex Norris]

We have not had success with chairs, and we have not had success with who should be on the board, so we move on to who should not be on the board. Let us see whether this alternative tack might prize the Minister away from not giving us his support.

The amendment would mean that representatives of GP practices with alternative provider medical services, or APMS, contracts were prohibited from participating in integrated care boards. That would mean that, under schedule 2, they could not provide that primary care representative.

Let me briefly explain the context. The vast majority of practices—nearly 70%—operate under the general medical services, or GMS, model. That is the standard contract and the most usual model of partnership whereby a CCG or NHS England contracts with a local general practice. Another quarter or so operate on personal medical services, or PMS, models. There is a little more flexibility for commissioners to tailor to local need—this is not agreed as a standard contract like the GMS at national level—and again the arrangement is with a local practice. However, these are not particularly en vogue; they are being phased out, I understand.

That leaves the remaining portion, which is on APMS. That is a much more flexible contracting model and very much a child of the previous decade. Here, commissioners can contract with organisations other than GPs or GP partnerships, and can contract, for example, with private companies.

APMS contracts—without that GP requirement and with shorter durations—offer the easiest way for large private companies to take over practices. Those are companies motivated by profits, rather than their patients, and their having a voice on the board would run contrary to what I am sure Members on both sides of the Committee seek to achieve. I would say it was contrary to the triple aim of the Bill.

However, this is a model on the march and one that could change general practice beyond recognition. My colleagues and I do not think it should exist, but we will make our case on that when we deal with clause 16 and amendments 28 and 29, so I shall have to keep the Committee in suspense. The amendment would mean that a representative from such an APMS partnership could not be part of the ICB and could not fill that place.

As my colleagues and I have made clear previously, we think it paramount that the Bill put patients front and centre. For many patients, using the health service begins and ends with their GP for big parts of their life. The GP is someone they have known for years, someone they can trust and someone who plays an active role in and knows their community.

The pandemic has created some access issues, but the care that people have received is still exceptional. The latest GP survey found that 89% of patients said that the healthcare professional they last saw was good at listening to them and giving them enough time, 88% said that that healthcare professional was good at treating them with concern, and 93% said they were involved as much as they wanted to be in decisions about their care and treatment. Our local GPs are really good and do the job really well. It is not much of a stretch to think that those are the sort of people that the public want speaking for them in these ICB structures. That would be very welcome.

We also know that, whether my supposition that the ICBs are going to be really big CCGs is right or not, CCGs had significant involvement from primary care clinicians and the ICBs will have less. That is definitely a point beyond contention, but there is still a reserved place on the board. However, this is a perfect opportunity for local GP leaders to fill that space, and with regard to APMS contracts, I do not think that those representatives will provide that same involvement.

I appreciate that the numbers will be relatively small—indeed, this might be quite unlikely to happen—but we should bear it in mind that APMS contracts do not require a GP to be a contract holder. They do not offer the same benefits to an ICB as a general or personal medical services contract holder, who is contractually required to be a GP. That is a significant difference. This position on the board should bring important perspective; it should not be wasted.

This is about two things: first, showing the best possible voice and secondly, putting a stop on creeping privatisation. Ministers have been at great pains earlier in the process, and certainly on Second Reading, to say that this is not about privatisation. Well, this is a very good chance to prove that.

--- Later in debate ---

[Edward Argar]

With your indulgence, Ms Elliott, I will turn to amendment 33 first. Integrated care boards will be NHS bodies, whose membership consists, at a minimum, of individuals appointed by NHS providers, providers of GP services and local authorities that coincide with the ICB. Any perceived risk of privatisation through the ICB membership provisions is, I believe, entirely unfounded—and, I feel bound to add, potentially unfair to the many public servants in the NHS who work for ICBs. Although service provision—I emphasise the word “provision”—by the independent and voluntary sectors has been, and continues to be, an important and valuable feature of this country’s healthcare system under successive Governments of all political complexions, it was never the intention for independent providers, as corporate entities, to sit on integrated care boards, nor for an individual to be appointed there to be a representative of such an interest in any capacity.

People must therefore be assured that the work of integrated care boards is driven by health outcomes, not by profits, and I am sure that there will be a consensus on that principle across this Committee. That is why there are already safeguards in place to ensure that the interests of the public and the NHS are always put first. The ICB chair has the power to veto members of the board if they are unsuitable, and NHSE has the power to issue guidance to ICBs in relation to appointments as part of its general guidance-making power. That sits alongside the robust requirements on ICBs to manage conflicts of interests, and NHSE’s wider duty to issue guidance to ICBs.

I turn to amendment 30, which seeks to exclude individuals whose GP practice holds an alternative provider medical services contract from being made a member of an ICB. APMS contractors include some private and third-sector organisations, but also some GP partnerships. These contractors include, for example, social enterprises and partnerships that provide services to homeless people and asylum seekers. This amendment would potentially prevent some individuals from being on ICBs, on the basis of the type of NHS GP contract that their practice holds.

I do appreciate the intent behind the amendments, namely the desire to avoid the appearance, and potentially even the risk, of privatisation and conflicts of interest. However, the effect would be to limit the ability of primary medical service providers to appoint an ICB member who might best meet the requirements of the local population, by reducing the diversity of GPs who could be appointed. While I can understand the intent behind them, I fear that these amendments do not do what they seek to do, and they would have unintended consequences. I will turn to those shortly.

We recognise that the involvement of the private sector, in all its forms, in ICBs is a matter of significant concern to Members in the House, and we are keen to put the point beyond doubt. However, having taken appropriate advice, I am afraid that that these amendments would not cover a number of scenarios—for example, lobbyists for private providers, or those with a strong ideological commitment to the private sector—and they would therefore not be watertight

As it stands, these amendments may well not offer the robust assurance that perhaps hon. Members intended. Therefore—this is where I may surprise the hon. Member for Ellesmere Port and Neston—to put this matter beyond doubt, we propose to bring forward a Government amendment on Report to protect the independence of ICBs by preventing individuals with significant interests in private healthcare from sitting on them.

As hon. Members will know from their attempts to draft these amendments, avoiding unintended consequences is not a simple matter. If appropriate, I would be happy to engage with either the hon. Member for Nottingham North or the hon. Member for Ellesmere Port and Neston in advance of Report. We may not reach a consensus, but, as they both know, I am always happy to have a conversation with them.

The Government are firmly committed to the founding principles of the NHS. We recognise the importance of its values, and the public service ethos that animates it. It is by no means our intention to allow private sector providers to influence, or to make, decisions on spending on the commissioning board—the ICB—and the spending of public money. The Bill does not allow that, but we will look to see whether we can find a way to put that unfounded fear to bed once and for all with an appropriately worded amendment that does not have unintended consequences.

Although I appreciate that much the same motive underpins amendment 27, it is worth considering why the integrated care board and the integrated care partnership are different bodies. The decision to create integrated care partnerships came from discussions with a number of stakeholders who revealed a strong case for the creation of a committee to consider strategically not only the health needs but the broader social care and public health needs of a population. It is not a body like the ICP, as we have heard, which will be directly accountable for the spending of NHS monies.

We therefore do not intend to specify membership for the ICP in the Bill, as we want local areas to be able to appoint members as they think appropriate. To support that, we have recently been working with NHS England and the Local Government Association to publish an ICP engagement document setting out the role of integrated care partnerships and supporting local authorities, integrated care boards and other key stakeholders to consider what arrangements might work best in their areas.

We would expect members of the ICP to be drawn from a very wide variety of sources and backgrounds, including the health and wellbeing boards within the system; partner organisations with an interest in health and care, such as Healthwatch; and potentially voluntary and independent sector partners and social care providers at that level, as well as organisations with wider interests in local priorities, such as housing providers.

To exclude independent providers from both the ICB and the ICP would, I fear, risk severely reducing the extent to which all parts of the broader health and care ecosystem could be drawn upon in the ICP context. It would exclude valuable expertise and would, for example, prevent social care providers who provide a small amount of domiciliary care to the NHS from sitting on the ICP. Furthermore, the ICP will not make commissioning decisions or enter into contractual arrangements that are binding, or make decisions about who gets funding allocations. Those are functions conferred on the ICB, hence the distinction that I make.

I therefore believe that membership of individuals from independent providers on the ICP does not present a conflict of interest in the way that hon. Members have asserted, certainly in the context of the ICB. I suspect that we may debate that further in the coming weeks, but taken with the ICB and the comments that I have made, we believe that this provides the right balance between recognising the distinctive accountabilities and responsibilities of the NHS, local authorities and other partners, and strongly encouraging areas to go further in developing joint working.

I hope that what I have said provides some reassurance to Opposition Members, and that they will be willing—I see them nodding—to engage with me to see whether we might find a greater degree of consensus. I should also say that I will obviously speak to the Scottish National party spokesperson on this as well, as I have done throughout. I addressed my remarks to the shadow Minister, but of course I extend that offer to her. I hope that on that basis, the Opposition Front-Bench spokesman will consider withdrawing the amendment.

[Alex Norris]

If the Bill is about collaboration, we ought to model that here. Given that very gracious offer, I am very happy to beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[The Chair]

We now come to amendment 33 to schedule 2, which has just been debated. Justin Madders, do you wish to move the amendment formally?

Health and Care Bill (Seventh sitting)

Alex Norris Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

I beg to move amendment 34, in schedule 2, page 120, line 26, at end insert—

“(2C) The constitution must require integrated care boards, and any committee or sub-committee of the board, to meet in public and publish all papers and agendas at least 5 working days before each meeting is held.”

This amendment mandates integrated care boards, and their sub-committees including “place based committees” to meet in public and publish all papers and agendas at least five working days before each meeting is held.

It is a pleasure to resume proceedings with you in the Chair, Mrs Murray. This is a resumption of our discussion on schedule 2, which lays out the rules under which integrated care boards must meet. For all the talk of local flexibility, the reality is that the regulations are quite tight in schedule 2; the amendment seeks to tighten them a little more, but not disproportionately so.

The amendment asks for two things: first, that the boards meet in public, and, secondly, that they publish their papers five days in advance. To start with meeting in public, it has been mentioned on a number of occasions that the 42 different integrated care boards are in different states of development. There will be systems that are well advanced and model good behaviours of transparency and accountability, but we have to set regulations to ensure a minimum floor standard, and this is what the amendment does.

For a struggling system, the worst-case scenario, as we have said before, is that it can become a closed shop of leadership appointed centrally by NHS England and the leaders of the big acute trusts, because it is they who have the power and the resources. We cannot legislate to improve the culture of those systems—that is not what legislation does—but we can ensure proper oversight to try to minimise the risk, and meeting in public is a good way to do that. Sunlight is the best disinfectant, as they say, and this will mean that the public have a good sense of what decisions are being taken in their interests.

A key part of that citizen oversight is to know what decisions are being taken and when. Including a provision in the constitution to publish papers with five working days’ notice seems a good way to do that. I would argue that that represents rather basic good governance, so it is a very low bar to clear. We have spoken before about wanting to allow integrated care boards to be able to vary to fit their local circumstances, but I cannot see under what circumstances it would be desirable or relevant to vary the publication of that information. I do not think there are any local circumstances that would call for that. The requirement would mean that members of the public, elected representatives and those who represent staff or anyone with a general interest would understand what is going to be decided and when, and would give them the opportunity to make representations so that the board members are making decisions in the full knowledge of the facts and the views of the broader system.

In the amendment, that requirement also applies to all committees or sub-committees. This matters, because we heard in the evidence sessions that it is almost inevitable that every system will want to establish sub-committees, both thematic—we heard from the system in Gloucestershire about its primary-care themed one, which I thought was a very desirable way to use a sub-committee—or, inevitably, given what we have said about the size of the footprints of some of the integrated care boards, place-based. It is important that the provision applies to those bodies too.

The question matters even more to the integrated care partnership and its status, and I hope the Minister will be able to address it. My reading of clause 20 and proposed new section 116ZA of the Local Government and Public Involvement in Health Act 2007 states that this is a committee of the integrated care board and the local authority. I would argue that that remains an oddity, because the process was pitched to us on the idea that we have an integrated care board that will be the official NHS fund-holding body, but then we have the integrated care partnership that will provide the broader involvement on an equivalent basis, not as a sub-committee. I hope that point can be addressed, but nevertheless it will be important for that body that the public know what is being discussed and when. We will come back to clause 20, but the commitment from the Government that the meetings and papers should be public is a good thing.

Conceptually, the amendment lands the ICB and any sub-committees at about the level of an executive board of a council. That to me feels about right. The Minister may have reflections about circumstances where, by exception, the boards may need to meet in private for certain decisions, as local authorities would do. There are ways to do that for councils, so I do not think it is beyond our wit to do the same for these bodies, too. As a default, the basic principle of public meetings, with papers published five working days in advance, seems sound.

[Karin Smyth (Bristol South) (Lab)]

I offer my support to my hon. Friend and agree with everything he said. There may be a response from the Minister, although I do not know what he will say, but there is some discussion that perhaps the amendment is not necessary, as this already happens and the Bill refers to publishing—but that is not true. There are exemplar trusts and bodies across the country that have a culture of openness, but NHS boards are secretive and protected.

We have numerous examples of whistleblowing and good journalism uncovering the depths of NHS bureaucracy. Boards with which I have dealings, not just locally in Bristol, do a lot out of the public eye, and a culture of not liking scrutiny has evolved over a couple of decades, even though they should be really proud that people are taking an interest. We need to change that culture, and having a reference in the Bill would help.

Trade union colleagues have often come to me to complain about how they are blocked from getting key information about plans for changes. Changes are announced, and management often want to start TUPE discussions without really understanding what is behind the change. The use of freedom of information requests results in variations across the country in who responds and how they respond. That needs to stop.

The default should be to make things public unless there are reasons not to. I was a non-executive director back in the noughties, and was led by a chair who had come from local authorities—a Labour chair, but I do not think that matters. People who were used to chairing in local authorities found it quite peculiar that the NHS wanted to discuss matters in secret. As a board, we made it the case and culture that managers had to say if there was a really clear reason, and on several occasions we challenged why things were not done properly.

The new NHS is not commercial. The Government tell us that we are not quite getting rid of the purchaser-provider split, but we are moving away from competition as the driver of the health service. The confidentiality argument should be disappearing. I hope that the Minister accepts that the very highest standards now need to be set around openness and transparency and need actually to be enforced. All levels of the NHS and all these committees and sub-committees, however we end up organising them, have to be cognisant of the Nolan principles, which should drive all their work.

If a trust is finally forced by a tribunal to disclose information, it should have been provided earlier. There should be consequences. Where there is a bad culture, we need to change it. To reference my hobby-horse, there should be a business case to support every major decision. Later we will discuss my new clause 7, which comes from the pain I have experienced trying to unearth business cases, particularly in wholly owned companies and subsidiaries, to deliver facilities management. I have asked for business cases only to be told, “No, it is confidential.” There should be no need for it to be confidential at all. I do not understand how a business case can be confidential—at best, a few lines might be sensitive, but not a full business case.

That shows that NHS bodies who fear a change think they have something to hide. It is wholly wrong. If a change is proposed, the case for change should be published. We need to know why it is necessary. I would go further; I would publish all details of the tender process and the contract management. If anyone wants to do business with the NHS, which we welcome, they need to be open and transparent. It really is a test of the intention to change course and move to an integrated, collaborative model, because as we exit the market, we need to be make sure that the wellbeing of the public and the patient really comes first in commissioning. As I say, that culture needs to be changed.

To come back to my theme, ICBs need to be the bodies that the public recognise and understand as being where some sort of accountability resides. That means that nothing should be secret. Let us go further: the public has the right to question. That is what we come back to. There has to be a figurehead—ideally an elected figurehead —or non-executive directors who can be truly independent and challenge that secretive culture. I hope the Minister will look favourably on the amendment.

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To summarise, I endorse what the shadow Minister and the hon. Member for Bristol South were saying, which is that the principle of transparency is one to which I think we would all expect these bodies to fully adhere. On that basis, I gently encourage the hon. Member for Nottingham North to consider not pressing his amendment to a Division.

[Alex Norris]

I am grateful for the contribution from my hon. Friend the Member for Bristol South. I completely agree that where we will see the worst practices across footprints, each and every one will be secretive and not invite scrutiny, so it is very important that we set arrangements to ensure that that cannot happen.

I am grateful for the clarification that the 1960 Act will apply, which assuages my first concern. On the second, relating to the notice of board papers, the Minister has essentially said that local footprints will have to set that element of the constitution themselves, but that the safeguards and schedules will mean that NHS England has to sign them off. In that sense, there cannot be wide divergence, because the centre would not permit it. I reiterate that there should be commonality. I cannot see why it would be seven days in one place and five days in another. I do not know how we could explain that, so I hope that in those conversations the Minister stresses the need for uniformity. Perhaps the guidance might include strong encouragement on that. On the basis of the agreement that we have in principle, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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

I beg to move amendment 43, in schedule 2, page 123, line 2, at end insert—

“(5) An integrated care board must apply all relevant collective agreements for staff pay, conditions and pensions.

(6) An integrated care board must ensure that all relevant collective agreements for staff pay, conditions and pensions are applied throughout the area for which it is responsible.

(7) Any integrated care board which wishes to employ anyone directly on an annual salary greater than £161,401 must receive approval from their integrated care partnership before confirming the appointment.”

This amendment puts into primary legislation the current practice that NHS bodies honour collective agreements over staff pay and conditions and gives the integrated care board a role in ensuring this remains the case.

It is a pleasure to see you in the Chair, Mrs Murray. I would like to say that it is a pleasure to see the Minister, although when I saw the headline that two Ministers from the Department had been promoted to the Cabinet, I had expected that he would be among them—alas, not on this occasion. I am sure it is only a matter of time. Of course, if the Minister and other Members on the Government side want to keep their phones on in case a call comes through, we will not be offended if they have to pop out for a couple of minutes. I hope the Minister’s rush of blood and damascene conversion to the perils of privatisation at the end of the sitting on Tuesday have not blotted his copybook too much.

I turn to amendment 43, which plays into several points that have come up in the evidence sessions, particularly the anxiety that was mentioned by Sarah Gorton of Unison in her evidence to the Committee last week. She said that she wanted to see in the legislation confirmation of assurances that have been given verbally and in guidance. She referred to conversations that she had had—I am not sure with whom, but I assume with officials in the Department. Those conversations were to the effect that there was

“no intention for any new parts of the system to undermine the collective arrangements”.––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 96, Q129.]

and that the “Agenda for Change” agreement would continue to apply across the board and, indeed, to ICB staff. That is an important matter to seek assurance on. Anyone who has been involved in “Agenda for Change” will know that years of hard, torturous work were involved in getting that agreed. Certainly, on this side, we know the value of the staff and their trade union representatives, and the importance that collective agreements have in bringing issues to the fore and ensuring a universality in treatment and a common understanding of the basis on which the employer and employee move forward.

Of course, whatever the collective agreements say, the staff would like to be offered increases that actually keep pace with the cost of living, rather than the real-terms cuts that we have seen in the last decade. However, as an overall framework for ensuring staff are treated fairly and consistently, it is certainly not something that we want to be chipped away at.

I will not try to persuade the Minister of the benefits of collective agreements across other sectors—it would be well outside the scope of the Bill—but it is worth pointing out that there is plenty of evidence from across the world showing that where workforces have negotiated terms and conditions within sectors and across whole industries, they tend to enjoy better terms and conditions and, crucially, better rates of workplace satisfaction and staff retention. As highlighted in the report recently published by the Health and Social Care Committee, the NHS faces an enormous challenge in retaining its workforce.

We do not want anything to undermine “Agenda for Change”. Sadly, though, we have seen attempts to do that in recent years, with the creation of wholly-owned subsidiary companies. I will not return to the argument about whether those are a good thing, because we have said that they are not, but let us examine for a moment why trusts sometimes seem eager to set these companies up.

There are, of course, huge financial pressures on trusts. I will not rehearse the arguments on that, but they are always looking at ways to reduce their costs, and potentially with these subcos to boost their income. The VAT advantages have been a big part of that, but one of the big concerns—cash-pressed trusts may see this as a big opportunity—is that the subcos potentially have the ability to move away from “Agenda for Change”. That is the heart of it; it is not that the trusts have a major objection to “Agenda for Change”, but moving away from it allows them to set their own terms and conditions, which is really a euphemism for saving money and cutting pay. We think that that kind of approach is a false economy and, ultimately, self-defeating.

There are other examples of where the private sector will step in. We saw the news this week that King’s College Hospital Foundation Trust will transfer staff at its urgent treatment centre in Denmark Hill to Greenbrook Healthcare under a three-year contract, starting in October. Of course, staff will expect TUPE to apply, but, as we know, it is not a panacea. It does not protect terms and conditions for ever more, so it is little wonder that the news of that change has led the workforce to raise concerns.

Unison’s written evidence sought clarification from the Minister that

“it’s not the intention that ICBs depart from Agenda for Change”,

which the Minister gave on Second Reading. The written evidence also states that

“UNISON would support amendments to ensure that ICBs will apply the relevant collective agreements for staff pay, conditions and pensions, and be responsible for ensuring that these are applied within the wider system. In addition, further reassurances should be sought that nothing in the Bill will compromise the assurances already given in the Employment Commitment, the terms of which should endure beyond the point of staff transfer.”

The evidence continues:

“Recently published guidance lists 10 ‘outcome-based people functions’”—

perhaps that phrase could be translated into plain English at some point—

“that ICSs will be expected to deliver from April 2022… In addition, the guidance suggests that the responsibility for engaging with trade unions will rest with the regional teams of NHS England / Improvement rather than with ICBs”.

That runs the risk of depriving unions of access to those who might be making strategic decisions in their area—or perhaps it just speaks to a larger truth about where power will lie in all this. We have covered those concerns in our amendment to some extent, but we would like reassurance from the Minister on some of the points we have raised about how this will all work in practice.

In particular, we need reassurance that the system will not undermine existing provider responsibilities on engaging with trade unions. As hon. Members will know, the vast majority of NHS staff will not be employed in commissioning bodies such as ICBs. The strong relationships with individual provider organisations should be a supplement to existing national and regional partnership forums. The concern is that the new kids on the block, the ICBs, will in some way disrupt those arrangements.

If, as we are told, the new ICSs—to use the correct terminology—will be system leaders themselves, it is not impossible that some of those leaders will want to set their own path in tweaking employment matters. We might see circumstances in which some agreement about staff mobility within ICSs comes to the fore, particularly for those whose duties cross organisational boundaries. In principle, that is no problem, as long as no ICB thinks that, as a result, it can move outside existing collective agreements. Our amendment would rule that out.

It is essential that ICBs have a positive role in all this and that they follow existing practice by referring to collective agreements. We would not want a re-emergence of what we saw some five years ago, with certain trusts trying to undermine collective terms and conditions. Those attempts failed, but we never know when that might re-emerge. We also believe that the ICB should honour national agreements for the staff it employs.

That should not need to be said—as we have heard, assurances have been given—but it needs to be made explicit in the Bill to give us the cast-iron lock that both we and Unison would like. We would certainly like some further assurances about whether the ICBs have the potential to circumvent or destabilise existing arrangements, should they seek to forge their own path at some point. We see this amendment as bolstering the commitment to “Agenda for Change”—I hope that the Minister will confirm that commitment when he responds —so that ICBs’ broad powers are not seen as an attempt to undermine or conflict with the hard-won terms and conditions that have been collectively agreed.

Turning to sub-paragraph (7) in the amendment, which relates to pay limits, hon. Members will have seen headlines in the paper, on Tuesday, I think, about the highest-paid NHS managers being “cleared out”; I think that was the term that was used. I am not quite sure what that means, other than redundancy. The story refers to a Government-inspired audit, which was—at least on Tuesday—going to be led by the then Chief Secretary to the Treasury, the right hon. Member for North East Cambridgeshire (Steve Barclay), who has since moved on to other matters. That is a shame, because he used to hold the same role as the Minister does now, and he would know exactly where to look if there were indeed examples of unnecessary management and bureaucracy in the NHS.

That news follows the headlines we saw last week about some ICB executives potentially receiving salaries of £270,000. Let us be clear what we are talking about here: that is the pay of 10 nurses. It seems that someone somewhere in Government is exercised about the number of managers in the NHS, but according to the King’s Fund, the actual figure is somewhere below 5%, and many of those managers hold dual clinical roles. If the Government think there is a problem here, I am not entirely clear what they think the scale of it is, or what the consequences would be if thousands of managers in the NHS were made redundant. I am sure that was not covered in the impact assessment, but we have the benefit of that now.

To be clear, the amendment is not about bashing managers at all. Every organisation needs managers if it is to be effective, and they play an important role in enabling clinicians to get on and do their jobs on the frontline. I am sure the Minister would not want to leave managers in the NHS with the impression that has unfortunately been left by some of the headlines this week, namely that there is no role for managers in the NHS. One could be forgiven for concluding that from Tuesday’s headlines. If the Government think layers of management, bureaucracy or management costs have got out of control, we can do something about it.

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[Karin Smyth]

I agree, and we will probably all have examples through the primary care networks of practices that were not in old houses but that had perhaps had a LIFT scheme or another new development. In my constituency, the Bridge View Medical practice was able to have a flow through the building and move patients downstairs because it had a large, fairly new building. The pandemic has shown that in an emergency we need to make sure that the community-based estate is brought together in some way. Actually, that applies not just to the health service, but to ex-local authority or even Ministry of Defence or other Government Department estates. The place-based aspect of the Bill should be encouraging people to do that locally. Because estates are not part of it, they will struggle to deliver on the service intent of the Bill.

[Alex Norris]

I am grateful for the opportunity to comment on amendment 17 and the insight that my hon. Friend the Member for Bristol South brings from her long period of working in the NHS. What is at the crux of this point is quite important. We have spoken quite a lot about integrated care and revenue, but the capital component is as important, so I am glad we have the opportunity to discuss it.

I have great affection for the Bulwell Riverside facility in my community, which co-locates two GP surgeries, community services and pharmacy services with local authority neighbourhood services, the local library and youth services. Pre-covid, I and the local councillors would be there every week for an event. Every year, my annual jobs fair is there—it is today, but we are not inside because of covid, so it is out in the marketplace. If any of my constituents are watching, we are there until 2.30 pm.

That joint service centre has driven a culture of integration and collaboration, exactly in the spirit of everything we have been discussing on the Bill. It is a very practical example of integration in practice. It was funded on the LIFT model because, at that point, more than a decade ago, that was the way to get money into the system. The logical consequences on the ground of the legislative direction that we are told is intended here will be more need for this sort of joint service centre model. We need to give that proper consideration.

As my hon. Friend the Member for Bristol South said, this element is one of the few bits of the 2012 Act that is not being removed to take us back to pre-2012 status. Then, primary care trusts could enter into these arrangements locally, whereas their successors, clinical commissioning groups, could not and, at the moment, the successor ICBs cannot either. The amendment would remedy that.

Why is that provision not being added back in? It looks a bit like a wheeze. Originally, PCTs would have had a 40% stake in the arrangements and would have benefited exactly as my hon. Friend said. Now, that stake is owned by community health partnerships. Who owns 100% of community health partnerships? That is the Department of Health and Social Care. It is not that nobody benefits from these arrangements—it is that the Department does, rather than local communities. We are told this Bill is about localisation and devolving resources and powers to local communities, so why on earth is this bit not going back in? It is definitely a point of interest, particularly with existing LIFT models.

On LIFT models, it may be that the Government do not think that they are in vogue now or that they are the right model. I would be interested to hear what other methods the Minister might prefer.

How to get capital back into the system is a significant point. The NHS backlog is now £17 billion, as the bill for austerity becomes due, so we will have to address it by one means or another. If that is not to be done through this system, I am keen to hear from the Minister how it is to be addressed.

Health and Care Bill (Eighth sitting)

Alex Norris Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

Finally, let me turn briefly to clause 17 which, importantly, provides a power to make transfer schemes in preparation for the time when ICBs take on primary care functions, by enabling NHS England to transfer property rights and liabilities to ICBs. The rights and liabilities that can be transferred under the clause include those in relation to a contract of employment, thereby ensuring a smooth transition to the new commissioning arrangements. Without the clause, we would risk the creation of instability for NHS staff and the possibility that ICBs could lack the necessary rights, staff and property effectively to commission primary medical, dental and ophthalmic care. I therefore commend clauses 16 and 17 and schedule 3 to the Committee.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to serve with you in the Chair, Ms Elliott. I wish to speak to amendments 28 and 29, and will also briefly address a couple of brief points relating to the clause.

I am grateful for the Minister’s response—it is handy to know in advance the likely arguments against the amendments. I referred to the amendments late on Tuesday afternoon, with regard to private company involvement in integrated care boards. We are heartened to hear what the Minister said about that and look forward to having those conversations. My original notes said that the amendments go a little further and might be a little rich for the Committee’s blood, and that may well be the case, but they are nevertheless important.

As I said the other day, the vast majority—around 70% —of GP services are provided on the general medical services contracting model, between local and national commissioners and a GP or GPs and their practice. A little more than a quarter of services are on the personal medical services terms, which allow greater local flexibility, although I understand that the intention is to phase them out. There is a small but growing number of APMSs, which we are debating. APMSs allow bespoke contracting with private companies, with no obligation for a GP behind them. The Minister mentioned their being time-limited as an asset; I am not sure that that is necessarily true. Of course, there has to be flexibility for commissioners to meet need, but my argument is that this is being misused and is operating as a loophole for private companies to enter the market and cream off profits in a way that I do not think is generally the direction that service users in the NHS want. Colleagues should not think that, because the model currently provides just over 2.5% of contracts, this is in some way small beer. The largest provider of GP services in this country is wholly owned by a US megacorporation and has 500,000 patients on its books. I do not think that is what our constituents want from their national health service in England, and I do not think that is what they expect it to look like either.

Therefore, it is reasonable to use the Bill to try to do something about it, because this will be the model. It will grow at pace unless it is checked, and there are many reasons to tackle the issue. It is not just because I find the model distasteful, which I do. First, such contracts are poor value for money. For a registered patient, the mean payment to an APMS provider is 11% greater than that to a GMS provider. Of course, the Minister made the argument on Tuesday that such practices often serve the hardest cohorts, so perhaps that could account for the difference, but that is not the case either. When patients are weighted according to need, the mean payment is actually 16% greater on APMS contracts—it gets worse. If we read that across the entire patient list across the country, it would be the equivalent of £1.5 billion. That is the risk, if this grows to be the dominant model. Such contracts also provide less satisfactory care, with a 2017 survey of nearly 1 million patients finding that APMS services generated lower levels of satisfaction.

Finally, the contracts are easier to walk away from. Within the NHS, we already know that when it stops working for private providers corporately, they are willing to just walk away from contracts and hand them straight back. I strongly say to the Minister that such arrangements are a distortion of the health service’s founding principles. They are costly, they are of lesser quality and they are less reliable.

Amendment 28 is designed to stop integrated care boards entering or renewing such contacts, and amendment 29 would do the same for NHS England. I fear that the Minister may have slightly catastrophised the impact of that, because if this was accepted today, there would be GP services that could no longer operate tomorrow. For a start, the Bill has an awful long way to go, and I gently say that if there is anxiety about health organisations working in advance and presupposing that this will become law at some point and will be operational in April, I am afraid that the Government started that a very long time ago and have already started to fill places in shadow. I do not think there should be any anxiety about getting prepared in this way, so that there would not be a cliff edge.

I am willing to take the argument that perhaps there is a better and more elegant way of drafting this, and I would happily accept an amendment in lieu, but what I cannot accept is nothing at all. Again, the Minister’s point on Tuesday was very good, because sometimes there will need to be a way to provide flexibility for very bespoke services. I think the example he used was services for street homeless people. Of course, that might be a very different model from that of the GPs on my estate. I would accept that as a principle, but the corporation that has the biggest patient list, at 500,000, is a bricks-and-mortar primary care service in my community. That is not a use of flexibility; it is using that as a loophole.

I do not think that can be right, and I do not think the answer can be that the provision needs to exist and therefore we must open this space for that sort of distortion. We are either saying, “There needs to be flexibility, and here is the best way of having a flexible system. Don’t worry—we’ll make sure it is not misused,” or we are saying that we are happy with such organisations entering the market. The Government need to say which one is their preference.

I will make a point about primary care networks before I move on to clause stand part. Obviously, primary care networks are not in the Bill, but I put quite a lot of stock in them. I think that, locally, they will be a very important unit of organisation of care services in our community. I want them to work, and I am playing an active role in the primary care network in my constituency. I think they have real potential. However, who will lead them if we lose our GP practices to those who do not have an interest in our community? The model will become much more distant and uninterested, based on finances rather than the local population. I believe that would be a very, very bad thing indeed. As I say, the amendments may not offer the best way to close that loophole, but I have not heard a better one, or indeed a desire to close it, so I wish to press the amendments to a Division.

Finally, a couple of quick points on schedule 3, which we do not intend to press to a Division. We have had quite a lot of discussion—the Minister touched on this in the previous stand part debate—about the arrangement of integrated care systems, such as they exist. At the moment, we know that NHS England holds certain responsibilities, the regional teams hold certain responsibilities and CCGs hold certain responsibilities at a local level. It is possible, after these reforms, that CCGs will be replaced by ICBs and the previous arrangements and responsibilities will remain unchanged, with NHS England nationally doing the same things, the regional teams doing the same things and ICBs picking up the responsibilities of their predecessors. I suspect, however, that that is not the intention, so I want to press the Minister a little bit on that.

The explanatory notes, on page 59, paragraph 286, state that the functions relating to medical, dental and ophthalmic primary care sit with NHS England, but that

“The intention is that Integrated Care Boards will hold the majority of these functions…in the future.”

Will the Minister expand on that? Does a “majority” mean two out of the three in a different area? Does he intend—again, we touched on this the other day—that this should all be devolved to the 42 ICBs at the same time, or will there be a sense of when each system is ready to pick up those important services? If so, what criteria will that be based on?

Finally, in case we do not come back to this topic—I do not expect the Minister to have an exhaustive list to hand—what is the thinking on other NHS England national and regional functions? Are they likely to be devolved to ICBs? Can he give an example of what sorts of things might be retained? He mentioned that we would want to retain specialist commissioning at a national level. The final question is this: is it ICB by default unless there is a very good reason why it cannot and therefore it has to be done at a national level, or is it at a national level unless it is proven that ICBs are competent to take it on? The answer may be a bit of a mixed economy, but if that is the case, I am keen to know what criteria he will use, or the Secretary of State will use, to make those decisions.

[Karin Smyth]

I rise to support my hon. Friend the Member for Nottingham North, who made an excellent case for amendments 28 and 29. While on a primary care trust board, I commissioned APMS contracts under a previous magnificent Government—I am not saying this one’s not magnificent, but—because they offered flexibility. Then, as now, they were a sign of a failure of the system and the model of primary care contracting to deliver, particularly in areas of high deprivation. To provide flexibility in Bristol, for example, we had an 8 am to 8 pm service in the city centre to allow better access for people in the city centre, partly to drive down demand on emergency care services, which is a circle that we just keep on going round. Whether they worked or not is a bit of moot point, but it is a model and it is clear that something is needed—I would certainly concede that—so I understand the Government’s difficulty here with having something that is flexible.

I was slightly concerned when the Minister said that the APMS model would be developed further. I wonder if he wants to come back on that. We have to accept that they are problematic at the moment and we would like to see them go because of that. They are now being used as a back door, a very unfortunate one, for large private companies to start hoovering up general practices, which is, yet again, a sign of failure as to why they cannot survive in their environment. If they are going to be developed further, that is something we would like to hear more about. If not now, perhaps the Minister responsible could come back to us on that. Patients are always surprised when they find out that their GP is a private contractor. I accept that this is a difficult area to be completely black and white on. We are certainly in favour of flexibility in developing services in areas of high demand where, for reasons around capital or the type of contract, a GP might enter into partnerships. We know that the workforce is changing rapidly and the model of partnerships is not as attractive and is not recruiting people into the service. It is—not to overuse the word—a crisis.

I am sure we have all been contacted by various bodies representing GPs in our own constituencies. They are fearful not just about the current pressures, but the future attractiveness of primary care. We are not going to get into the future model of the contract today, but I always pity the poor Minister who has to negotiate the contract.

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[Chris Skidmore]

The amendments would place a legal duty on integrated care boards to support and promote the use and development of research in their local health and care systems. The existing legislation talks about the health system; this is the Health and Care Bill, so it makes sense that the duty to promote research should also promote research in care settings.

Importantly, amendment 7 would promote and support the conduct of research alongside universities, which drive research outputs and innovation in healthcare. We would all agree that that has been highlighted throughout the pandemic: if it was not for our universities, we would not have all received a vaccine, in respect of which the United Kingdom has been at the forefront of research and innovation.

In the specific context of the Bill, it is important to require ICBs to engage with universities and other research settings on the development of the healthcare research workforce. ICBs will have a vital role in ensuring that we have sufficient numbers in not only the health workforce but the healthcare academic workforce, which is key to overall healthcare workforce sustainability. That is particularly important for the development of the clinical academic workforce. Clinical academics work in higher education institutions, conducting cutting-edge research and educating the future workforce while also providing clinical expertise to health and social care services. Because they remain clinically active, their research is grounded in clinical practice and questions that matter to services and patients.

Data from the Medical Schools Council staffing survey shows that although the total number of NHS medical consultants and GPs has risen by 40% over the past 15 years, the numbers of clinical academic have simply not kept up to pace—in fact, they have decreased, from 7.5% to 4.2% of the workforce. The proportion of clinical academic GPs has remained stable, but at just 0.4% of the GP workforce. Furthermore, less than 0.1% of the workforce in nursing, midwifery and the allied health professions are clinical academics. Increasing clinical academic capacity is essential to advancing evidence-informed practice and innovation in healthcare in the future. The point here is that expansion of the healthcare programme of student numbers on the UK Government’s intended scale also requires an expansion of the number of healthcare academic staff.

The 2019 academic staffing centres of the Council of Deans of Health identify challenges for universities in recruiting staff and an ageing academic workforce in healthcare subjects. In England, 36% of academic staff are over the age of 50, and 9% are over the age of 60. That suggests that the academic workforce is significantly older than the healthcare workforce as a whole. It suggests that, within the next 15 years, almost half of the academic staff will be at or near retiring age, with many already likely to have retired. Without significant renewal of the academic healthcare workforce, not enough staff will be left to keep up with the number of students.

It is key that senior leaders in both the higher education and the healthcare sectors cultivate a culture of support for clinical academics. ICBs, health and social care providers and universities need to work in partnership to support clinical academics and clinical staff interested in secondments or joint appointments to universities. There should be opportunities for clinical staff to obtain experience and skills in teaching and also in research.

Amendment 7 ensures that ICBs remember their responsibilities to research, to local research priorities and to developing a local clinical academic research workforce, and universities are vitally involved in that important work. I think I am the only Member of this House who has been both a Health Minister and a Universities Minister twice. When I went into the Department of Health and Social Care, we were talking about integration between healthcare settings and social care settings. We have a similar problem with integration when it comes to looking at the medical workforce and ensuring that the education settings and the healthcare settings also integrate better together.

Amendment 8 returns to this point. It would require integrated health and care boards to work with universities to promote education and training in their local health and care systems. Universities are committed to co-creating healthcare services through working with practice partners, further education colleges and other stakeholders to plan and deliver the future workforce. I know that, when we come to clause 33, we will be talking about workforce planning at length, but this amendment would help to enable us to plan in advance to mitigate some of the problems that come with workforce planning for the future.

Universities are rooted in their local and regional communities and focus on improving healthcare outcomes and driving up economic and social wellbeing through providing programmes to meet skills gaps in those local areas. This is highlighted through the work of the universities during the pandemic, including the University of the West of England in my own locality hosting a Nightingale hospital, and the deployment of thousands of healthcare and medical students and some academic staff within clinical practice to expand the NHS workforce at the height of the pandemic. We all want to pay tribute to those medical students who, with no extra salary, gave up their time to volunteer to help staff on some of those covid wards at the time.

In England, universities currently sit on local workforce action boards and on sustainability and transformation partnerships to ensure that education is central to local healthcare planning. The amendment ensures that universities and colleges continue to be actively engaged by ICBs to plan and deliver on local workforce needs and priorities to ensure a sustainable workforce. This should take place alongside continued work with Health Education England.

Healthcare programmes are holistic and necessarily constituted of theory and practice components. For example, a registered nursing programme consists of 4,600 hours of education across three years—2,300 hours of academic learning and 2,300 hours of theory learning. Universities and their practice placement partners need to be involved in national and local workforce planning to ensure that there is adequate placement capacity in the system. As I saw when I was a Health Minister, placement capacity has long been recognised as a constraint to sector growth. Even if the hospitals wanted to expand, they did not have the placements to be able to deliver on the demand that was there.

ICBs must be involved in developing placement capacity and innovation and work with partners to increase placement opportunities outside the NHS, including in private healthcare, the third sector, social care, research and teaching, and international exchange. ICBs also need to work with education providers to think about developing education placements to support digital innovation and online and blended delivery, particularly considering the learning we have from the pandemic. That will help to support higher education institutions to manage the continued challenges posed by placement capacity problems, considering health service pressures.

Requiring ICBs to work with universities and colleges is also key to ensuring the success of healthcare apprenticeships and new technical qualifications such as T-levels. Universities work in close collaboration with local employers to develop and deliver healthcare apprenticeships. They are also committed to ensuring smooth articulation between further education and higher education, and universities are working with colleges to ensure that the healthcare T-levels and the new higher technical qualifications are rolled out successfully.

The amendment would ensure that the planning of future workforce numbers and sufficient placement capacity for all learner routes must be developed in partnership with education providers. That is crucial.

[Alex Norris]

I congratulate the right hon. Gentleman on his amendments and the case he made for them. I hope that he remembers with fondness his visit to the University of Nottingham and Nottingham Trent University when he was Universities Minister. He will have seen then the significant role that they play in our community, and I think they provide a good model for some of the things that we are talking about. I hope the Minister will address the points about clinical academics in particular. They were very well made, and I thought the right hon. Member for Kingswood also provided the basis for what will be a really interesting discussion on clause 33.

What attracts me to amendment 7 is that it is really important to send a signal to the leaders of integrated care boards that we want research to be central to their mission, as NHS Providers said in its evidence, and that we do not see them solely as administrators of health and care spending on a day-to-day basis, who every winter have to engage in collective crisis management to keep the lights on. We have much broader horizons in mind for them. If this is about new and enhanced models of more integrated care, we have to harness the expertise of academia. Hopefully, if this was effective and worked as a two-way process, with academics learning from inside the system and the systems learning from best practice from around the different footprints, that would be really powerful.

That relates neatly to the point about inequalities, from the beginning of our line-by-line consideration. The argument in favour of making that a priority was not about some sort of quixotic search for solutions or saying that something must be done, so let us just do something; rather, it is about taking evidence-based, high-quality interventions that work and putting them to work elsewhere. The sort of insights that amendment 7 proposes would certainly do that.

When I read amendment 8, my first instinct was, “I wish I had tabled it,” because I think it is great. We want to foster a culture where we invest in and develop our people. That is true whatever someone’s role is in the health and care service. Of course, that is really important in the NHS, and we all have a clear picture of what that looks like, but it is even more important in social care. We undervalue the role of social care in so many aspects, obviously and most tangibly in pay and conditions, but we also do not invest in people. Imagine how much more attractive a career in care would become if someone’s training prospects went beyond the limited ones offered by whoever their employer happens to be and instead a wealth of other opportunities and courses backed by top higher education providers in their community was opened up.

My family’s life was transformed by the impact that night school had on my mum’s skills. She progressed from being an unqualified person working in childcare and turned that from a job into a career. That was completely transformative, not just for her life but for mine and my sister’s. How terrific would that sort of picture be for people entering the care profession. It would be a wonderful thing. So there is a lot to go at here, and I am very interested in hearing the Minister’s views on how we can try to foster that culture, if not through amendments 7 and 8.

[Dr James Davies (Vale of Clwyd) (Con)]

I rise to speak in support of the agenda raised by my right hon. Friend the Member for Kingswood in his amendments 7 and 8 and the need for integrated care systems to ensure that NHS organisations for which they are responsible conduct and resource clinical research.

I think all would agree that the UK life sciences sector is world-leading. That was evidenced during the pandemic by the way in which early PCR testing was brought forward for covid, by the recovery trial and by vaccine development and so on. In this country, however, the location of existing activity is all too often limited. We have world-renowned centres of excellence, often associated with teaching hospitals. I would do nothing to weaken that. The Government’s levelling-up agenda needs to extend involvement in such activity across the country. But at the same time, it can strengthen what Britain has to offer to patients and the world as a whole, bringing economic benefit to the country as well as to the NHS through increased income.

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[Chris Skidmore]

I thank the Minister for his considered comments on these amendments. They are probing amendments, and I do not intend to press them to a vote. I hope, however, that the Department will consider not only the discussion that we have had in Committee today, but a letter that was sent to the Minister’s office on 14 September from Universities UK, the Medical Schools Council and the Council of Deans of Health, which have all signalled their support for a form of words in an amendment that recognises the potential difficulties about placement planning and the opportunities represented by putting measures in the Bill about ICBs demonstrating integrated working.

I have been in Bill Committees before—I am now legislating to take out a lot of what I legislated for 10 years ago, when I was dealing with what became the Health and Social Care Act 2012. These Bills do not come around very often, so we have a fantastic opportunity, as the oral evidence sessions demonstrated, and I fully appreciate it. I have removed and re-tabled one of my amendments, to clause 33, as a result of the feedback from the oral evidence sessions.

There is a tension about how prescriptive we should be when the very culture of the Bill is about locally led practice and delivery and ensuring that we give health service managers and clinicians the opportunity to decide what is best for their local areas, so I do appreciate that prescription here may be unnecessary, but I felt it was important that I raised this as an opportunity to make a change in the Bill.

When it comes to clause stand part, I would like to speak more generally on clause 19 about the value of research, which my hon. Friend the Member for Vale of Clwyd has spoken about. I think we have an opportunity—it is one that I do not want to miss—when it comes to embedding research within the future of the NHS. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Alex Norris]

I beg to move amendment 46, in clause 19, page 25, line 37, at end insert—

“14Z58A Power of the Domestic Abuse Commissioner to obtain information

(1) The Domestic Abuse Commissioner may require an integrated care board to provide the Domestic Abuse Commissioner with information.

(2) The information must be provided in such form, and at such time or within such period, as the Domestic Abuse Commissioner may require.”

This amendment places a requirement on Integrated Care Boards to share information with the Domestic Abuse Commissioner at their request.

This is the first of a couple of amendments relating to domestic abuse. I hope it is not necessary, but it is my best avenue for establishing a point. I am really hoping for a one-word answer from the Minister—in my experience, a one-word answer is better than a two-word answer—and I hope that we can make quick progress with the amendment.

In England and Wales, the Domestic Abuse Act 2021 created the post of Domestic Abuse Commissioner, who is in the vanguard of holding to account authorities and agencies to ensure that their process and plans promote our national attempts to tackle domestic abuse. Currently, the post is filled by the excellent Nicole Jacobs. She has the power to obtain information from public bodies such as the local police, the local council and the Care Quality Commission, so that she can express her views as to whether those organisations are acting in line with well-evidenced best practice in the decisions that they take. That is an important way in which we can be assured that public policy decisions on the ground from day to day reflect the national consensus on what we are trying to achieve.

Currently, NHS bodies are in scope of the commissioner’s powers, and I want to clarify that ICBs and any relevant sub-committee would also be in scope. The composition of the boards will not matter, and there will be no shielding behind commercial confidentiality. The body will sit consistently with other, similar bodies, and the commissioner will be able to get the information she needs to do the job that we have asked of her.

[Edward Argar]

I am grateful to the hon. Gentleman, and I share his view that it is crucial that integrated care boards co-operate with the Domestic Abuse Commissioner. I think I speak for the whole Committee when I say that we agree that the health and social care system has a crucial role in preventing and tackling domestic abuse, and in supporting victims who experience this horrendous crime. Indeed, before the last reshuffle, when I moved from Justice to Health, I was one of the Ministers working with the Under-Secretary of State for the Home Department, my hon. Friend the Member for Louth and Horncastle (Victoria Atkins), on the genesis of what is now the Domestic Abuse Act. Therefore, we wholeheartedly welcome the introduction of the Domestic Abuse Commissioner’s role in the Act.

The commissioner has a vital role to play in monitoring the response to domestic abuse, sharing best practice and challenging bodies, including in health and social care, to go further and to do more. The commissioner will require information, support and co-operation from integrated care boards as well as a range of other public bodies. That is why the Domestic Abuse Act contains a duty to co-operate with the Domestic Abuse Commissioner, and we have made it clear that that will apply to integrated care boards and their component parts. It will also apply to requests for information from the commissioner. That is a little more than one word, but I hope I have reassured the hon. Member for Nottingham North that there is already such provision, as there should be. I hope that he will feel able to withdraw his amendment.

More broadly, the Department for Health and Social Care will be taking steps to ensure that integrated care boards also have the right guidance and support to ensure that they fulfil their duties in relation to domestic abuse, as well as violence against women and girls, and sexual violence more broadly. We will be following the Government’s recent violence against women and girls strategy by engaging with current ICSs, the wider sector and the commissioner, so that we identify best practice and share that guidance across the system to ensure that all parts of the system play their part.

[Alex Norris]

I am grateful for that answer and clarification. On that basis, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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

[Edward Argar]

This clause inserts 31 new sections into the NHS Act 2006. It is the cornerstone of the integrated care board provisions, as it sets out the functions and duties that ICBs are required by legislation to fulfil. Clause 19 contains a number of provisions and duties in respect of ICBs. Given the importance of these provisions in the Bill, I will take Members through them, if they will forgive me, in a little detail.

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It is also important that every partnership recognises that children are not a homogenous group and have distinct needs at different ages. Strategies should also take into account the needs of children across the age range. Above all, it is crucial that there is a clear vision for children’s health in every integrated care partnership to ensure that children are prioritised and not forgotten about during the move to statutory ICSs.

[Alex Norris]

I am grateful to the hon. Member for Eddisbury for tabling the amendments and to the hon. Member for Vale of Clwyd for stepping in to give the Committee a chance to discuss them. I agree completely with what he said about the Bill being a real opportunity on child health in this country and I hope that we can take it.

We should be saddened by what Barnardo’s said in its written evidence:

“Children growing up in England…face some of the worst health outcomes in Europe”—

particularly those growing up in poverty. That is really saddening, not least because even prior to the pandemic, according to Action for Children, over 4 million children were living in poverty, including a staggering, breathtakingly sad 46% of children in black and minority ethnic groups. We must seek to do better. These things should stop us in our tracks, given the wealth that we as a country have, the technologies we have, the schooling we have and the assets we have, yet we cannot give our young people, particularly the poorest children, the best start in life. That is really sad.

The only enhancement that I would make to the amendments is that, rather than making them about ages nought to 25, I would extend the range to include the six months prior to birth, because we know how important those services are. I hope, in that spirit, that we may hear some enthusiasm from the Minister and his Government about implementing all the recommendations of the Leadsom review. I know that it will be hard, because it will involve acknowledging some dreadful decisions over the past decade, such as the reduction in Sure Start but, nevertheless, that report has real potential to be the bedrock for a return to something much closer to proper early intervention in this country. We might not have the saddening and completely avoidable outcomes that we have, so I hope that we hear some good news from the Minister on that.

[Edward Argar]

I am grateful to my hon. Friend the Member—I cannot pronounce that—and to my hon. Friend the Member for Eddisbury, on whose behalf my hon. Friend for Vale of Clwyd spoke. I also wish to put on the record my gratitude to Lord Farmer and his team for the work that they have been doing in this space. I have had the pleasure of meeting them, and—to reassure the shadow Minister—I have already met once, or possibly twice, with my right hon. Friend the Member for South Northamptonshire (Dame Andrea Leadsom) to discuss her review. I know that my hon. Friend the Member for Bury St Edmunds has also worked with her on it, and we continue to work together to try to find ways to move that forward.

I hope that all Members agree that the creation of integrated care boards and ICPs represents a significant opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people. We acknowledge that these amendments understandably intend to ensure that the needs of children and young people aged 0 to 25 are represented on the ICP and are considered by the ICP when developing its strategy. While we entirely agree with the intentions behind the amendments, we come back to the point that we wish to provide local areas with the flexibility to determine what will work best for their systems, their priorities and how they develop their plans and membership. Overly prescriptive approaches in the Bill would risk making it harder for systems to design the approaches that will work best in their area.

Turning to amendment 54, we would not want ICPs to create plans for children disconnected from the wider healthcare system. We know that the very best systems consider how their health systems are meeting everyone’s need, including where there are transitions between different stages of life. However, I do hope that I can provide some further comfort for my hon. Friend the Member for Vale of Clwyd. We are working on bespoke guidance for babies, children and young people, which will set out clearly how ICBs and ICPs are obliged to deliver for them. This will cover the importance of the ICB forward plan and the ICP strategy and how they can set clear objectives for babies, children and young people. The Department is working closely on the drafting of this guidance with NHS England, the Department for Education and, indeed the relevant Minister, my hon. Friend the Member for Chelmsford (Vicky Ford)—I presume that she is still the relevant Minister as we speak. We will also be working with all stakeholders, including the National Children’s Bureau, in the coming months. I suspect that this is a theme and an issue that we will return to at various points both in Committee and indeed in the further passage of this legislation.

I hope that I can reassure my hon. Friend the Member for Vale of Clwyd on this matter. I entirely understand where he is coming from, but ask that, on this occasion, he does not press his amendment—or the amendment of my hon. Friend the Member for Eddisbury—to a vote.

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There are wider questions about ICPs, which are set out in clause 20. How are they performance-managed? How do they run? Will there be funding for them to ensure that they can discharge their functions effectively? Presumably, they cannot provide other services, but will the Minister confirm that? Will they be able to form their own bodies themselves? There is plenty more where we need some meat on the bones. I hope the Minister will be able to provide that when he responds to our amendment.

[Alex Norris]

Amendment 83 builds on my hon. Friend’s argument about creating some balance between the integrated care partnership and the integrated care board, so I will not repeat it. I simply underscore the fact that the ICPs have the money, power and accountability at the moment, but there is a risk that they become a closed shop and not bodies about integration at all.

We are told that integrated care partnerships will be the way in which the broader health and care family and the community will come together as they lead and play a pivotal role. We need a safeguard in the Bill to ensure what we would do if the relationship breaks down. The amendment is a version of what Sir Robert Francis from Healthwatch said about one possible way in an evidence session. I am not prescriptive about this, but I am keen to hear what the Minister might suggest to give us comfort on this. If the ICPs are to function as promised, their plans ought to have some sort of status, so that if the integrated care board chooses to diverge, it must make a public statement that it is going to within 30 days and then publish its reasons with evidence within 60 days.

There is an equivalent provision in NHS England for responsibilities held at a national level. If nothing else, this is basic accountability. It does not restrict any activity, so there is no risk in it. Even if a partnership does not like the decision made or value the reasons given, it cannot remove the chair of the board. Although the constitution has already prevented that, at least we will know what has happened, so the safeguard is quite modest. There is a blizzard of different ways to do it, but I hope that we can have some comfort on ensuring a balance between the partnership and the board, if not at this stage, then by the time we come back on Report.

[Karin Smyth]

Will the Minister share with us what he thinks the difference is between ICPs and health and wellbeing boards?

Health and Care Bill (Ninth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 21st September 2021 Public Bill Committees

[Edward Argar]

NHS England and NHS Improvement, comprised of Monitor and the NHS Trust Development Authority—the TDA—requested the primary legislative changes to support the merger of their organisations, and these clauses are fundamental to fulfilling that ambition. In recent years, NHS England and Monitor, as part of NHS Improvement, have been working closely together with a view to acting as a single organisation with a single operating model. They already have aligned board and committee arrangements and joint senior executive appointments through the joint working programme. Despite the progress made, there are limits to the extent to which they can collaborate under the current statutory framework.

Establishing a single statutory body responsible for the health care system in England has several clear benefits. First, it will create a more joined-up approach across the NHS to provide national leadership and speak with one voice to set clear and consistent expectations for providers, commissioners and local health systems. Secondly, it brings services, support and improvement under a single regulatory and legislative framework. That will deliver improved care for patients, enabling better use of collective resources, removing unnecessary duplication and ultimately making better use of public money. The merger will provide clearer lines of accountability so that the public can be assured that any service they use meets the same requirements around safety and quality.

[Alex Norris (Nottingham North) (Lab/Co-op)]

One of the problems that we have found in Nottingham around driving integration was the duplication of lots of different regulators and metrics, which meant that organisations were often working to different purposes. This obviously tidies that up a bit in terms of regulators. Does the Minister envisage going further in the future?

[Edward Argar]

I am grateful to the shadow Minister for that question, which reminds me of some of the questions that he used to ask me in this room about what the future held when we discussed delegated legislation. I am always cautious not to predict the future, but hopefully it will be helpful if I set out the principles that I think should apply. I agree that unnecessary duplication that does not bring clear and tangible benefits to patient safety or improve outcomes is clearly undesirable. Therefore we will seek to streamline where appropriate, but without compromising patient safety or the outcomes that patients experience. While not predicting the future, I hope that gives him some reassurance of the direction of travel as I see it.

Clause 26, along with other provisions in the Bill, including clause 29, makes the legal changes necessary to bring these organisations together as one legal entity. Clause 26 abolishes Monitor and introduces schedule 5, which contains amendments that transfer Monitor’s functions to NHS England in order to fulfil the Bill’s intention to merge Monitor and the NHS TDA into NHS England to form a single body. The schedule transfers powers and duties from Monitor to NHS England and repeals provisions that are no longer necessary in the light of the merger. For example, Monitor’s functions in relation to NHS foundation trust mergers and acquisitions in sections 56 and 56(a) of the 2006 Act, and in relation to licensing providers in sections 81 to 114 of the Health and Social Care Act 2012, will all transfer to NHS England.

We acknowledge that bringing together the commissioning functions previously exercised by the NHS commissioning board, and the regulatory functions previously exercised by Monitor, under a single organisation could be perceived as giving rise to conflicts of interest. The Bill will therefore ensure the proper management of any such conflicts, and we will work with stakeholders on robust processes that will safeguard the separation of responsibilities and improve transparency. For those reasons, clause 27 seeks to insert new section 13SA, which deals with minimising conflicts between the body’s regulatory and other functions, into the National Health Service Act 2006.

The clause places a duty on NHS England to minimise the risk of conflict or manage any conflicts that arise between its regulatory functions and other functions. In the event that a conflict were to occur, NHS England would be under a duty to resolve or manage that conflict and to ensure appropriate transparency. NHS England must include within its annual report details of such conflicts and how it had complied with its duties to manage them under new section 13SA of the 2006 Act.

Clause 28 amends section 100 of the Health and Social Care Act 2012, which relates to the modification of licence conditions for providers. Licences are the basis by which NHS Improvement and, in future, NHS England set conditions on providers as to the terms on which they can operate. The clause requires that when NHS England makes a major change to the standard licence conditions, as permitted under section 100 of the 2012 Act, it must assess the likely impact of the change or publish a statement explaining why such an assessment is not needed.

The clause also provides that the impact assessment carried out by NHS England must be included in the notice of the modification that is sent to the relevant licence holder and others, as required by section 100(2) of the 2012 Act. This new requirement is intended to make it clearer why NHS England is altering a standard licence condition, which we think is in the interests of providers and the smooth running of the system.

Clause 29 abolishes the NHS TDA and works in harmony with clause 26, which abolishes Monitor and other provisions in the Bill that confer functions on NHS England in relation to providers, in order to merge the two organisations into NHS England to form a single body. In transferring functions that were formerly delegated to the TDA, we have considered the mechanisms and processes associated with those duties and assessed the best fit for the system, to ensure that the relationships already in place are not unduly affected. Clause 29 revokes the directions that established the TDA, and subsections (3) and (4) include consequential amendments that remove references to the TDA. They will no longer be relevant once the TDA is abolished.

Clause 30 makes a consequential amendment to NHS England’s general functions to reflect its oversight of NHS trusts and foundation trusts due to the merger of NHS England and NHS Improvement. The clause ensures a joined-up approach to decision making, allowing NHS England to understand the services required to best serve patients. It amends section 1H of the National Health Service Act 2006 so that for the purpose of discharging its duty to promote a comprehensive health service in England, NHS England must exercise its functions in relation to English NHS trusts and foundation trusts, as well as in relation to ICBs, which will replace the current reference to CCGs, so that services are provided for that purpose.

As part of the merger of NHS England, Monitor and the NHS TDA, and as a consequence of the abolition of Monitor and the NHS Trust Development Authority, clause 31 gives the Secretary of State the power to make schemes to transfer the staff, property, rights and liabilities from Monitor and the TDA to NHS England. These transfer scheme provisions follow a similar protocol used within the Health and Social Care Act 2012 for the transfer of assets, rights or liabilities on the abolition of the National Institute for Clinical Excellence and the Health and Social Care Information Centre. The transfer schemes used then proved effective and efficient, ensuring a smooth transition and no impact on the services they delivered.

Finally, clause 32 contains a regulation-making power that allows the Treasury to vary the way in which any relevant tax has effect in relation to the transfer scheme. Regulations made under this power can be used to ensure that no taxes arise, and that there are no changes to the tax positions of either the transferee or transferor body. It is appropriate to avoid unnecessary tax complications relating to a transfer scheme between public bodies. The types of taxes that can be varied are set out in the clause.

Without this clause, the transfer of assets or liabilities between the bodies mentioned in clause 31—namely Monitor, NHS Trust Development Authority and NHS England—could give rise to unintended tax liabilities. As I have highlighted, this merger has clear benefits and is central to the Government’s plans for establishing a more integrated, responsive and accountable health and care system.

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[Hywel Williams (Arfon) (PC)]

I beg to move amendment 85, in clause 33, page 40, line 11, at end insert—

‘(3) The Secretary of State must consult the Welsh Ministers before the functions in this section are exercised.”

This amendment would require the Secretary of State for Health and Social Care to consult the Welsh Government before the functions on workforce assessments in this clause are exercised.

I will be brief, given that much of what I would otherwise have said has been covered in the debate on the previous group of amendments. I will just say to those on the Front Benches, in their discussion of the genesis of the NHS, that success has many parents. Aneurin Bevan of Tredegar was the father of the NHS, based on his experience of the provision of health in that area, but it was also based on the foundation that was set up by my predecessor but three as Member for Caernarfon, David Lloyd George.

Having got that out of way, the amendment would place a duty to consult the Welsh Government on workforce assessments. Although the amendment is a probing one, I am concerned that the devolution settlement remains somewhat complicated and sometimes unclear, even in its current iteration. As a piece of history and a reference to how that settlement can cloud matters, I will mention a question I asked a former Labour Secretary of State for Health, Mr Alan Milburn, some years ago about nurses’ pay. His response, which I committed to my memory, was “It is one of the abiding joys of my life that I have no responsibility for things Welsh.” Unfortunately for both Wales and him, he actually had responsibility for nurses’ pay at that time. Even Secretaries of State are not perfect, let alone Ministers of State and others. That situation has now been resolved.

The danger is always that the remaining integration of parts of the Welsh health service and health service in England might be overlooked. I referred to that earlier in respect of services and people from Wales—and people from England, for that matter—accessing health services on the other side of the border. People in north Wales specifically will recognise the names of individual hospitals in England. I refer briefly to Alder Hey on the Wirral, which provides services to children with severe conditions. There is the Royal Liverpool; the Christie in Manchester, which provides specialist cancer treatment; and the hospital in Gobowen, which has for a long time provided orthopaedic services. Recently, severe casualties and people who have suffered road traffic accidents have been helicoptered to Stoke for specialist treatment. As I said the other day, around 13,500 Welsh people access GP services in England, and 21,000 or so people from England access GP services in Wales. Those are the 2019 figures.

The workforce-training and education aspects of cross-border arrangements must be considered because staff are mobile. People from Wales access training in England and then return to Wales, and it works the other way around as well. In my own constituency specifically, the school of nursing at Bangor University has for a number of years trained nurses from all over the UK and elsewhere. We are now establishing a medical school that will certainly be training doctors who will return to Scotland, England or Northern Ireland.

The other positive opportunity that proper workforce planning would present the health service throughout the UK is in the specialisms that we hope to develop in Wales—particularly in my area of north Wales. Those specialisms include, for example, treating injuries arising from accidents on our coasts and mountains, for which we already have some specialism. There are also particular issues around mental health and multilingualism, particularly in talking therapies and work with children and older people.

There are opportunities for people who might be trained in Wales before going over to England, and vice versa. For the reasons that I have outlined, I think it essential that those matters be taken into consideration in workforce planning.

[Alex Norris]

It is a pleasure to serve with you in the Chair once again, Mrs Murray, and to follow the thoughtful contribution by the hon. Member for Arfon.

The hon. Gentleman’s points about interdependency are important. Of course, we cherish and build on the devolved settlement, but we understand that we still have important relationships, not least at our borders. I thought that his point about specialised care was a thoughtful one, too: we know that as conditions or treatments become complex, there will be specialisations, and we would never want artificial barriers to get in the way of people accessing specialised care. His point about training was also good and jumped out to me.

Yesterday, I spoke to a surgeon in my community who took great pride in working in the hospital where he was born. In between, he had gone away; I am told that there are parts of the world other than Nottingham—I dispute that fact—and he wanted to go and see some of them. That will inevitably involve crossing borders, and it is important that that is reflected in the Bill. That will happen from nation to nation, but in the future it will happen from integrated care system to integrated care system. Where there is divergence, we need to be thoughtful of it.

The statement of values relating to cross-border care said:

“no treatment will be refused or delayed due to uncertainty or ambiguity as to which body is responsible for funding an individual’s healthcare provision.”

That is an important principle because it sets out that it is the job of the system rather than the individual to understand and navigate the separation between different bodies that may diverge but which work together in common purpose. That is easy to say, but hard to do at times. As I say, that is something that we will see between integrated care systems in time, too. That is true for patients, but also for staff, whether those staff work in Wales but live in England or vice versa, and for the important interrelationships between border integrated care systems on the Welsh border and the NHS in Wales.

There will be devolved and separate competencies between those bodies, but the human beings who make those systems go live side by side in communities, sometimes even next door to each other. A decision taken in one place, of course, impacts on everybody; we see that a lot in social care. Local authorities are under so much pressure at the moment, both in the resources that they have to fund social care and finding individuals to staff that care. There could be price wars at the borders that mean that individuals move between organisations more frequently than they would in a system that was better planned. We have to be mindful of that.

During the evidence sessions, we heard about the safe staffing legislation for nurses in Wales. That is the sort of thing that would already impact on border CCGs, and will do on integrated care systems in due course. That will only grow as the considerable workforce pressures that we discussed in the previous debate bite down even harder. Again, we must be mindful of that. It is crucial that there is a collective approach—a minimum approach—where the NHSs in neighbouring nations have due regard to each other. If the workforce becomes a zero-sum game, we will all lose in the long term.

I was heartened in those proceedings to hear about the contact between the Minister and his colleagues in Wales. I know that he takes matters seriously in Wales and across the United Kingdom, which is good. We might hear more about how that works with regard to the work- force. In the meantime, we support the inclusion of this measure in the Bill and the fact that it will be a priority.

[Edward Argar]

I am grateful to the hon. Member for Arfon. Although I represent an east midlands constituency, in sunny Leicestershire—the hon. Member for Nottingham North would argue that Nottinghamshire is sunnier—I have a huge affection for Wales. In every speech he gives, the hon. Member for Arfon brings to the fore his pride in Wales and his constituency. In the vein of highlighting successful politicians representing Welsh constituencies, I take this opportunity to put on the record a tribute to my former Parliamentary Private Secretary, my hon. Friend the Member for Ynys Môn, who has become the PPS to the Secretary of State for Wales. I congratulate her on that appointment. It is well deserved; she has looked after me very well during her time in this House. I am grateful to her and put my congratulations to her on the record.

I am grateful to the hon. Gentleman for bringing the amendment before the Committee. It would require the Secretary of State to consult Welsh Ministers before the functions contained in clause 33 were exercised. Clause 33 would insert proposed new section 1GA into the National Health Service Act 2006, which, as we have just debated, would require the Secretary of State to publish, at least once every five years, a report describing the system in place for assessing and meeting workforce needs of the health service in England.

The shadow Minister, the hon. Member for Nottingham North, alluded to a point regularly made to me by my hon. Friend the Member for Vale of Clwyd. Although politicians and people in this House might see neat administrative boundaries drawn on a map, the reality is often much more complex. Certainly, those boundaries should not be seen in their everyday lives by constituents and others, who on occasions rightly need to exercise their right to access specialist services in England; I dare say there will be occasions where the counterpoint is true, and people living on the English side of the border may access health services on the Welsh side. We need to recognise that and work pragmatically with that reality.

Although in many other areas of the Bill we will work closely alongside the devolved Administrations, we do not agree that there is a formal need to impose an obligation in the legislation to consult Welsh Ministers before the Secretary of State exercises the specific power in proposed new section 1GA. I will turn to how we work with the Welsh Government in a moment.

Health and Care Bill (Tenth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 21st September 2021 Public Bill Committees

[The Minister for Health (Edward Argar)]

As I said this morning to Mrs Murray, and I will repeat this afternoon for your benefit, Mr McCabe, it is a pleasure, particularly following the reshuffle, to still be serving under your chairmanship.

Clauses 34 and 35 would allow the Secretary of State to confer the exercise of his public health functions on NHS England or integrated care boards, and would allow those functions to be further delegated or subject to other collaborative arrangements, as defined elsewhere in the Bill.

Clause 34 substitutes proposed new section 7A for the existing section 7A in the National Health Service Act 2006, originally created as part of the 2012 health and care reforms, and amending the 2006 Act. To date, section 7A has been used to support the commissioning of key national NHS public health programmes, including our world-leading screening and immunisation programmes. The Government’s intention is that it should continue to do so. These public health services are embedded within, or have a clear affinity with, local NHS delivery mechanisms—a clear example being the delivery of childhood vaccinations by general practitioners.

Proposed new section 7A fulfils the same purpose as the original, in that it enables the Secretary of State to delegate the practical exercise of his public health functions to other bodies, but it is updated to keep pace with the thrust of the Bill and enable a wider range of delegation and collaboration arrangements. Not to do so would risk leaving public health programmes behind, with unnecessary restrictions on, for example, the range of bodies that could enter collaborative arrangements. The clause also consolidates amendments to section 7A made previously by the Cities and Local Government Devolution Act 2016 in respect of inclusion of combined authorities as bodies to which the exercise of public health functions may be delegated.

In addition, to ensure that the delegation or joint exercise of functions does not lead to reduced accountability for delivering services, we have proposed appropriate safeguards that make further provision on joint working and delegation arrangements. For example, the Secretary of State will be able to set out in regulations which functions can and cannot be delegated, impose conditions in relation to the delegation or joint exercise of functions, and specify the extent of such arrangements. Furthermore, the parties will be able to agree terms regarding the scope of the delegation arrangement. NHS England will also have the ability to issue statutory guidance in relation to functions that are being delegated or jointly exercised under those provisions. Subject to those safeguards, the clause supports the aims of greater health and care integration and a focus on improving population health outcomes.

Clause 35 introduces a new power for the Secretary of State, by direction, to confer the exercise of any of his public health functions on NHS England or ICBs. The clause, again, goes with the grain of the Bill more generally in resetting the relationship between the Secretary of State, as rightly accountable to Parliament, and an enlarged NHS England with an expanded set of responsibilities, which include direct commissioning and oversight of some health services.

The Bill is moving away from a focus purely on competition, and is instead re-emphasising the value alongside it of integration and collaboration. That includes being very clear on the role that the Government have to play. To that end, there is a suite of proposals in the Bill that assert the Secretary of State’s ability to intervene, set direction and make decisions, not as a substitute for clinical expertise, but in setting that clear direction and being accountable. I suspect that, if not on these clauses, then on those we will debate in a moment, that will come to the fore in our discussions.

Clause 35 is, to an extent, illustrative of that and relates closely to, for example, clause 37’s power to direct NHS England. As the law stands, and indeed as it would stand with the changes proposed by clause 34 alone, the Secretary of State’s ability to delegate the exercise of his public health functions effectively depends on securing agreement with the body being delegated to. That arrangement has generally worked well since its inception as part of the 2012 reforms, and as far as possible the Government intend to continue to operate in that way. However, the power gives Minsters a backstop if agreement is not reached in a timely way or is unreasonably withheld. It also enables them to give clear instructions where needed or where it would be more efficient to provide a direction rather than set up a whole arrangement.

Delay and confusion can and do affect the health of those relying on public health services, so the backstop power reflects the proper relationship, as we see it, between the Secretary of State and the public health system. It also sits alongside other mechanisms, notably regulation-making powers, in relation to local government’s exercise of public health functions. However, it is important to emphasise that directions must be published as soon as practicable, and the power would, of course, have to be exercised within the normal bounds of ministerial decision making, accountability and transparency.

Furthermore, any decision to exercise the power will be premised and guided by general public law principles and in line with the Secretary of State’s general statutory duties. Those duties will of course form part of any Secretary of State’s reasoning on whether it would be appropriate to exercise the power. In particular, they would need to consider section 2A(1) of the NHS Act 2006. As such, the Government believe that clauses 34 and 35 embody a proportionate addition to the Secretary of State’s powers.

[Alex Norris (Nottingham North) (Lab/Co-op)]

As the Minister says, the clauses relate to public health. We might previously have anticipated that the hon. Member for Bury St Edmunds (Jo Churchill) would have fielded them, but obviously she has moved Departments. I want to take this opportunity to put on record my thanks to her for her service as Public Health Minister. We worked well together, particularly in the proceedings on the Medicines and Medical Devices Act 2021. We have disagreed over the course of our work, and that is good—disagreement is good in a democracy—but we always disagreed well. I wish her well in her new role, although I might highlight the irony that, after all the work she did in public health to reduce fizzy drinks consumption, the top of the order of business at the Department for Environment, Food and Rural Affairs at the moment is presumably trying to restore carbon dioxide supplies to get those fizzy drinks going again—I am sure she will seek for them to be sugar-free, if nothing else.

Today is also my first opportunity to formally congratulate and welcome the hon. Member for Erewash (Maggie Throup) to her new role as Public Health Minister. I have long thought that it is pretty much the best job in Government, and gives the Minister the chance to shape and improve the lives of millions, if done well. From my work with her as a near neighbour, I know that she will give the job her all. I look forward to working with her and scrutinising the work that she does.

Of course, the job of Public Health Minister has been made an awful lot harder by the preceding decade. The other day I spoke about the bill for a decade of austerity falling due, and that is manifest nowhere more than in the provision of public health services and the impact of cuts on those services. In his introduction to these clauses, the Minister characterised the legislation as protecting the status quo, but the status quo relative to where we were in 2012 is very different: public health funding for 2019-20 was down 15% on where it was prior to the changes in the 2012 Act. If we set that against a growing and ageing population and all the attendant extra spending challenges that go with that, the real-terms impact is much greater. That has meant significant cuts: a cut of nearly half for support for health at work, the place where many of us will fall sick; a cut of a quarter for NHS health checks, a core preventative tool; and a cut of a quarter for smoking cessation programmes, despite how effective they are. Of course, the areas with the greatest needs have suffered the most and experienced the greatest cuts. Those cuts do not even fall equally.

For all the talk that we hear from the Government about prevention—we see it in these proceedings, the White Paper and the Bill—the reality is that Government policy over the last decade has made things much harder for our health system by creating extra demand. That is devastating not only for those individuals who have missed out, but for the system too. There is much greater demand on our health system as a result of the decisions that we have taken, and that is sad.

We have talked a lot about the 2012 Act, and much of what we are doing in Committee is removing its provisions, because they were not very good. However, one area where there seems to be no disagreement—no suggestion from the Government or the Opposition that we might change the position—is the idea that public health should go back home to local government. That is still an area of consensus that we can build on—of course it is. It means that our excellent public health staff, spearheaded by our world-class directors, can influence not only traditional public health-type services, but the whole range of services that shape the public’s health: licensing, planning, leisure, social care and much more—all those important things our local authorities do. It is just a shame and a wasted opportunity that this period has been characterised by cuts, particularly to those with the greatest need, rather than by investment in our communities.

I shudder to think of two things. The first is the amount of time that those skilled staff have spent on what is euphemistically called “service redesign” but is actually cuts. What could that amount of wasted time have been better spent on? The second is the professionals in that field who have chosen to leave because they do not want to be part of that. That is a real shame, and has really hindered our approach to tackling public health.

The Opposition do not intend to divide the Committee on clauses 34 and 35; at the end of the day, we would much rather that public health funding was spent at a local level than at a national one. We think it will have greater impact, and frankly we can get better value from it by combining it with local services. However, I want to test the clauses a little, starting with clause 34.

What we have seen in proceedings so far—I think this is sitting 10—is that, in reality, this is not an integration Bill; it is an NHS reorganisation Bill under an integration banner. I heard the Prime Minister himself promising a further White Paper, and presumably a further Bill, on integration in the future. The Minister has said that this Bill paves the way, but this was never a paving Bill. I challenge anybody to find in the White Paper or any publication from the Government relating to this piece of legislation the word “paving”—that is, until the Minister introduced it after the Prime Minister’s rather unhelpful intervention.

We heard from the Minister himself, when explaining to the Committee why a councillor cannot chair an integrated care board, that NHS bodies do not permit councillors to do so. He is telling us that this is about NHS bodies, not about partnership bodies. These are NHS bodies; they are accountable to NHS England and they can be altered by NHS England.

It has been a settled point of public policy for the past decade that public health is delegated to local authorities, for all the good reasons I mentioned. This may well be just my understanding, but I do not want to let this clause go without testing it: proposed new subsection 7A(2) provides for the range of eligible bodies that the Secretary of State can delegate the powers to. The first is NHS England, which would make sense in the case of big, national programmes such as the ones the Minister talked about in terms of vaccination. Another is a local authority, which makes sense for all the reasons I have given.

Yet another is a combined authority, which I suspect was not a feature of the 2012 Act—I do not think, although I might be wrong, that combined authorities were yet a twinkle in a local government leader’s eye at that point. However, with a combined authority, any arrangement would surely be by the consent of its members, rather than by delegation to the combined authority itself. Combined authorities are generally skeleton structures that act as an agglomeration of interested parties, rather than significant entities in themselves, so surely a local authority would receive those powers first and then, by agreement, transfer them to combined authority level with its partners.

Finally, there is an integrated care board. What is the reason for that? If these things get delegated to local government, why would they be delegated to an NHS body? Is that not an attempt, rather than repealing the provisions in the 2012 Act that moved public health back to local authorities, to do it on a de facto basis without addressing the point? That might be an unintended consequence, so I hope the Minister will address that and say that that is not the case.

Last Thursday, we dealt with the counterpart conversation to this one. We have debated multiple times the provision for health functions of the Secretary of State or NHS England to be delegated to the integrated care boards. That is in the spirit of what this legislation is about— local decision making—but at no point was there ever a proposal for any of those functions to be delegated to a local authority or combined authority. That, again, gets to the root of the problem with this Bill, and the core reason why the Government’s frequent integration efforts stall, spin their wheels and do not go anywhere. Local authorities are not treated equally, whether that manifests in social care—a very visible inequality in our health system—or in public health, as in this case. They ought to be equal partners, but they are anything but. Again, I hope the Minister can address that issue.

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[Edward Argar]

I suspect that, with this, we get to the main event of this afternoon’s proceedings.

I begin with clause 37, which introduces powers for the Secretary of State to give directions to the newly merged NHS England. This merger, which is widely welcomed, of three different bodies with different accountability arrangements into one has inevitably required us to look at the appropriate accountability arrangements for the future, and the extent to which the accountability arrangements have evolved and kept up with the evolution of the organisation. The powers in the clause will ensure the appropriate balance between democratic accountability to the Secretary of State and the NHS’s clinical and day-to-day operational independence.

Clause 37 will give the Secretary of State new powers over a newly merged and larger NHS England. It does not give the Secretary of State any new powers over other NHS bodies. It gives the Secretary of State precisely no new powers over clinical decisions. The clause is about ensuring appropriate accountability mechanisms between the democratically elected Government and one of the biggest arm’s length bodies, if not the biggest. That is a principle of democratic accountability in a publicly funded national healthcare service, and I am sure it is accepted not just by the leadership of NHS England, but by Opposition Members, even if they may not feel that the clause reflects their interpretation of it.

In practice, NHS England will continue, as now, to make the vast majority of its decisions without direction, consulting the Government and others as it needs to. The Government’s primary means of shaping the NHS agenda continues to be the mandate to NHS England, which has been an established means of providing direction to NHS England since 2013.

As we have learned in recent times, events can move fast, and the mandate may not be adaptable to all circumstances—and nor was it designed to be when it was conceived. The powers in the clause are designed to supplement the existing mechanisms, such as the mandate, to give the Secretary of State the ability, where he or she deems it appropriate and in the public interest, to provide direction and to intervene in relation to NHS England’s functions. Of course, the Department’s title is “Health and Social Care”, and while NHS England will rightly continue to be focused on the NHS, the Government must take a wider view—and this wider view may lead us, on occasion, to a different conclusion about the appropriate course of action from that held by NHS England colleagues.

There is already a strong and close working relationship between Ministers and NHS England. The clause helps to formalise that in a way that is more transparent for everyone to see, building in the normal expectations of ministerial decision making and accountability by requiring Ministers to issue directions in writing, and to ensure they are published and made in the public interest. Any decision to exercise this power will be premised and guided by general public law principles and broader statutory duties.

To ensure the NHS’s continued clinical and day-to-day operational independence, proposed new section 13ZD also sets out specific areas where the power of direction in section 13ZC cannot be used. The Secretary of State is unable to use this power to intervene in the appointment of individuals by NHS England, in individual clinical decisions or in relation to drugs or treatments that the National Institute for Health and Care Excellence has not recommended or issued guidance on.

We believe that clause 37 is crucial for ensuring that we have the right framework for national oversight and accountability of our health system, and of one of the largest arm’s length bodies, responsible for over £130 billion of public money. The clause ensures, in proposed new section 13ZE, that appropriate levers are in place—as there are for other arm’s length bodies—for Ministers to respond and take swift action if NHS England fails to carry out any of its functions. It also ensures, in proposed new section 13ZF, that Ministers have the levers they need to direct NHS England to provide information. Without it, we would be expanding the functions, responsibilities and powers of NHS England without ensuring that there are appropriate accountability arrangements in place for this large integrated body.

The changes that clause 37 introduced are proportionate, in our view. They reflect the evolution of NHS England in recent years, changes to the wider system and the appropriate expectations on Government to support, challenge and steer the system, while also leaving it free to determine operational matters.

Clause 62 amends the National Health Service Act 2006 by repealing the duty on the Secretary of State and NHS England to promote autonomy. The rationale for doing so comes is two parts. First, the response to the pandemic has further highlighted the importance of different parts of the health and care system working together in the best interests of public and patients. By repealing the duty to promote autonomy, the clause further enshrines integration and collaboration at the heart of the legislative framework underpinning the system.

The second reason for repealing that duty is to ensure compatibility with the duties elsewhere in the Bill on NHS organisations, including NHS England, to consider the effects of their decisions on the better health and wellbeing of everyone, equality of care for patients and the sustainable use of NHS resources. To avoid any conflict in duties, it is important to remove NHS England’s duty of autonomy, as these new duties require NHS England to co-operate and work closely with other partners, rather than autonomously. Repealing the duty of autonomy will also make it easier for NHS England to facilitate co-operation within the system—when commissioning services or issuing guidance, for example.

Neither the provisions in clause 37 nor those in clause 62, or indeed anywhere else in the Bill, do anything to change the nature of NHS England as an arm’s length body. I hope that I can reassure the hon. Member—I fear that I may not—that the removal of these duties does not mean that Ministers are about to start interfering in the NHS or in any other body exercising functions relating to the health service.

Integration is at the heart of the Bill. By creating integrated care boards and removing unnecessary bureaucracy that can get in the way of local organisations wanting to work together, we are putting more power and autonomy in the hands of local systems, and that is our intention here. We are seeking to strengthen local leadership and empower local organisations to make decisions about their populations. We believe that both clauses not only support that intention, but strengthen it, and I commend them to the Committee.

[Alex Norris]

The Minister rightly pointed out my mixed metaphor, so I will undertake to avoid metaphors in this contribution. It is hard not to feel like an undercard to the main event here—that is a simile, of course, rather than a metaphor, and I gave no such undertaking on similes.

I might surprise the Minister by agreeing with bits of what he said: we do not intend to divide the Committee on clause 37 and we do think that there is an important distinction between the powers in clauses 37 and 38, which I think will come out in the debate. However, if we went out to Parliament Square now and straw-polled people walking by, asking them who they thought was responsible for the NHS in England at a national level, I think we would wait a very long time before anyone gave any answer other than the Government and, by extension, the Secretary of State.

[Justin Madders]

And the Minister.

[Alex Norris]

And of course the Minister, through appropriate delegation, and we are all the better for it. The Minister can quote me on that—but not on a political leaflet, as that would be very challenging for me.

Covid has shown that the public think that the politicians they elect are accountable for the decisions taken in the interests of their health, however they might manifest in ordinary life, so I think the repeal of the duty to promote autonomy, set out in clause 62, probably follows inevitably from that. We want an expert-run health service that works together and follows the best available evidence and science, not one that is unaccountable and diverges from the interests and expectations of the public at large.

That leads me nicely to clause 37. It is possibly a tautology to say that if someone is held responsible for something, they ought to have responsibility for it, as the clause set outs. To put that bluntly, with more than £100 billion of spending—40% of the Government’s revenue budget—going into that area, people will expect political accountability. If NHS England is not seen to be acting in the public interest at the highest possible levels, there ought to be a mechanism, by exception, to correct that. It is the exceptional part that is really important.

That is defined negatively in the clause by what the Secretary of State may not do—for example, hiring or firing an individual, which I think is right, or directing the healthcare of a specific person. I do not think the Secretary of State would want to be in that position with important cases of individuals who are in the public sphere, or have the ability to act outside NICE guidelines on drugs or treatment, as happens in such cases. I do not think that is a good system, hard though it may be when prominent cases come to our attention.

That gives us a common-sense reading of what these clauses provide for the Secretary of State. Yes, the buck stops with the Secretary of State and his political colleagues as a collective if there are major failings in the health service or major failings of Government and of leadership, but the clause does not give Ministers carte blanche to pick and choose—undoubtedly with political pressures in mind—whether to involve themselves in the detailed running of the service. I think that will be covered in clause 38.

A concern raised by the Nuffield Trust in evidence was that there should be a stronger mechanism by which such decisions can be scrutinised. Will the Minister address that? I heard what he said about publication of information about the Secretary of State’s decisions, but why not provide for a parliamentary mechanism by which decisions could be scrutinised? That would ensure public confidence that there is no Executive overreach or direction at a low level of how our healthcare service operates, which I do not think would be at all desirable. I hope that the Minister will address that in his remarks.

[Karin Smyth (Bristol South) (Lab)]

I would like the Committee to take a moment to mourn the loss of the principle of autonomy as a guiding driver of the health service over some 20-plus years. That principle is part not just of the Lansley reforms, but of previous Labour reforms, and indeed of reforms by the Government before that. The idea was that the system would become more efficient and responsive with more autonomous units, rather than a great mass of health authorities, hospitals and systems that are rarely understood by local people, and that the competition of autonomous units would drive financial and service efficiency, for example. This is quite a moment, and I do not think we should just let it pass.

When I was a member of a primary care trust, which I may have shared earlier, our local region had “earned autonomy.” That meant that if we did certain things particularly well—bringing waiting times and waiting lists down, or fulfilling financial balance requirements, for example—the local team, board and chief executive would earn more autonomy to do more. In modern parlance, things became more permissive, and they were trusted to do something.

--- Later in debate ---

I commend the clauses to the Committee.

[Alex Norris]

It is a pleasure to follow the Minister’s admirably comprehensive coverage of the clauses, which I will try to meet in similar terms.

We recognise that the clauses address a number of technical changes to the status of NHS trusts and NHS foundation trusts in this country. We do not oppose them as we think they are consistent with the broader aims of the Bill: moving us from a world of competition to one of collaboration. I recognise that there is a great deal of transposition in the clauses, so very little will be different in substance, and that is why I will probe the Minister, who may well have pulled his punches with them. Why did he not go further?

In reality, the clauses, which are a significant part of the Bill, tidy up previous Acts but do not change enough of their substance. Nothing in the clauses—as with far too much in the Bill—will make anybody better, shorten waiting times, ensure safer staffing levels, address crumbling facilities, or do anything about the other myriad issues faced by the health service and Ministers. The Bill is in danger of creating the illusion of acting without really acting, like repainting a building and pretending it is a new hospital.

On clause 39, I listened carefully to what the Minister said about there being no plans to unsettle or change the provider landscape, meaning it is necessary to end the assumption that all NHS trusts will become foundation trusts. I agree with that basic principle because the debate has moved on significantly from that. It is less about a competition-based system and more about a system of collaboration. Indeed, as the Minister said, notably, there is a greater focus on the ICS as the unit of understanding in the community rather than the acute hospital.

As a result of that, however—this is not in the Bill —we will have two tiers, or two different sets of trusts, littering the landscape. We will entrench a system of trusts that are simultaneously autonomous and not, competitive and not, responsible for their own bottom lines and not, and free to spend their accumulated capital and not. That is a mess. If we tried to explain to a dispassionate observer why different trusts could do different things, we would not be able to. Were we designing a system from scratch, we would never design it like that. I would argue that the Bill is the closest we will come to designing a system from scratch, so I am surprised that that two-tier system has not been addressed in a more meaningful way. That would send a strong signal that NHS trusts and NHS foundation trusts are fully part—not semi-detached parts—of the NHS. They are public bodies and we expect them to act like public bodies.

On clause 40, I do not think I had anything to ask the Minister beyond the points that he made. Clause 41 deals with consequential amendments.

On clause 42, and at the risk of asking a daft question, although I do not think it is, but we will find out, what is the point of licensing trusts? Is this not just creating a bogus sense of distance from the centre, when actually the rest of the Bill is designed to consolidate NHS England as the regulator, the funder and the powerful operator? Why create this licensed distance between NHS England and its providers, other than the fact that it has been custom and practice for the past 10 to 20 years to do so? Is the licence really going to be worth the bother of printing out, or is it not just a legacy of a model of independence and composition that successive Acts have featured, but from which there is now a universal keenness to move on?

--- Later in debate ---

[Alex Norris]

I, similarly, will not go on at great length. The clauses are consistent with the stated aim to move from competition to a culture of collaboration. It is therefore right that under clause 43, NHS trusts will have regard to the impacts of the decisions that they make on their neighbours, with particular reference to promoting the triple aim.

I want to press the point about what is meant by “relevant bodies” in proposed new subsection (4). The Bill states that it means NHS England, the integrated care board, NHS trusts and NHS foundation trusts. All of those, of course, make abundant sense. However, we are missing an opportunity to extend it more broadly to the health and social care family, within which the Bill is meant to promote integration. The obvious exclusion is local authorities.

In previous proceedings, the Minister chided me for jumping about in respect of whether he was going too far or not far enough. I am going to take the cheese on that. There is no inconsistency between saying that in one provision—for example, the powers of the Secretary of State—the Government are going too far, and in another—for example, the status of NHS trusts—they are not going far enough. Provided that those two things are not interdependent, of course the Government might be going too far on one thing and not far enough on another. I reserve the right to say that as I see it.

I might just go back to the Minister at this point on jumping around, because the Bill started as an integration Bill. It was going to be the great integration of health and social care, and what a moment this was going to be in British healthcare history—probably second only to 1948. Obviously, that fell apart straight away because there is not much about social care in the Bill—only two clauses out of 135. Then the Prime Minister said, “Don’t worry, we are going to come back with an integration White Paper in due course.” Presumably legislation would follow that. At that point, the Minister said that this was a paving Bill.

[Edward Argar]

A foundation Bill.

[Alex Norris]

Foundation is even lower than paving, so I am not sure that that is a recommending analysis. Then earlier today, the Minister said that of course integration could take many forms. It could be integration of many bodies, and in this case many bodies within the NHS could be integrated. I gently say that, if we are wondering what exactly we are integrating, the title of the legislation is the Health and Care Bill, so I would start with health and care. I think we are missing that opportunity.

The reason for local authorities not being on this list may well be that we cannot bind the NHS to other non-NHS bodies, but that makes my case rather than argues against it. It is therefore not an integration Bill; it is just an NHS Bill. We will come back—that is the point. I keep saying this for a reason. We will have to come back to address that point, because the reason we are considering primary legislation is that systems have outstripped the status of legislation on the statute book. However, if we do not go far enough to catch up with them, we will have to do so in the future. There is an aspiration to do that sort of integration not just within the NHS, but within the broader health and care family. I really think that while it is not too late, we ought to consider what more we could do to put local authorities into this conversation.

As for clause 57, it is welcome that these duties also apply to foundation trusts, but it again highlights the fact that we are going to get to a point where the difference between a foundation trust and other trusts will be a distinction without a difference. We really ought to think about revisiting that, and I hope we will get the chance to do so yet.

Finally, of course it makes sense to amend licences, even if it perhaps does not make sense to have licences. I hope that the Minister can respond in particular to the point about local authorities.

[Edward Argar]

I have always been clear that the Bill adopts an evolutionary rather than revolutionary approach to driving forward greater integration, not only within the NHS in a locality but between the NHS and local authorities. On multiple levels, this is a Bill about integration and partnership working, and of course one on which the Prime Minister, ambitious as he always is for this country, wishes to build and go further.

The shadow Minister asked some specific questions about local authorities. The reality is that there is a different evolution and genesis in our local government system and the social care that sits with it, compared with the NHS. Up until 1948, effectively we saw that both were local and place-based. The National Health Service Act 1946 and the establishment of the NHS in 1948 set the NHS on a different path, which essentially looked upwards. It was a national system, albeit place-based, and it was national in its accountabilities, whereas local government continues to be based around different accountabilities at a local level.

Although it is important that we do exactly what we are doing, as the Prime Minister continues to, which is to drive forward greater partnership working and integration, we have to recognise those different developmental paths and the challenges they pose. In that context, local authorities do have, as the shadow Minister knows from his time in local government, their own distinct duties and accountabilities. The triple aim should lead NHS bodies to engage with local authorities—for example, in considering the health and wellbeing of the people in England or in their area. It pushes and nudges the NHS to think more widely about how it engages.

Equally, it is important to note that there are other measures in the Bill, such as the ICBs and the partnerships, that bring together those two bodies with their distinct DNA. We want to make it easier for them to work together in partnership and to integrate further, but we do recognise those different accountabilities and approaches —one directly accountable through local councillors to a local community, and the other part of a national system. These measures, we believe, will drive the NHS to go further in having heed to those local factors. That may not fully answer the shadow Minister’s point, but I hope it goes some way to doing so. With that, I commend the clauses to the Committee.

Question put and agreed to.

Clause 43 accordingly ordered to stand part of the Bill.

Clauses 44 to 50 ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Steve Double.)

Health and Care Bill (Eleventh sitting)

Alex Norris Excerpts

Committee stage
Thursday 23rd September 2021 Public Bill Committees

[Edward Argar]

As we have discussed, clauses 39 and 40 make it clear that the Secretary of State continues to have the ability to create new NHS trusts. Clause 58 is an integral part of ensuring that the NHS has the correct provider landscape necessary to deliver integrated care and to respond to emerging priorities.

The clause allows NHS England to make a transfer scheme relating to NHS trusts and NHS foundation trusts. Such a transfer scheme can provide for the transfer of property, rights, staff and liabilities from one NHS provider to another to ensure that the right resources can, when necessary, be transferred to support the delivery of services across the NHS.

NHS trusts and NHS FTs will be able to apply jointly to NHS England to make transfer schemes under the clause. NHS England, as the national regulator, may grant the application for the transfer scheme if it is satisfied that all necessary steps to prepare for the scheme have been undertaken. The process can ensure, for example, that all transfer schemes are in the best interests of patients and represent value for money for the taxpayer. Transfer schemes for NHS providers are crucial to ensuring that we have a flexible, adaptable provider landscape to deliver the best care to our patients.

Clause 59 introduces schedule 8 to the Bill, which amends chapter 5A of the National Health Service Act 2006, which relates to trust special administrators. Schedule 8 outlines the changes to the process and authorisation for the appointment of trust special administrators, including the reporting mechanisms.

A trust special administrator is appointed to take charge of the trust, at which point the trust board of directors—in the case of NHS foundation trusts, the governors—are suspended. Trust special administrators may be appointed by NHS England to exercise the functions of a chairman and directors of an NHS trust, or the governors, chairman and directors of a foundation trust, where that is necessary to secure sustainable and high-quality services and where other interventions to secure financial or clinical sustainability have been exhausted.

Schedule 8 co-outlines the changes to the process and authorisation for the appointment of trust special administrators, including the reporting mechanisms. The changes are part of transitioning the provider-based functions of Monitor and the NHS TDA into NHS England, and it does not represent a substantial change in policy approach. It also transfers delegated duties placed on the NHS TDA to NHS England in relation to the appointment of a trust special administrator to an NHS trust. It also transfers functions of Monitor to NHS England in relation to the appointment of a trust special administrator for NHS FTs.

The administrators are to be appointed by NHS England to make recommendations about actions to secure sustainable and high-quality services. NHS England must appoint a trust special administrator if required to do so by the Care Quality Commission. Otherwise, it may make the order to appoint only if it considers that to be in the interests of the health service and if the Secretary of State has given their approval.

The process remains broadly the same under schedule 8, giving NHS England the appropriate role in relation to NHS trusts and foundation trusts. However, one change I draw to the attention of the Committee is in relation to NHS trusts: both NHS England and the Secretary of State will receive the administrators’ report, which will state which action, if any, either is to take. The schedule confers a shared duty on NHS England and the Secretary of State to consult one another before taking any decision on action.

The provisions enable NHS England to discharge its responsibility for the support and oversight of NHS trusts and foundation trusts, including taking on Monitor and the NHS TDA’s regulatory and inspection powers in relation to such trusts. They provide transparency to the appointment process and its reporting mechanisms, and clarity to the system in securing and delivering sustainable and high-quality services when the trust providing them has been placed into administration. I commend the clauses and the schedule to the Committee.

Government amendment 15 will ensure that integrated care boards are consulted when the Care Quality Commission requires NHS England to make a trust special administration order and ensures that the process properly accounts for all future commissioning arrangements involving those boards. Proposed new section 65B(4)(b)(ii) introduced under paragraph 2 of schedule 8 retains the existing requirement for the Care Quality Commission to consult commissioners of services from the NHS trust in question. The commission considered that to be appropriate. However, it does not account for situations where, in future, an NHS trust may provide services in an integrated care board area without formally providing services to that integrated care board. For example, where an NHS trust ends up spanning two integrated care board areas, those boards may decide to have a lead commissioner of services from an NHS trust. The purpose of the amendment is to put beyond any doubt that any integrated care boards that might be impacted by a trust special administration order being triggered for an NHS trust should be consulted as part of the formal process.

Similarly, Government amendment 16 will ensure that integrated care boards are consulted when NHS England decides to make a trust special administration order and that the process properly accounts for all future commissioning arrangements involving ICBs. Proposed new section 65B(5)(b), introduced by paragraph 2 of schedule 8, retains the requirement for NHS England to consult commissioners of services from the NHS trust in question, if

“NHS England considers it appropriate”.

However, that again does not account for situations where, in future, an NHS trust may provide services in an ICB area without formally providing services to that ICB. For example, where an NHS trust may end up spanning two integrated care board areas, those boards may decide to have a lead commissioner of services from a trust. The purpose of the amendment is to put beyond any doubt that any integrated care boards that might be impacted by a trust special administration order being triggered for an NHS trust should be consulted as part of that formal process.

Amendments 15 and 16 ensure that the trust special administration process reflects the role the ICBs will play and the different levels of autonomy and status between different NHS trusts and foundation trusts under the present system, putting the need for calibration and consultation at the heart of the measure. For those reasons, I ask the Committee to support the amendments.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to serve with you in the Chair, Mrs Murray. There is not a tremendous amount to get excited about in these clauses and amendments, but I want to ask a couple of questions of the Minister.

On clause 58, it makes sense to provide for a time where there needs to be a transfer of property, rights or liabilities from one NHS trust or foundation trust to another. Indeed, I suspect that our conversations about boundaries in earlier parts of the Bill are far from finished. That may have a knock-on impact on providers, so we may see it used in the near future. On the powers reserved for NHS England to create transfer schemes, it is not greatly surprising that it is the ultimate arbiter of applications. That is consistent with the rest of the Bill.

I could not tempt the Minister to cover one point in the final grouping on Tuesday evening, and I hope he might expand on it now. Where are the integrated care boards in this? Surely they would have a significant view about changes to the providers, and possibly the splitting up of providers—the Minister mentioned cross-border trusts, and how that might be led with lead providers. It is not inconceivable that the integrated care boards might have significant views, so should there not at least be a sense that their views have been sought? If not, there ought to be support, which would probably be desirable. In the previous grouping, we covered the fact that that was also true for trusts entering special measures and for trusts becoming foundation trusts. Again, there was no sense of what the ICB’s role was. I do not think that the Minister mentioned that in his summing up. I hope that he might do so on this occasion.

I heard what the Minister said about Government amendments 15 and 16, which I have a lot more sympathy for. I raised this issue on Tuesday night. Where the Care Quality Commission and NHS England are involved in a trust failure situation, they should of course want the ICB to be a part of that process. I believe that the point the Minister made was that amendments 15 and 16 will amend the clause sufficiently to ensure that integrated care boards have their say in situations of failure. I hope he will clarify that ICBs in any such situation will get due consultation about what comes next.

I accept the Minister’s point that clause 59 does not represent a material change in direction or policy from where we are today, but instead tidies up who is responsible and deals with new arrangements for NHS England, as set out earlier in the Bill. Again, there is not much of a reference to the ICBs. Hopefully we get clarity that the point of the amendments is to put that back in. If so, obviously we would support that, but I would wonder why that has not happened in other places—both in this group and previous ones too.

The Minister will love how granular this inquiry is. I ask it for no other reason than out of a genuine desire to know the answer; I am not trying to catch anybody out. Schedule 8 replaces section 65KD of the National Health Service Act 2006. Proposed new section 65KD mentions ICBs—I think it was about the only reference to them in the schedule, before the Government tabled amendments 15 and 16—and provides for what happens should an ICB fail to discharge its functions. In that case, under proposed new subsection (5)(b),

“the Secretary of State may exercise the functions of NHS England under section 14Z59(2), (3)(a) and (5)(a)”,

which are introduced by the Bill.

Proposed new section 14Z59 is titled:

“Power to give directions to integrated care boards”.

At that point, the Secretary of State has taken over NHS England’s role and now acts as NHS England himself or herself. Can the Minister explain why that would be necessary? If we are saying that an ICB is part of a failure of circumstances, not discharging its functions properly, would not the first port of call traditionally be the centre—NHS England—to step in and provide support, or is there a judgment that the national leadership has failed too if the local leadership has failed, and therefore the Secretary of State must be the next link in the chain?

I am conscious that that is a granular query, but I think the provision departs from principles earlier in the Bill. It may well be that this is a very specific and niche example, in which case there is less to worry about, but I would like an explanation on that, and on where ICBs are in the grand processes around clause 58. When changes happen, what consultation does there have to be with them, and what support will they have?

[Edward Argar]

On the shadow Minister’s central question about where ICBs fit in, he is right that we envisage their being, as we have discussed throughout, central to decision making in their locality. He is right to highlight that, as drafted, there was the potential for them to be regarded as not front and centre, hence Government amendments 15 and 16, which we hope add clarity and add that ICBs will be consulted, for example, when a special administrator is being appointed. We wanted to include them as part of that process. I fully acknowledge that, as drafted, there was a degree of ambiguity. That is why the Government introduced the amendments. I do not like having to amend my own legislation, but I think it important that we do so here.

[Alex Norris]

The Minister should not be shy about that at all. It is good sign, and shows that, after publication, he is still reflecting on the Bill and improving it as we go along. That is a strength rather than a weakness. However, these are amendments to schedule 8. I am surprised that there are no counterpart amendments for clause 58 or to the group that we discussed previously, which included clauses 39 to 42 and clauses 44 to 50. Why was the judgment made not to amend those in a similar way?

[Edward Argar]

We took the view that in this case there are very obvious consequences. In normal circumstances, we envisage collaborative work with, and the involvement of, the ICB. I was very keen that we were explicit here. It could be argued, as I would have done, that the clauses did not prohibit such co-operation, but I wanted to be very specific, because the appointment of a special administrator and the actions likely to be taken in that context could have profound impacts on the system. I wanted to be absolutely explicit about the need to involve ICBs.

The hon. Gentleman asked a detailed and granular question about paragraph 15(4) of schedule 8, and the powers in proposed new subsection (5)(b). The key point is that we would envisage it going up through the chain of accountability—chain of command is wrong word—but it is important that we recognise, as we do with the Bill, that the Secretary of State has a role in that chain of accountability to the House, to the public and to others. That theme has run through a lot of the discussions of the legislation, so we therefore think it appropriate to include the Secretary of State in that subsection.

Question put and agreed to.

Clause 58 ordered to stand part of the Bill.

Clause 59 accordingly ordered to stand part of the Bill.

--- Later in debate ---

[Edward Argar]

I would not prejudge the passage of the legislation and how the House might judge it, but I look forward to such a scheme being introduced expeditiously, if I may put it that way to the hon. Member. I hope I can also reassure the Committee in respect of amendment 107, which was not selected but raised issues pertinent to the clause more broadly. This is important. It is right that the amendment was not selected—I appreciate that it was not tabled by a member of the Committee—but it does highlight issues that we need to put on the record. I appreciate the impulse behind it.

Although NHS staff pay and conditions are outside the scope of the proposed payment scheme and are protected by provisions made elsewhere, unions and other representative bodies may wish to be reassured that their members are able to go to work in appropriately funded services. I hope I have given reassurance on that point and set out why I feel the amendment, although I am grateful that it was not selected, would be unnecessary, as the Bill already requires NHS England to consult with integrated care boards, relevant providers and any other person the NHS thinks appropriate before publishing a payment scheme. It must also publish an impact assessment of the proposed scheme, ensuring that any potential consultation is properly informed of the potential effects of the scheme. I appreciate that the amendment was not selected, but I put those points on the record as I can understand the intent behind the amendment and I wanted to offer those reassurances. I hope I can persuade Opposition Members not to press amendments 84 and 100 to a vote, but I may be unlucky in that respect.

Clause 66 introduces schedule 10, which amends the Health and Social Care Act 2012 by repealing the national tariff and replacing it with the new NHS payment scheme. The national tariff has for many years improved access to services and driven up quality across the NHS, but as we move towards a more integrated system focused on prevention, joint working and more care delivered in the community, we need to update the NHS pricing systems to reflect new ways of working since the tariff was introduced, and in the light of the covid-19 pandemic.

The new NHS payment scheme will build on the success of the tariff. It will support stronger collaboration than ever before, with shared incentives for commissioners and providers of services to improve quality of care and promote sustainable use of NHS resources. The scheme will move away from a wholly payment-by-activity approach to an approach that supports more joined-up ways of delivering services, with commissioners and providers working together to deliver the best quality care.

The new payment scheme will remove perverse incentives for patients to be treated in acute settings and allow more patients than ever before to be treated closer to home and in the community. It will allow NHS England to guide the health system, through the development of guide prices for entire care pathways, while ensuring that local systems have the necessary flexibility to deliver high-quality care and use NHS resources sustainably.

The payment scheme will specify rules that commissioners must follow when determining prices paid to providers of NHS-funded healthcare services. It will allow significant flexibility over the current pricing scheme, and allow rules to set prices, formulas and factors that must be considered when determining prices paid. It also allows for in-year modifications to the rules, to reflect changes in the costs of providing services.

Crucially, the scheme will also allow the NHS to set prices for public health services commissioned by the NHS, on behalf of the Secretary of State, such as maternity screening, to allow for seamless funding streams for episodes of care. These changes to increase the flexibility and reduce transactional bureaucracy associated with the current tariff are, we believe, crucial to integrating care and tackling the elective backlog. I therefore commend this clause and schedule to the committee.

[Alex Norris]

Clause 66 is exceptionally important, so I cannot promise the same brevity as the Minister. I think the rules work slightly differently on the hard stop on a Thursday than they do on a Tuesday.

[The Chair]

Order. There is no hard stop on a Thursday.

[Alex Norris]

I am grateful for that clarification. If I am interrupted by colleagues in order to meet the conventional times, I will not take that as a kindness.

The clause governs how billions and billions of pounds will be spent every year, so it is surprising that it is so thin: three lines under clause 66 and a rather broad schedule 10. People could read into it whatever they want. My hon. Friend the Member for Bristol South made a good point that we could be in the business of filling that out for a very long period.

I am also surprised that the Minister is so reticent about the Secretary of State’s involvement and that this power is solely reserved for NHS England. We are not suggesting that the Secretary of State would want to set payment levels for specific treatments; but the Secretary of State, either today or in the future, may want some sort of say over what is being incentivised in the system and how that extraordinary purchasing power works in practice, whether that is about innovation, prevention or incentivising buying British, for example. That is something in which I would expect there to be some political interest.

The Minister talked about using clause 37, but that is a rather blunt tool. What we offer in amendment 100 is much lighter and much less drastic than using the clause 37 powers. If the Government will not accept our amendment, I am surprised that they have not introduced a similar one of their own. Perhaps they may yet do so.

The history of the tariff and payments bears an airing here, because it informs our future. It is an itinerant journey, which all Governments of the day, of different political persuasions, have their fingerprints on. This is not a partisan issue; it is about getting this right for the future. The purchaser-provider split in the ’90s and the development of various market and quasi-market systems was patchy and sporadic. That is a topic that has launched a thousand dissertations. Sometimes it feels like we aimed for payment by results, which is a noble cause, but in reality we can very easily get to payment by volume, and that is our challenge.

Going back even further than that, it was even less satisfactory. Traditionally, we had funding mechanisms that were very hard to understand and worked by adding a bit to the previous year’s allocations, and then really sophisticated people might make some downward adjustments for efficiencies and upward adjustments for assumed increases in activities. Inevitably, bits of the health service would get into trouble and would need bailing out, and new ideas would be dolloped out without much of a process. We have, to a certain extent, returned to that during covid. Block funding has given trusts one less thing to worry about. That was probably wise, but we would not want to do it forever.

The idea of the tariff was a variant of the 2012 Act. It could, I guess, incentivise competition on quality, but not really on price, as in a real market, as the Minister said. Prior to that, in the first decade of the century, the introduction of payment by results was one of the factors that allowed the longest successful period in the history of the NHS, which saw waiting lists come tumbling down—so much so that the demand for queue-busting private options evaporated and private providers became suppliers to the health service, rather than suppliers of private healthcare.

Payment by results, or pricing, can be a tool to tackle waiting lists. Given that Conservative Governments leave office with spiralling waiting lists, that is worth remembering for the future. Although that may be a discussion for another day, I want to ask the Minister whether he thinks NHS pricing is likely to be part of the recovery strategy. It is all well and good saying that this may take years and years to come to fruition, but what about now?

The historic decision back in the first decade of this century was that private providers should be paid the same as the cost of the NHS, so that there is no financial incentive to use the private sector. I think that is a wise principle, but it can and has been worked around. We have seen some very dodgy, spurious outsourcing of services, such as cleaning, which was an absolute disaster in Nottingham.

There are and have always been large swathes of the health services where payment by results or volume did not apply. One was mental health, where defining the product was far from easy, so it was very difficult to price. For many years, the mental health sector wanted to be part of this, but that never happened. That is much less of a priority for the sector now; it is just desperate for proper funding. It continues to struggle.

Of course, in such a system we will always have gaming and bureaucracy. Any system such as this gets gamed. Upcoding is one example, where the work that is billed for gets put into the highest-paying category. We have invoicing, chasing errors, and disputes over such coding, the actual volumes of work done and all the rest. That was hugely prevalent when payment by results first arrived for primary care trusts, and I think it is still with us in some form today. The cost of the market systems, data collection and processing is well above the cost of providing entirely necessary management information about cost and volumes.

Of course, that is not to make an argument for no prices at all. For decades, the NHS as a system did not really have any idea what anything cost. The accounts were not particularly well kept, and there were no data collection systems and staff doing analysis. As a result, the variations were huge, and that did not work in the interests of the system. I am arguing not for a no-cost regime, but for one that lands in a sensible place and does not become an industry in itself. At the moment, we have no idea, because what is on the face of the Bill is so broad, and the Minister is promising quite a long walk into the future with not a lot of certainty.

Many discussions about the long term plan, the formation of STPs—then accountable care systems, then integrated care systems, and now ICPs—and the rest have been about co-operation and collaboration, a return to non-market days, and a dilution of the commissioner-provider split, at least so far as NHS bodies are concerned. There will still be a strong current to say that there has to be some sort of tariff and benchmark as a guide, but some will say that there may be some sort of ability to vary as circumstances dictate—a kind of “Trust me, guv” arrangement whereby people of good will and common purpose can decide what is best, and that would be acceptable. To an extent, that flexibility is understandable if we are talking about the internal workings of an integrated, publicly provided NHS.

However, when we are talking about £10 billion more a year of contracts with private acute care providers, that is real money exiting the NHS bank account, so we need to be much more careful. That is where amendment 84 comes in: there has to be some sort of limitation on what private providers are paid. I was not at all convinced by the Minister’s explanation that there might be different costs, because of course there are different costs, the No. 1 cost being the need to derive profit from the contract. That is already a big cost. Of course, that can be met by compromising on quality or through downward pressure on what staff receive, but that is also a bad thing, so I did not think that was a particularly persuasive argument.

When it comes to all this money going out to private providers, there really ought to be some standardisation of the contract. If amendment 84 were accepted, we would have greater assurance that this is something done based on need, not cost or convenience. We would much rather invest in the NHS itself, taking away any perverse incentives to lean on the private sector as a resource pool and any risk of sweetheart deals due to our reliance on the good will of for-profit organisations.

In conclusion, we do not want the Secretary of State to price up a hip operation, but we do think there ought to be some interest in what our purchasing does in this country, to ensure that it is as good as possible. I do not think we should be using the blunt and brutal tools in clause 37, so I hope that the Minister will think again about amendment 100—if not now, then at a later point in proceedings.

Ordered, That the debate be now adjourned.—(Steve Double.)

Health and Care Bill (Twelfth sitting)

Alex Norris Excerpts

Committee stage
Thursday 23rd September 2021 Public Bill Committees

[The Chair]

Mr Norris, before we go to the vote I want to give you an opportunity to respond, particularly on the amendments, so we can be clear about what you are up to.

[Alex Norris (Nottingham North) (Lab/Co-op)]

I will give a quick indication, if that is okay, Mr McCabe. I take what the Minister has said about amendment 100, and I hope that he will continue to reflect on it. At many points, the Bill reserves specific powers to the Secretary of State, but if we do not need to do so, because the Government can just use clause 37, why on earth would we ever do that? I actually think this would be a very suitable place to do it, but on that basis, I will not press amendment 100. I would like to push amendment 84 to a vote.

Question put and agreed to.

Clause 66 accordingly ordered to stand part of the Bill.

Schedule 10

The NHS payment scheme

Amendment proposed: 84, in schedule 10,page 197, line 17, at end insert—

“(1A) The NHS payment scheme must ensure that the price paid to any provider of services which is neither an NHS Trust nor an NHS Foundation Trust cannot be different from the price paid to an NHS Trust or NHS Foundation Trust.”—(Alex Norris.)

This amendment ensures payment to private providers can only be made at tariff price to prevent competition for services based on price.

--- Later in debate ---

[Karin Smyth]

I will not push my amendment to a vote, but I seek responses from the Minister. I want to highlight the issue that we touched on earlier, and I am grateful for his comments, about how end-of-life and palliative care are the responsibilities of these new bodies.

This particularly relates to coming out of the pandemic, but even before the pandemic we had numerous reports from the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying about how people approaching the end of life do not feel supported to make the decisions they are faced with, are not always given an honest prognosis and do not know what options or choices they have. I think the issue of patient choice is very important in this clause, and I feel very strongly about it. I think this could generally be stronger in the Bill, but I will particularly highlight what is in my own amendment.

Amendment 93 would enable dying people to have conversations about what matters most to them, which is the first step to ensuring that they are at the centre of any decision making about their own care and treatment, and it starts the advance care planning process. I have been fortunate in that I have had three children, and I talked through my birth plans and my choices for the whole experience very carefully. It was presented to me as part of the process of giving birth. It does not always go well, as we know—we had a baby loss event today in Parliament, which many of us could not be part of.

The principle of choice at fundamental points in people’s lives as a patient is one we have embedded in the health service. Co-production of care for most incidents that we face is a fundamental part of clinical practice. Only at the point when people are most vulnerable, at the end of life, is the principle of advance care planning and co-production in their choices and prognosis something we are still not prepared to contemplate in the health service. It really is as basic as that. If I can make those choices about when I am giving birth, we should be able to make those choices when we are on the pathway of the end of our lives.

The evidence on advance care planning in order to support people on where and how they die is well made. This is about promoting earlier access to palliative care, communication, reducing conflict, helping families understand what is ahead and making the person less likely to have to go through rushed accident and emergency and distressing journeys into hospital. There is a need to start supporting advance care planning, and I would welcome the Minister’s comments on where the Government now think they are on that.

A key part of this amendment is proposed new paragraph (c), on authorities and new ICBs having

“regard to the needs and preferences recorded in such conversations in making decisions about the procurement of services.”

The full value of advance care planning can be realised only when individual care preferences are reflected in actual treatment decisions. Again, that is about empowering patients, something that I hope Members from across the House support.

[Alex Norris]

This is an important clause and an important amendment. We have said on many occasions that we want a model that promotes collaboration, rather than competition, but in doing so it is important that we do not create 42 closed shops, where a patient has little agency over their care. That will not feel right for those individuals and it risks weakening a culture of the pursuit of excellence and the best standards of care. Therefore, enshrining choice for citizens actually becomes more important in a collaborative system, so it is right that this is being addressed.

The Minister might not have a reply immediately on this, but he might be able to work with one from his officials about reports overnight in Nottingham, where there is no choice now over someone’s cancer care and such care is being “rationed”—that was the word used—because of workforce shortages. That is exceptionally alarming and will lead to some dreadful outcomes for people in our city. I hope there could be a follow-up letter about what is being done to switch those services back on immediately.

Turning back to the Bill, it is right that NHS England would have the power to investigate cases and direct an ICB as to how to rectify failure. It is good that there is a provision whereby investigations can be averted by an undertaking from an ICB to rectify the failure directly; that feels like the right level to start at. I am keen to understand from the Minister how he expects a person to enter the system and enter into that mechanism. Are they likely to be expected to contact NHS England directly to trigger an investigation or will there be a local process at an ICB level first before escalation? It would seem reasonable that we should exhaust local options before escalating to the regulator. If that is so, what prescription will there be, perhaps in guidance, if not in the Bill, for the form that that takes, so that an ICB that is not engaging positively with an individual cannot act like a blocker to elevating that? Perhaps we could consider bringing in a trusted third party at a local level—for example, Healthwatch would very well placed.

We saw in written evidence concerns that the current plans might not go far enough. The National Community Hearing Association said in its evidence:

“Existing rights to patient choice do not go far enough and typically only apply to primary care and consultant-led services. Giving patients more choice and control over their care for non-consultant-led services, especially for long-term conditions such as adult hearing loss, results in better health outcomes and helps tackle health inequalities. We would ask the Committee to press the case for the regulations to be made under this power to expand a patient’s right to choice. Regulations can do this by enabling patients to choose an NHS community provider for their hearing care where clinically appropriate. Currently only 50% of NHS regions in England offer patients this choice, resulting in inequalities in access to care.”

I wonder whether the Minister has considered that and could perhaps give us his reflection on the matter.

--- Later in debate ---

[Edward Argar]

The shadow Minister is right in surmising that once LETBs are abolished, their functions will be discharged by HEE directly in the manner he has set out. On his specific questions, HEE will continue to have responsibility for workforce planning and will engage with regional people boards, integrated care boards and the regional directorates of NHS England to carry out this function. Those responsibilities will be set out in a report that we will publish describing the system for assessing and meeting the workforce needs of the health service in England, as debated in relation to clause 33—to which we may yet return, either on the Floor of the House or in the other place.

We are not removing local or regional workforce planning from the statute, as the hon. Gentleman suggested; HEE will continue to have responsibility for that workforce planning. The LETBs were sub-committees of HEE and reported to the HEE board in any case, so clause 77 just removes some of the rigidity in respect of how HEE had to operate. As is the theme throughout this legislation, this clause seeks to give a greater degree of flexibility and permissiveness to allow the system to adapt to changing needs. On that basis, I ask that it stand part of the Bill.

Question put and agreed to.

Clause 77 accordingly ordered to stand part of the Bill.

Clause 78

Hospital patients with care and support needs: repeals etc

[Alex Norris]

I beg to move amendment 98, page 68, line 22, at end insert—

“(2A) A social care needs assessment must be carried out by the relevant local authority before a patient is discharged from hospital or within 2 weeks of the date of discharge.

(2B) Each integrated care board must agree with all relevant local authorities the process to apply for social care needs assessment in hospital or after discharge, including reporting on any failures to complete required assessments within the required time and any remedies or penalties that would apply in such cases.

(2C) Each integrated care board must ensure that—

(a) arrangements made for the discharge of any patient without a relevant social care assessment are made with due regard to the care needs and welfare of the patient, and

(b) the additional costs borne by a local authority in caring for a patient whilst carrying out social care needs assessments after a patient has been discharged are met in full.

(2D) The Secretary of State must publish an annual report on the effectiveness of assessment of social care needs after hospital discharge, including a figure of how many patients are readmitted within 28 days.”

Clause 78 is the final clause of part 1, but it is an important one, and we hope that the amendment improves it. I will be interested to hear the Minister’s views. This all relates to discharge to assess, where patients are discharged from hospital into the community setting and have their care needs assessed at home, or wherever they have gone from hospital, rather than waiting to be discharged from hospital and having to stay there longer than they clinically need to before the assessment takes place. Importantly, this is something that has been trialled during the pandemic. There is a lot of vulnerability at that point, and this process will matter to a lot of people. It is right that we give it proper consideration, and I think we ought to tighten it up.

I will confess that I have gone back and forth on the principle of discharge to assess, and I have had this conversation with colleagues in recent months. When the Bill was published, my first instinct on this clause, as former local authority social care lead, was a negative one. I felt—I still have this lingering doubt—that there was a real risk of patients essentially being parked in the community to the detriment of their health, with the obligation and cost put on local authorities. Of course, in many cases, some of that will be borne by continued healthcare funding. However, in the end that will become a local authority responsibility for each individual, and there will be a significant risk of them being readmitted shortly afterwards.

Local authorities are already scandalously underfunded to meet the social care needs of their population. Adding some of the most vulnerable people to that list and to the quantum of need that needs to be met will add greater risk, so I have serious reservations. This is not a conceptual debate, and that makes life easier; we have evidence to work with. Through no one’s planning, we have essentially run a de facto pilot scheme during the pandemic, so we know of what we talk. We have a sense of what is going on on the ground, and clause 78 will put it on a permanent footing.

On matters relating to local government, I always fall back on my former colleagues in local government. Their views on this are very clear, and I have had this conversation with them a lot. It always ends up with me saying, “Are you sure?” However, we should not miss their evidence. They say:

“The repeal of legislation related to delayed discharges is good news. This paves the way for the continuation of discharge arrangements which have worked well during the pandemic. The emerging evidence is that going home straight from hospital is what people want.”

I can certainly understand that. They also want greater clarity on the future of this de facto pilot from next month, in the interregnum between when the Bill becomes law and when the funding runs out next month. That is a very reasonable request, and I hope the Minister can respond. The strength of feeling from local government colleagues—our experts by experience—cannot be ignored, and that is why we are seeking to improve rather than prevent this innovation. It does need improving.

Important concerns were raised in the written evidence from Carers UK, which says:

“Under the CC (Delayed Discharges, etc.) Act 2003 a carer’s assessment can be requested and if so, a decision must be made about what services need to be provided to the carer, whether by social services or a consideration by the NHS, to ensure that the ‘patient is safe to discharge’.”

That will be repealed by clause 78. However, they will still be able to fall back on the Care Act 2014, so the carer will get a carer’s assessment under that if they wish. Presumably, that will now take place post-discharge. That is quite a significant change. A great deal of people will become family carers overnight. They might not be conscious that that will happen, but before anybody has made any assessment of their capability to do so, they will quickly find themselves operating as family carers for very vulnerable people immediately post discharge. By the time they get the carer’s assessment, they may well have been struggling to cope for a significant period of time. That could have some dreadful consequences, which is why amendment 98 states that there must be an assessment within two weeks. Obviously, we would want it much more quickly than that, but two weeks is a bare minimum backstop.

I do not think that this is catastrophising. According to research that Carers UK submitted, 26% of carers had not been consulted about discharge before the discharge of the person they care for, and a third were consulted only at the last minute. I do not think that is setting families up to succeed. If the Minister thinks that that will get better as a result of these innovations, we would welcome that, but I would like to understand why he thinks that might be the case and how the situation will look better. Carers UK recommends putting greater responsibility on the integrated care board to have oversight of how discharge to assess is working for the individuals in their care and across their footprint more generally. That is what we have sought to recommend with amendment 98.

The concerns of Carers UK are echoed by the British Association of Social Workers, and social workers, like family carers, have first-hand experience of the trial. The association worries about there being a move away from the fundamental point that the wellbeing principle is uppermost, and its evidence is concerning:

“A survey of Social Workers conducted in December 2020 involved in hospital discharges highlighted that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers felt that the voice of the individual was lost”.

It is quite significant to say not only that skilled staff would not be able to play their normal role in the process but that the individual’s voice would not be there.

The worst manifestation of the provisions in the clause would be for it to be in the system’s interest to move people out of hospital, because that would then be the priority. We need to make sure that that is not the case. The British Association of Social Workers would rather that the clause was not in the Bill at all, but we have not gone that far and have sought to improve it by putting a maximum two-week wait time in the Bill. That would be prudent. The amendment would also centre the integrated care board in the management and oversight of the process. If the integrated care board is to act as a system leader and integrator, surely such a system process—this is the ultimate system process—that touches on the borders between institutions ought to be within its purview. Otherwise, where will the oversight come from? Who will hold the different parts of the system to account?

I hope that the Minister addresses the concerns I have expressed, because this is an important and, in the plainest-speaking sense, risky decision. There are ways to mitigate that and we have suggested a good one in the amendment. I am keen to hear the Minister reflect on that.

[Karin Smyth]

I echo the comments of my hon. Friend the Member for Nottingham North. We discussed this when the Bill hit the Vote Office, because from a system management point of view I saw this change as a positive move. It was necessary in the system to increase the flow out of hospitals, particularly in the pandemic.

We talk about flows out of hospitals, but we are really talking about individuals—our nearest and dearest. During the summer, my husband and I were both responsible for supporting my mother and my mother-in-law in and out of the system, and my mother-in-law was part of the discharge to assess programme. This is not the place for me to rehearse the traumas of becoming, as my hon. Friend so eloquently put it, a family carer overnight and realising, if I did not know already, how little there is outside hospital. My hon. Friend’s point about families suddenly becoming responsible carers overnight is really important. Thousands and thousands of families are finding themselves in that position. Most people would agree about discharging people out of hospital as soon as possible, particularly given the fear of covid and people not being able to go into hospital to see their loved ones. In my mother’s case, she was discharged very quickly, and we went to get her because there was no ambulance service.

The closure of hospitals to visitors adds to the trauma of an acute episode, and people then have to take on that responsibly. People are assessed for care and told in the same sentence, “You’re assessed for care, but there is no care,” and that care takes several weeks to come into play. Among my own family and my in-laws, we have a clinical person in the team, we are fairly articulate, we are knowledgeable about the system and we perhaps know what we are taking on and have the capacity and capability to manage the situation, but it is deeply worrying that people who have no advocate or no other support—even social workers—are told when they are discharged that they need assessed care but there is none. It will take some time for us to understand what has happened to thousands of people who have found themselves in such a difficult position. I am particularly worried about people who have no advocate.

I suspect that the Minister will not accept the suggestions in the amendment now, but I hope he will take advice so that we can understand better—perhaps through an assessment—what has happened to people who have been discharged in the last few months without having support in place. We need to hear about that.

--- Later in debate ---

[Edward Argar]

I am grateful to the hon. Member for Nottingham North and the hon. Member for Bristol South. I knew that the hon. Member for Nottingham North and I had a shared background in local government, but I did not realise that it may have covered the same portfolio. I share his view on two points in particular. First, we have had the opportunity, of necessity, during the pandemic to see how the approach might work in practice. My instinctive reaction is that I can see how it works from the perspective of the system and the health service but, with my old council hat on, I would say, “How does it work from our perspective?” What we have seen throughout the pandemic has not been without its challenges, but it has broadly worked.

Like the hon. Gentleman, I am always happy to speak to my local councillors, who will not hold back in telling me what they think is working and what is not. However, I do think that this is the right approach when implemented properly. We know that if people stay in hospital longer than is medically necessary, it affects not only the system but individuals’ physical and mental health. It is therefore right that we get people home or to an appropriate interim place where they can be cared for and continue their rehabilitation in the right setting.

The amendment would introduce a new requirement for local authorities to carry out social needs assessments either before a patient has left hospital or within two weeks of discharge. Integrated care boards would have to agree the process with local authorities, including any penalties when local authorities fail to assess people within two weeks. It would also introduce a requirement for an annual report to be produced

“on the effectiveness of assessment of social care needs”

post discharge. As I hope I alluded to in my opening remarks, I entirely appreciate the intention of the amendment—all patients must receive the care that they need on being discharged—and understand where the hon. Gentleman and his colleagues are coming from, but I am not sure that it is the best way to advance that objective.

Existing discharge guidance states that health and social care systems must determine the most appropriate discharge pathway for each person to ensure that they receive the interim care and support they need, pending full assessment. Legislation already requires the NHS to meet people’s health needs, and local authorities must still assess and meet people’s adult social care needs. We are co-producing new statutory guidance on how the existing statutory duty for health and social care partners to co-operate will apply in relation to discharge. By way of reassurance, where local areas follow the discharge to assess model, unpaid carers are still entitled to a carer’s assessment where they are not able to care or need help. A carer’s assessment should be undertaken before caring responsibilities begin for a new caring duty or if there are increased care needs.

As all colleagues who have been involved in local government or the NHS will know, the devil is in the implementation rather than the detail in this case. We must ensure that the system works. The entitlement is there, and we must ensure that that pulls through into practical realities. The hon. Gentleman will be aware that the discharge guidance also states:

“Before discharge a determination must be made about the status and views of any carers who provide care, including that they are willing and able to do so.”

Evidence broadly suggests that when long-term needs assessments are carried out at the point of optimum recovery, that leads to a more accurate evaluation of needs and more appropriate care packages. Many people discharged from hospital require longer than two weeks to recover; we fear that requiring social care needs assessments to be completed within two weeks of discharge would create an extra layer of bureaucracy. In practical terms, it would not necessarily function in people’s best interests.

Our extensive engagement with health and social care partners has highlighted how current bureaucratic discharge requirements, including penalties for local authorities, can damage relationships and create discharge delays, and they do not support collaborative working across sectors. We fear that creating a new penalty for local authorities for failing to carry out assessments would again risk creating a tension within the system, which would go against the spirit of the integrated working that the Bill seeks to support and the good co-operation that I would argue normally and generally occurs. Our existing clause creates freedom for local areas to develop discharge arrangements that best meet their local needs.

I fully appreciate the need for accountability, which is why we are working with NHS England to publish hospital discharge data from 2022 onwards that will include data on the destination and discharge pathways being used to support people after they leave hospital.

For those reasons, I gently encourage the hon. Gentleman to consider not pressing his amendment to a Division.

[Alex Norris]

I am happy to say that I will consider that request; obviously, I have heard what the Minister has said. I was slightly heartened to hear the point about guidance. I suspect that if we do not see something exactly like what I propose in the amendment, we will see something very similar to it being put in the guidance.

However, we do not have that guidance at this point, which leaves us with two alternatives: either we press the amendment to a Division or we do not. If we do not, we will not be opposing the stand part debate, which means that we might create the impression that we have waved through something that we are concerned is too loosely defined. For that reason, we have to press the amendment to a Division.

Question put, That the amendment be made.

--- Later in debate ---

[Alex Norris]

I shall not duplicate anything I said in the previous debate. I fully support what my hon. Friend the Member for Bristol South said. We accept that hospital is a bad place for a sick person to be once their initial ailment is dealt with. They do not want to be around all sorts of illnesses when they are susceptible.

I want to make a final point on rehabilitation and re-ablement, as the Minister called it. That is at its most valuable as early as possible. Getting a person into their rehab and exercises rather than just being parked in an armchair is a big part of someone’s bouncing back from physical injury, and it helps with mental health as well. It is not desirable for them to wait a long time for an assessment because that will be a part of how they bounce back, rebuild their lives, and re-able and rehabilitate themselves. That strengthens rather than weakens the case for trying to be very tight about how quickly we want that to happen.

Health and Care Bill (Thirteenth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 19th October 2021 Public Bill Committees

[Edward Argar]

It is a pleasure to serve under your chairmanship, Mr Bone. As a member of the Government, I am well aware that seeking to curry favour with you in the Chair is a futile task, but none the less I wish you a happy birthday.

The amendments ensure that the drafting of the clauses covers all healthcare, whether delivered by public bodies or by the independent sector on behalf of the NHS or not, and that the relevant persons are captured by the requirement to comply with information standards. Those are matters of technical detail, and ensure that the changes made by clause 79 are coherent and consistent.

Amendment 117 makes minor changes so that information standards can apply to public bodies that exercise functions in connection with the provision of healthcare in England. It ensures that information standards can be applied to public bodies, even if the healthcare is not provided as part of the NHS. Similarly, amendment 118 ensures that information standards can apply in the processing of non-NHS and NHS healthcare information.

Amendments 119, 120 and 121 make consequential changes as a result of the previous amendments. Without those changes, there could be uncertainty about whether information standards can be applied to healthcare information generated outside the NHS. Without the amendments, we might not be able to ensure that data relating to NHS services—such as data about services provided in private patient units or by independent sector providers—flows through the system in a standardised way so that it is always meaningful and easy to understand for any recipient or user.

Clause 79 amends the Health and Social Care Act 2012. It allows the publication of mandatory information standards relating to the processing of information, including its transfer, collection and storage. Health and adult social care providers must currently have regard to information standards, but the clause would require providers to comply with them. The clause allows for the application of mandatory information standards to private providers as well. It requires regulations to be made about procedures for creating information standards. The clause also includes a power to require information from providers for the purpose of monitoring compliance with information standards.

The measures will help ensure that information flows through the system in a standardised way so that it is easily accessible and useful, and they will help to ensure the security of that information when it is processed. Given that publicly funded providers are already required to have regard to information standards, the clause will cause minimal disruption to compliant providers but will enhance the Department’s ability, on behalf of the public, to deal effectively with cases of non-compliance.

By applying information standards to private providers, the clause aims to improve the experience of patients who move between publicly and privately funded services by their own choice, such as individuals who choose elective surgery by a private provider. It does that by enabling the setting of standards that encourage the frictionless movement of information between those providers, with the aim of supporting timely and appropriate patient care decisions.

We consider the clause a crucial enabler for the creation in its broadest sense of a modern heath and care service whose systems are integrated and responsive to the needs of patients and users. I commend it to the Committee.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume proceedings on the Bill with you in the Chair, Mr Bone. I would extend birthday greetings to you, but I know that Tom Brady and the Tampa Bay Buccaneers are already giving you all the joy that you need at this time of the year.

[The Chair]

That has more influence.

[Alex Norris]

I thought that might get more traction with you.

I also take the opportunity on behalf of Opposition Members to pass our sincere condolences to Government Members and to pay tribute to our friend Sir David Amess. He was a wonderful man: funny, kind and caring. I say that now because my final conversation with him was about the Bill, which precluded me from joining him on a trip. He commended me on my diligence but also cautioned me not to work too hard. I will always remember that; it was classic David.

As the Minister said, we have reached the data part of the Bill. It is important for everything we talked about in part 1, because all the new cultures that we seek to foster will fall over if the data does not work and, as he said, flow freely back and forth between organisations. At the end of the day, ensuring that data can port between different organisations is our problem to solve, not that of the patient or the individual. Therefore, if we are to have properly joined-up care, it is vital that those who provide care have a full sense of who they are caring for and what is needed.

I will not cover the Opposition’s really good amendment to the next clause, which would improve it further, until we get to it. In that spirit, we do not intend to divide the Committee on this group of amendments or on the clause more generally, but I have a couple of points to address, which I hope the Minister might come to in his summing up.

On the clause in general, the Opposition support putting the entire health and care system on the same footing for information standards. As we heard in oral evidence, one of the major blockers is the myriad data systems used across the health and care landscape, many of which cannot talk to each other. When I was an adult services portfolio holder in my local council, I saw how hard it was sometimes even for council systems to talk to each other—I do not know whether that was remarkable or inevitable—never mind systems across different organisations and, in this case, the public, private, and community and voluntary sectors. That is a real challenge. I do not think we can remove that completely—systems may look different because of their different purposes—but there must be some attempt to standardise.

The Opposition do not oppose the clause, but proposed new section 6B in subsection 2(c) allows organisations to opt out—we might want organisations to be able to do that in some circumstances—and proposed new section 6C provides that regulations will cover when that is allowable. However, it is hard to know whether the clause will work until we have seen whether the regulations are strong enough and set a high enough bar on opting out. Will the Minister confirm that the measure allowing for opting out will be very much exceptional and that we will not see any nonsense about commercial confidentiality? We want data to flow across sectors, and that confidentiality has traditionally been one of the barriers to that.

Let me turn to Government amendments 117 and 118, which will expand the scope of the organisations covered. That is good. If we are to share data between social care and more traditional healthcare services, that includes a big landscape of non-NHS providers and perhaps even non-local authority providers, and it is right that information standards should be aligned. There must be a common basis on which to build. The Minister said that in general most organisations are probably already in that space and paying the due regard that they need to, but I fear that these things will be easier in concept than in execution. I am keen to learn what assessment the Minister and his officials have made of how ready the disparate providers in this landscape are to meet these new requirements, whether he thinks there will be a transition period, and whether providers will be helped to do this. Otherwise, the implementation of this strong concept in the Bill will not work. I hope the Minister can address that.

[Edward Argar]

May I put on record my gratitude to the hon. Gentleman for his kind words about our late colleague? I suspect that the Health team and the shadow Health team will also speak of him in oral questions in the Chamber in a little while. The hon. Gentleman’s anecdote was all too typical of Sir David and his approach to these things. I think the last time I spoke to Sir David was at our party conference; I had to do something on the platform, and he seemed mildly bemused by the fact that I was rushing off to have my make-up done before I went before the cameras. He then insisted on posing for a photograph with me. It was typical of him. We all miss him terribly in this place, as of course, most importantly, will his wife.

I am also grateful to the hon. Gentleman for his support, in broad terms, for clause 79 and the Government amendments. He is absolutely right about the importance of data flowing freely and safely for the benefit of patients. That is why the clause strengthens the wording of the Health and Social Care Act 2012, so that it says “must…have regard to” and “must…comply with”.

The hon. Gentleman asked a number of questions. First, he talked about the option of opting out from regulations. I can offer him reassurance on that; yes, I hope that its use would be exceptional, rather than the rule. Our assessment is that there is already widespread compliance with what we are seeking to do here, but as he rightly says, we have to make sure that we have as robust a framework as possible, because it is up to us to make this work for the patient, rather than their having to work their way around a challenging framework.

The hon. Gentleman’s final point was about the burden of execution. He is absolutely right; as we all know in this place, and from our previous careers in local government—we talk about this a lot—something can look immaculately thought-through and put together on paper, but when we hit the reality of practical implementation, there can be significant challenges. It is not our assessment that there will be significant burdens or challenges with implementation; I go back to my point that our understanding is that the vast majority of these requirements are already adhered to. However, I am happy to keep the matter under review, and to make sure that we tweak the implementation if we need to, and are sensitive to the reality on the ground.

Let me put a bit more flesh on the bones on the subject of the waiver—the opt-out, as it were—as we may touch on the subject when we come to the hon. Gentleman’s later amendments and in subsequent clauses. The thinking behind the waiver is that there may be circumstances in which an organisation feels that it genuinely cannot meet a published information standard that applies to it. That is why there is the waiver power. It could apply to use it, but that request would have to be considered very carefully by officials before it was granted.

I hope that I have given the hon. Gentleman some reassurance, but he knows, I hope, that I seek to be pragmatic in much of what I do, and in the implementation of the provisions, I will seek to apply a degree of common-sense pragmatism.

Amendment 117 agreed to.

Amendments made: 118, in clause 79, page 69, line 21, at end insert—

“(aa) in subsection (3), for ‘services’ substitute ‘care’;”.

This amendment makes it clear that the Secretary of State’s power to set information standards extends to information concerning health care other than NHS care.

Amendment 119, in clause 79, page 70, line 2, at end insert—

“(d) in subsection (7)—

(i) at the appropriate place insert—

‘health care’ includes all forms of health care whether relating to physical or mental health and also includes procedures that are similar to forms of medical or surgical care but are not provided in connection with a medical condition;”;

(ii) omit the definition of ‘health services’.”

This amendment is consequential on Amendments 117 and 118.

Amendment 120, in clause 79, page 70, line 29, at end insert—

“(3A) In section 251C (continuity of information: interpretation)—

(a) after subsection (6) insert—

‘(6A) “Health services” means services which must or may be provided as part of the health service in England; and for that purpose “the health service” has the same meaning as in the National Health Service Act 2006 (see section 275(1) of that Act).’;

(b) for subsection (7) substitute—

‘(7) Adult social care’ and ‘public body’ have the same meaning as in section 250; and ‘processes’ and ‘processed’ are to be read in accordance with the meaning of ‘processing’ in that section.” —(Edward Argar.)

This amendment is consequential on Amendment 119.

Clause 79, as amended, ordered to stand part of the Bill.

Clause 80

Sharing anonymous health and social care information

[Alex Norris]

I beg to move amendment 109, in clause 80, page 71, line 15, at end insert—

“(4A) Before the power in subsection (1) may be exercised, and every five years thereafter, the Secretary of State must review, and lay before Parliament a report of that review, the possibility of combining the exercise of that power with the exercise of the powers under which—

(a) the General Practice Data for Planning and Research programme, and

(b) other data-sharing programmes

are run.”

I am moving this amendment in my name and those of my colleagues. There has been some disappointment that on part 1 of the Bill we have not been able to move the Government particularly far from what was originally presented in the Bill. As has been said a number of times, this Bill ought to drive integration in health and care services, but instead we really have a reorganisation Bill, with a promise from the Prime Minister to return with an integration White Paper in due course—when presumably some configuration of all of us will come back and do all this again. It is hard to think that we have not left some opportunities on the table, so I hope we can do better on parts 2 to 5 of the Bill, and I do not think there is a better place to start on that than amendment 109, which would significantly help the Government with an issue that they have been struggling with for more than a decade.

It is obligatory for Health Ministers and shadow Health Ministers to start by saying that data saves lives, and it does. It tells us what is happening in our communities and our country and how we may need to change services to meet the needs of populations. But if it is done right, it can also tell us what will happen in the future and what future needs we will have to meet. For the purposes of designing health and care services, that is golden information. It gives us the chance to get ahead of the curve, to make good early investments and to avoid dreadful workforce gaps, which we are seeing at the moment and which have been created over the last decade.

We are fortunate that there is no country in the world better set up for high-class use of data than ourselves. We have a single health system in each of the four nations covering our entire populations. Of course, our data is spread over more places than simply NHS databases. If we can get it organised, we ought to have the most rich understanding of our population’s health and of the outlook for the future. What an extraordinary gift that is, but we are not using it effectively enough at the moment and we can do much better.

I remember, early in my stint as shadow Public Health Minister, meeting a group of dentists, one of whom said to me that they can not infrequently recognise the signs of certain eating disorders by the impact that frequent vomiting has on the back of a person’s—in these cases, generally a young person’s—teeth. They found it hard to understand why they had no idea whether anyone else who provided care for that individual, or perhaps even the individual themselves, knew that that had happened, because they had absolutely no broader healthcare information about the person. Of course, there are important circumstances in which we need to create firewalls to protect privacy, and we would want people to have only the information that they needed to do their job properly, but in this case the clinician felt like they were flying blind and unable to provide the very best care for this person as a whole person rather than caring just for the teeth of the person.

As an Opposition, we want to see data used well, wisely and in an integrated manner, and if there has really been only token integration in part 1 of the Bill, why not see the real thing in part 2? As I have said, the history here for the Government is chequered. Only this summer, through the General Practice Data for Planning and Research programme, the Government sought, with a characteristic, I might say, lack of touch, to grab all the data from England’s GPs without explaining to patients why they wanted it, what they would do with it, who would use it and who would not use it. Again, it feels as if it is more than a three-word slogan: not enough time was taken to explain this, and the result was entirely predictable.

According to a survey done by Which?, 55% of people had heard of the scheme and, of those who had, 71% felt that the NHS had not publicised the scheme well. Of those unaware of the scheme, nearly 40% stated that they would now be likely to opt out of it. Fifty per cent. of the respondents who were aware of the plans said that they had heard about them through news or social media rather than official sources. Forty-two per cent. said that hearing about the scheme made them trust the NHS less—that was a particularly startling finding. And nearly one third of those who knew of the scheme and had opted out of it had found the opt-out process overly complicated. What a mess. In the end, we saw 1.4 million people opt out, despite how hard it had been made to do so, and the plans were soon punted into the long grass, to return at a date not specified.

This is a real hammer blow for the confidence in how the state and the country handle data. These were the headlines on 13 and 14 October alone. The Bracknell News had, “Thousands of people in Bracknell Forest have opted out of sharing their medical records”. The Somerset County Gazette had, “MORE than 10,000 people in Somerset West and Taunton have opted out of sharing their medical records”. The Lancashire Evening Post had, “Thousands in Preston block bid to share medical records”. The Wirral Globe had, “Tens of thousands of people in Wirral have opted out of sharing their medical records”. The Bolton News had, “Nearly 20,000 Bolton patients opt out of sharing their medical records for research.” There were similar headlines in the Shields Gazette, Hemel Hempstead Gazette, the Hartlepool Mail and more. If it were not so serious, it would be funny.

--- Later in debate ---

[The Chair]

Alex Norris, gently or otherwise.

[Alex Norris]

I thank colleagues for their contributions, which I thought were really good. This is an important area, and it is important that we give it a proper look. The points that the hon. Member for Central Ayrshire made about the different types of data were important, and the run-through of their benefits and disbenefits was well made. I know that we will get to them again when we debate future amendments, so I will not prejudge that conversation. I still feel strongly—this relates to what the Minister said—that we have reached a point in the public conversation where there is no differentiation left, and that is the point that Simon Madden made. Because the temperature of the discussion has been elevated, they will be seen as one. That is what I have sought to address in my amendment.

My hon. Friend the Member for Bristol South was right to say that we have had a lost decade. That is, sad because it means that there have been healthcare improvements that we have not made. Over that time, extraordinary workforce gaps have emerged, and we would perhaps have been able better to plan around them if we had had a greater sense of the growing healthcare needs in our population. She is right that getting public trust back will be a “mammoth exercise”. That is why we have advocated for getting everything under one roof, in a single process.

The Minister mentioned that we all have a responsibility to explain data, and that it is important to make the arguments that we make in here out in our communities. I agree, but I feel I have much less of a responsibility to do that when the process is snuck out over the summer at short notice, without our ever having had a conversation about it. There could have been some effort to build consensus. I would have been willing to have difficult conversations with colleagues and constituents about it on that basis, but the way the process was handled made it impossible to defend. It left right hon. and hon. Members in the very strange circumstance of helping people to opt out of a system while thinking that that was not a good decision for them, or for anybody. As local representatives, we have a responsibility to people who ask for help.

I still do not get the sense from what has been said since then, publicly or in these proceedings, that the Government really understand the public message that they have sent, and I fear that that means we will keep repeating this conversation. In the amendment I simply ask that before the powers in the clause are turned on, a statement is made about how we seek to use these processes, and any other data processes, and handle them as one piece. That feels like a very modest ask.

I am going back and forth on whether to press the amendment to a Division. The Minister’s offer was a kind one, and I am conscious that I am putting a lot of this at his door. He did not create this process, but he is here speaking to part 2, so it is at least half him. Perhaps, when the dust has settled from what happened over the summer, we can have a conversation soon between Government and Opposition Members about how to do such things differently in future.

[Edward Argar]

I am happy to reassure the hon. Gentleman that either I or the relevant portfolio-holding Minister will happily have that conversation with him.

[Alex Norris]

I am grateful for that, and on that basis I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 121, in clause 80, page 71, line 20, leave out “250(7)” and insert “251C(6A)”—(Edward Argar.)

This amendment is consequential on Amendment 120.

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

[Edward Argar]

As we alluded to in our discussion on amendment 109, the clause inserts a new section into the Health and Social Care Act 2012. It has the sole objective of increasing the sharing of anonymous data for the benefit of the health and adult social care sector. The provision applies only to information that is in a form that does not identify any individual or enable the identity of any individual to be ascertained. It allows health and social care public bodies to require such information from other health and social care public bodies and from others who are commissioned by public bodies to provide health and adult social care services. As we discussed in relation to amendment 109, the provision requires those bodies to share only information that they already hold in anonymous form; they are not required to process information held in order to render it anonymous.

The use of “anonymised” in the title of the inserted chapter is a typographical error to be corrected. It does not reflect a change in the policy intention, nor does it have any practical impact on the clause. Anonymous information—information that does not identify any individual or enable the identity of any individual to be ascertained—can already be shared without the need for safeguards to ensure privacy and confidentiality. The provision will mean that public bodies will be able to require such information to be provided to them for the benefit of the health and adult social care sector.

The hon. Member for Nottingham North made an important point about understanding the message from the public on data. He may have a different interpretation, but I think the message was, “Data saves lives, but it is our data. We want to know and approve of how our data is used and have control over it.” People recognise that data can improve care and treatment, but it is their data and they want to be reassured and comfortable about how it is used and the safeguards that are in place, and that it is their choice rather than something that is done to them.

The new power to require sharing of anonymous information will complement section 251B of the Health and Social Care Act 2012, which places a duty on certain health or social care organisations to share information about an individual with certain persons where that will facilitate the provision of care to the individual and it is in the individual’s best interests. Both measures underline the importance of sharing data proportionately and appropriately to improve services and care.

The clause will also complement key provisions in the Bill, supporting those that strengthen the duty to co-operate across the health and care system. Regulations will provide for exceptions. Issues such as minimising the burden on providers and protecting commercially sensitive information may be taken into account when introducing exceptions. It is intended that proposed new section 251D(1), which allows for anonymous information to be required, will not be commenced until the regulations are made and the exceptions are clear. Given the extensive debate that we have had on amendment 109, I will stop there and commend the clause to the Committee.

Question put and agreed to.

Clause 80, as amended, ordered to stand part of the Bill.

Clause 81

General duties of the Health and Social Care Information Centre etc

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

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NHS Digital will continue to be subject to data privacy laws in relation to its use of data; also, its legislative framework and processes place strict controls on its dissemination of data. Those controls include a requirement that any sharing of information be for legitimate purposes, such as those connected with the provision of health or adult social care, and scrutiny by NHS Digital’s independent group advising on the release of data, which advises NHS Digital on the appropriateness of sharing any confidential information. The clause will provide NHS Digital with the clarity it needs to use health and care data to benefit the public and support the health and care system safely and appropriately. I therefore commend it to the Committee.

[Alex Norris]

As the Minister says, the clause deals with the Health and Social Care Information Centre, known to its friends as NHS Digital. This is a crucial body, and everything we have heard in debate so far, and in part 1 of the Bill, makes NHS Digital’s role even more central. The provisions in the Bill are modest; to use the Minister’s preferred language, they are de minimis. NHS Digital will be crucial as the body that can bring together, under one roof, information held by various organisations, and that can make sense of multiple systems in order to get the right information out, which is difficult. As we have heard, the history is chequered.

I hope that when the Minister sums up, we will at least hear a commitment that goes beyond what is in the Bill, and that NHS Digital is empowered to get a grip on our data across the entire piece. This is very much in the spirit of what I just talked about; there are multiple processes, all of which will at some point go through NHS Digital, which makes it an important clearing house. I hope Ministers will have a keen eye on its resources, and technical expertise. There is a real need for the organisation to demonstrate leadership, politically and at official level, and to pull the system together. I hope that we will hear a little about that, and about the outlook for NHS Digital. I am grateful for the point about private companies’ data; I will not reiterate that.

[Edward Argar]

I am grateful to the shadow Minister for his remarks and their tone. I hope that I can reassure him, in the few brief moments that I will take to sum up, that we recognise entirely NHS Digital’s current and potential role in helping to pull the piece together, adopting an holistic approach to data, and making sure that there is a coherent data strategy that works. I am confident and reassured that it has the technical expertise and resources to continue to develop its work and deliver for people in this country. I also reassure him that it continues to be a key priority of Ministers and the Secretary of State to ensure that NHS Digital has the tools it needs to do the job, so that, to go back to the thread that has run through our debate this morning, it uses its data to save more lives and provide more treatment, and does so in a way brings the public and our electors along with it. I hope that reassures him, and I am grateful for his remarks.

Question put and agreed to.

Clause 81 ordered to stand part of the Bill.

Clause 82

Collection of information from private health care providers

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

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[Alex Norris]

We think that this measure is particularly important. Private companies must play their role in the process and share their information, just as we would expect the NHS and local authority bodies to do. However, we want clarity that there will be no refuge to be had from hiding behind bogus confidentiality on commercial grounds. That is not explicitly recognised in the Bill, but I am hoping that I have read this right and the Minister can confirm that that is because proposed new section 251ZA, which clause 79(3) will insert into to the 2012 Act, allows the Secretary of State to compel the provision of that information if they judge it to be necessary.

[Edward Argar]

That is my understanding. If I have misunderstood, I will, of course, correct the record for the shadow Minister.

Question put and agreed to.

Clause 82 ordered to stand part of the Bill.

Clause 83

Collection of information about adult social care

[Alex Norris]

I beg to move amendment 143, in clause 83, page 73, line 23, after “assistance” insert

“or any form of reablement and rehabilitation provided under section 2 of the Care Act 2014 to reduce the need for care and support”.

This amendment is consequential on NC47.

[The Chair]

With this it will be convenient to discuss new clause 47—Registration of tertiary prevention activities in respect of provision of social care—

“(1) Section 9 of the Health and Social Care Act 2008 is amended in accordance with subsection (2).

(2) In subsection (3), at end insert ‘or any form of reablement and rehabilitation provided under section 2 of the Care Act 2014 to reduce the need for care and support’.”

This new clause would bring reablement and rehabilitation provided under section 2 of the Care Act 2014 to reduce the need for care and support into the purview of the Care Quality Commission.

[Alex Norris]

These measures would bring reablement and rehabilitation provided under section 2 of the Care Act 2014, for the purpose of reducing the need for care and support, into the purview of the Care Quality Commission. Unlike other adult social care functions, rehabilitation and reablement services are not currently part of regulated adult social care activities. There is no reporting, guidance on service standards, monitoring or inspection. That is despite the fact that rehab activities carry a level of risk similar to that of other adult social care interventions. This is particularly pertinent because rehabilitation services will be critical for those who are recovering from long covid.

One example that would fit into this category is vision rehabilitation. There is evidence from the Royal National Institute of Blind People that there are individuals who have been waiting since 2018 for their vision rehab. That will, of course, have been affected by the pandemic. However, those waiting more than two years, who have had this very profound change in their lives, need to develop new skills that they previously would have relied on their sight to achieve. The sooner that can be done, the better, because there are going to be so many other obstacles to adapt to.

The pandemic alone is not reason enough to offer comfort there. In the RNIB’s research, an inquiry made to lead councillors for adult social care in England last year found that about four in 10 did not know that vision rehabilitation formed part of that portfolio. An element of that will be because it is an unregulated function. Having been such a portfolio holder, I remember that you are very conscious of regulated provision in your area, because of the seriousness that comes with that, and I want to explore this gap a little.

Of course, the past 18 months have been extraordinary circumstances. Being a regulated activity on the same level of other adult social care activities would not fix the problems on its own, but it would have made a difference. It would certainly have given those gaps greater prominence. That might have been the beginning of addressing them. Indeed, there is a sense in the sector that this level of regulation would improve the visibility and priority of these services to senior managers and lead members by allowing for better data collection, for guidance, for quality standards to be developed by the National Institute for Health and Care Excellence, and for inspection services by the Care Quality Commission.

I will not say much more on that. It may well be that this is not the best mechanism to do those things, but I would be keen to understand why this particular element of adult social care is unregulated when so much effort is put into regulating other elements of it. Rehabilitation and reablement are particularly important.

[Edward Argar]

I am grateful to the shadow Minster for tabling the amendment and enabling us to have this discussion and air this issue. I understand his intentions in the amendment and new clause 47. It is right that social care services are appropriately and effectively regulated, and this includes rehabilitation and reablement. However, I do not believe that the amendment and the new clause are the right way of achieving the intended outcome.

Where providers carry out regulated activities as defined under schedule 1 to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, rehabilitation and reablement services are already within the scope of the CQC’s activities. As such, most rehabilitation and reablement services are CQC registered and are usually carrying on the regulated activities of accommodation, personal care, and treatment of disease, disorder or injury.

The definition of social care in section 9 of the 2008 Act is already sufficiently broad to cover reablement and rehabilitation provided under section 2 of the Care Act 2014. If there are concerns about the scope of CQC regulatory activities in relation to these services, they would perhaps be more appropriately picked up as part of the ongoing review of the 2014 Regulations. That work would probably sit better there. We intend to publish the response to that public consultation on the review in due course. For that reason, I would encourage the hon. Gentleman to withdraw the amendment and perhaps seek to use that process and that review as the mechanism by which to further air these issues.

[Alex Norris]

I am grateful for that reassurance. That does provide comfort, certainly on the CQC aspect. The driver behind the amendment was as much that the CQC sharpens its focus for local authorities. I am not quite sure that we have got to the point where this will close that gap. However, there is a good mechanism by which to do so, so I might pursue this later, rather than pushing it to a Division.

Amendment, by leave, withdrawn.

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

[Edward Argar]

This clause inserts a new chapter 3 into the Health and Social Care Act 2012, relating to information about adult social care. It introduces a new power for the Secretary of State to require regulated adult social care providers to provide information relating to themselves, their activities or individuals they have provided care to. The information may be sought only for purposes connected with the health or adult social care system in England, and its processing will need to comply with the UK general data protection regulation. Disclosure of commercially sensitive information is restricted under new section 277B(2).

As the shadow Minister set out, the clause enables the Secretary of State to delegate this function to the Health and Social Care Information Centre—known to its friends as NHS Digital—or to a special health authority, or to arrange for other persons to exercise them. Any such person would be subject to the restrictions on onward disclosure set out in new section 277B in the same way as the Secretary of State.

The clause is crucial for helping us to fill data gaps, understand more about self-funders and better manage emergency situations. Data from local authorities can show only part of the picture, as individuals who privately fund care have little or no contact with a local authority. That needs to be addressed to support local authorities to manage provider markets and secure improved outcomes for all receiving care and support.

The provisions will support a consistent and transparent approach to the processing of data across privately and publicly funded care to enable improved safety and quality of provision. Without that data, our ability to effectively identify and manage emerging risks and issues and to take appropriate action will be restricted.

The clause will enable us to collect higher-quality and more timely information, fill data gaps, support high-quality provision of services, and manage risks at local, regional and national levels. I therefore commend it to the Committee.

[Alex Norris]

To date we have discussed 83 clauses, and we might finally have found a little note of integration. Local authorities not only want to share their data, but they want a greater sense of the data that they do not have, as the Minister said. They are desperate to do this. They want the all the needs of their service users to be met, but they are frustrated by a system that is atomised and hard to navigate. We know that that is also exhausting for patients and their families. I know that local authorities will jump at the chance to use the provisions effectively, but I have a couple of questions.

First, is there an expectation and obligation that the data sharing will be a two-way street? There are times when local authorities are frustrated about their ability to get information either out from the centre or from local health services. I would not want that opportunity to be missed. Secondly, to reiterate a point I made earlier, it is a pain getting systems to talk to each other. Will the Minister and his officials look at what support and time may be needed to implement the measures?

--- Later in debate ---

[Edward Argar]

The clause inserts a new chapter into the Health and Social Care Act 2012 dealing with the enforcement of information provisions. It enables regulations to be made to impose financial penalties on private providers that, without reasonable excuse, fail to comply with an information standard or a requirement to provide information, or that provide false or misleading information. I am sure that you, Mr Bone, and members of the Committee will be pleased to hear that the regulations will be subject to the affirmative procedure in Parliament. This allows us to provide for enforcement in respect of private organisations, which are not subject to usual accountability mechanisms and judicial review in the same way as public bodies. The clause also provides for the regulations to set out details such as the amount of the penalty, as well as safeguards such as notice of the penalty and an opportunity for the person to make representations and to appeal to the first tier tribunal. 

Clause 84 enables the Secretary of State to direct a special health authority to exercise the enforcement functions under regulations made under these new provisions and to give directions to the special health authority about the exercise of those functions. That provision and the related information provisions in the Bill are part of the wider strategy for health and care data, which aims to ensure more effective use of data across health and adult social care to deliver better treatment for patients, better health results for people who need care and support, and better decision making, research and support for those on the frontline. Our expectation is that those aims will be delivered through the commitments in that data strategy, including the legislative changes that we are making. The use of fines or, in the case of public bodies, judicial review is—as always—a mechanism of last resort but an important part of achieving those aims. I therefore commend the clause to the Committee.

[Alex Norris]

The clause is an important counterpart to clause 82. If private organisations do not comply with their duties, enforcement will be necessary, although we hope it will not prove to be so very often.

As the Minister said, much of this has been left to regulations, so we are flying a little blind, but his point about the affirmative procedure is welcome as we will have a chance to revisit the issue. Ahead of that, however, we suggest that the Government consider two things in formulating regulations. First, a private company should not be able to pay its way out of its responsibilities. The fine alone should not discharge the notice, and instead the information should still be forthcoming.

Secondly, in pursuit of that, under section 54 of the Modern Slavery Act 2015 the Secretary of State has the power to injunct a company and stop it trading if it does not comply with its responsibilities to publish a statement on modern slavery and its supply chain. A similar provision in the Bill would be highly effective. I hope that the Minister and his officials will consider that when they formulate the regulations. We will have a further debate on this at that juncture.

[Edward Argar]

I am happy to bear in mind those sensible points as we look to the formulation of regulations. I am grateful to the shadow Minister.

Question put and agreed to.

Clause 84 ordered to stand part of the Bill.

Clause 85

Medicine information systems

--- Later in debate ---

[Alex Norris]

I congratulate the hon. Member for Central Ayrshire on her amendments and the case she made for them. I remember with fondness that during proceedings on the Medicines and Medical Devices Act 2021 we were able to offer constructive ways in which information regarding medical devices could be collected and used. We managed to move the Government on that. I hope we have similar success on these proposals too, because those were arguments well made.

Amendments 65 and 66 get to the heart of building confidence regarding data among the general public. There is widespread understanding about anonymised data and about datasets so big that individuals cannot be recognised, but we know that sometimes, if we want more detail, and particularly around rarer conditions or in rural and more isolated communities, we risk identification. Giving our information leaders the tools with which to protect individuals while still delivering the desired outcome is a sound principle and is part of hearing the message that was sent from our constituents, so we can start to rebuild trust. Providing such extra tools would be proportionate.

Turning to amendment 64, devolution is at its best when the four nations can exercise the advantage of local knowledge and leadership but collectively harness separate oversight to tackle collective challenges. That is important, particularly for the use of data. I strongly believe it will be in the interests of people across the United Kingdom for all four nations to have similar systems of standards and alignment on data. I am conscious that the challenges in north Nottingham will be similar to the challenges in north Cardiff, but devolution may well mean that services in Cardiff are different from those in Nottingham; that is part of the process. It can also mean that the outcomes are different, and we may want to know that, so that one community can, if it wants to, change to replicate what another is doing. I am not arguing against common usage; I think it is important, but we do not want a situation where the Secretary of State seeks to act with overbearing control as a first among equals. The mutual benefits of sharing data are so clear to all parties that they ought to be able to be agreed on a good-faith and negotiated basis. It should not need compulsion from the Secretary of State; in fact, that would be a significant failure. Therefore, the opt-out specified would be proportionate in this case.

Amendments 61 and 62 are crucial. The general practice data for planning and research process fell over because a significant part of the population did not trust the Government to handle their data appropriately. There is widespread concern about the Government’s relationship with big commercial entities, whether in the planning process, political donations or covid contracts. They are not scare stories or political fluff; they are real issues, they are in the public consciousness, and there is a sense that that relationship and the balance with the commercial sector is not one where the calibration is right.

On data, we must at every opportunity send the loudest possible signal that there are irremovable firewalls between people’s data and commercial usage. That works on two levels. First, as mentioned there is a lack of trust that the data will not be handed over to big commercial companies. We know that the mega-giants in social media have an insatiable desire for our data, and the old adage that social media is only free because our data is the product rings true. The NHS is not like a social media platform, though; it is free at the point of use, but we have paid for it through our taxes. It is not a free service we get in return for sharing our data, and there is no mandate to simply pass on the information collected as a result of our healthcare.

Let us be honest: what confidence would we have in sending the Government to negotiate with these companies? We have seen the painstaking process involved in just getting them to pay tax in this country; I would not, with full confidence, send a Prime Minister to negotiate a fee for our data, because I suspect we would end up paying the companies. This is an opportunity to be absolutely, immovably and irreversibly clear that we do not think that they should be near this data.

Secondly, it is worth reiterating that it is not as simple as just not handing data over. Even through legitimate and beneficial use of data, we are still at risk of getting a bad deal. For example, we no doubt want to use population-level healthcare to work out what conditions we may need new treatments for in the future. For that reason, we want researchers to use this data, and from that new treatments and drugs will emerge. Big pharmaceutical companies stand to gain from this, so how is it to be accounted for? We have a stake and have played a part in that process, so we ought to have a share of the benefits. How will the premium that we pay for the new treatments reflect the contribution that we have made—bluntly, where is our dividend? Those are the reasons that the GPDPR process fell apart, and why there is so much suspicion about the Government’s handling of data more generally. If we keep repeating the same approaches we will get the same outcomes. This is a moment to change that and to send a signal that our data will be protected from commercial interests; I hope the Minister will meet this moment.

Finally, on amendments 60 to 63 and 67, I will not rehearse the arguments I have previously made. I can conceive of times when NHS bodies, local authorities, community and voluntary sector providers or private sector providers might fall short of the expectations we have of them on data sharing, and exceptions where the Secretary of State may need to step in. That is why the Opposition have supported earlier clauses in part 2. That is a reasonable and proportionate way of ensuring that the data sharing regime is an enabling regime. I cannot think that applies to the devolved nations. All four nations are partners in the common pursuit of improving health outcomes; we may diverge in approach, but the common goal is the same. I cannot conceive that there will be such a divergence on data that it would be legitimate and wise to resolve it by working without shared consent. I hope, in the light of the arguments made, that the Minister will revisit that point.

[Edward Argar]

To the point made by the hon. Member for Central Ayrshire about the relationship with Edinburgh, while it is correct that a number of these clauses, and a large part of the Bill, were not finalised in their drafting until a day or two before publication, it is important to say that since the beginning of this year Scottish Government officials have had sight of the intentions and have been discussing with UK Government officials the wording and content of these clauses. I appreciate that this is not necessarily the same as a Minister seeing the exact wording, but that relationship and transparency has been there at that level.

I also put on record my gratitude to Humza Yousaf, the Cabinet Secretary for Health and Social Care. I spoke to him a week or two ago, and with tragic timing, in that conversation he asked me to pass on his best wishes to James Brokenshire for his recovery. I know that they got on well, and I hope that I have a similar relationship with Humza, who is pragmatic, and I appreciate the work that he is doing on this. We continue to talk, because I am keen that we have that healthy relationship and it is my intention that we respect the Sewel convention and work together to come to an agreed position. It is challenging because there are genuine differences of principle on how things should be interpreted, but I am committed to working with him, as he is with me, to find a way to reach a common position that respects everyone’s principles and approach.

The medicine information systems clauses give us an important opportunity to ensure we have the highest quality evidence on which to base critical regulatory decisions. If we get this right, there is real potential, which has been alluded to by all Members, to take a step forward in the way medicines are monitored, risks are identified and action is taken to protect patients. We need to provide for the most effective operation of this system to realise the full benefits for patients across the UK.

The detailed operation of the system will need to be carefully considered further as we develop the regulations under the clause. It will probably be important that the systems are able to receive information that is fully identifiable to ensure accurate linkage and deduplication of data. That is necessary to ensure that the information system is able to capture a comprehensive picture of a patient’s treatment to generate robust evidence, and that if a patient moves from one area of the UK to another, they are not lost from the registry.

Robust decision making on patient safety must be made using accurate data, which can only be achieved by processing identifiable data from the four nations to create the UK-wide information system. That necessitates precise data linkage due to the nature and potential rarity of harmful events based on multiple identifiable data points. It is proportionate to use identifiable data to understand potentially adverse patterns early.

Patient-identifiable information is also necessary where inclusion in a registry is to be used as a risk minimisation tool, where a patient needs to be identifiable in the registry to their healthcare providers, or if information systems are linked with wider safety monitoring mechanisms already in place, such as the yellow card scheme, through which the public and healthcare professionals can report adverse incidents experienced with a medicine to MHRA, to further strengthen the data it collates.

It is not necessary to make provision in the Bill, because the powers in clause 85 give the ability to follow the most appropriate approach on the collection and disclosure of data, following discussion with stakeholders on the detail of the future regulations. The confidentiality and security of patient data and the reassurance that offers to patients is paramount. I hope I can assure the hon. Member for Central Ayrshire and other Members that all data held in a medicines information system will be processed in compliance with data protection legislation, which places crucial safeguards on the use of that information. That includes data principles such as lawfulness, fairness and transparency, purpose limitation and data minimisation—meaning that the minimum necessary information will be collected to meet the required purpose.

I recognise the importance of ensuring the appropriate and proportionate use and access to information in a medicine information system. As part of our consultation on the regulations to establish and operate a medicine information system, we will engage with patient groups and other stakeholders across the UK, as well as the devolved Administrations, on the content and scope of the system to ensure we do what is right for patients.

On amendment 64, at official level we have been in discussions with the devolved Administrations since February about the provisions in the Bill, particularly those for which at an early stage we identified a shared agreement that legislative consent was required. Clause 85 is one of those. I would like to put on record my gratitude to those officials—we often talk at ministerial level, but they worked very hard for some time in the spirit of finding a way forward that works for everyone. Let me say the same in respect of the devolved Administrations, who have spent considerable time working with us.

Without going into too many details, because those discussions are continuing, I have had constructive discussions with the Cabinet Secretary for Health and Social Care in Edinburgh. I am keen, as he is, to do what we can to move those discussions forward. I hope we will be able to provide further reassurance over any outstanding areas of concern to the DAs, and where necessary and agreed, to table amendments ahead of Report. I hope that gives the hon. Lady some reassurance that I am directly engaged with the Cabinet Secretary and I will continue to be so. I am due to have another conversation with him in the coming days, and I have in my bundle another draft letter I am due to send him addressing some of the details of the granular points we are now looking at. I hope we will be able to make progress.

For medicine information systems to be truly effective as a tool, they need to cover all patients using the medicine across the UK. The regulatory decisions taken on the basis of the data collected will apply to the licensing of that medicine across the whole of the UK. My concern about Scottish Ministers choosing whether Scottish providers should or should not participate in the information system is that it could risk a fragmented approach, which is why we are having those discussions at policy level.

--- Later in debate ---

[Edward Argar]

As we have discussed in the context of the various amendments, clause 85 inserts a new chapter, 1A, into the Medicines and Medical Devices Act 2021. It introduces a new power to make regulations that would provide for one or more medicines information systems to be established and operated by NHS Digital. The power may be exercised only for the specified purposes set out in the provision: namely, purposes relating to the safety, quality and efficacy of human medicines and the improvement of clinical decision making in relation to human medicines. The clause sets out the types of provisions that could be made by the regulations and, to ensure full engagement, includes a mandatory public consultation requirement that must be fulfilled before any regulations are made.

Medicines information systems will enhance the capture and collation of information on the uses and effects of specific medicines across all four nations, including medicines prescribed to patients by the NHS and private healthcare providers. That information will be used by the Medicines and Healthcare Products Regulatory Agency to enhance post-market surveillance of medicines by enabling the development of comprehensive UK-wide medicines registries, which will be used to drive improvements to patient safety. The evidence generated through medicines registries can be used to inform regulatory decision making, support local clinical practice and provide prescribers with the evidence needed to make better-informed decisions. For example, where safety concerns have led to the introduction of measures to minimise risk to patients, comprehensive medicines registries will enable early identification and investigation of cases where those measures are not being followed, so that additional action can be taken to improve safety at national, local or individual patient level.

The clause also ensures that we have the right powers to promptly modify what data is collected by NHS Digital as the need for new or different information about a medicine emerges in the light of changing or developing public health needs. That will provide the ability to rapidly respond to emerging risks to patient safety if and when they develop.

Given the overarching aims of the clause, it makes sense that the provisions will ultimately sit within the Medicines and Medical Devices Act 2021, which has a similar power for establishing information systems for medical devices in section 19. To ensure the effective operation of both the medicines information systems and the medical devices information systems, the clause also introduces necessary technical amendments to the MMD Act.

The clause drives forward improvements to the safety measures that protect patients in the UK against avoidable harm from medicines, and supports the need for the establishment of registries as recommended in the independent medicines and medical devices safety review, published last year. The clause directly supports putting patient safety at the heart of regulatory decision making. It will ensure that we have robust and comprehensive evidence to address public health concerns, and enable mechanisms to track the use and effects of medicines, based on public health needs. I therefore commend the clause to the Committee.

[Alex Norris]

I had intended to go the entire period that I am in this place, however long that might be, at least trying to be a young Member, if not a new Member, but clause 85 amends a piece of legislation that I was on the Bill Committee for previously, so I feel that I cannot do that now. That is really startling. Nevertheless, as I said earlier, I and the hon. Member for Central Ayrshire argued strongly for this in Committee on that Bill, and I certainly would want to see this used properly and developed. With all the daily treatments that there are—and certainly when it comes to the medical devices that are inserted into people on any given day and on every day of the year every year—we really ought to know what those things are and, when there is a problem, be able to deal with it quite quickly.

I will make one final point. The Minister references, quite rightly, the independent review—the Cumberlege review. We will be revisiting the matter in the new clauses, because the Government have not done the job properly on that review. Although there are elements in this clause that make good on some of the commitments, there are very significant things that have been left out and that the Government do not intend to do, and they have really let down the families by not doing them, so we will be returning to that point, and I hope to find the Government in listening mode when we do.

[Edward Argar]

I have nothing further to add to what we have said, save that I am always in listening mode when the shadow Minister is making his points.

Question put and agreed to.

Clause 85 accordingly ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Steve Double.)

Health and Care Bill (Fourteenth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 19th October 2021 Public Bill Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

A lot of this covers the issues that we discussed in relation to data, consultation and consent. I respect that these are UK-wide bodies, whereas data is within the devolved systems, so that was an even bigger issue, but there must be recognition that although health is devolved, the regulation, licensing and registration of staff for bodies of this sort affect the devolved health services. There should at the very least be proper, genuine consultation, rather than changes simply being made.

As we discussed this morning, we saw how NHS Digital—in essence, an England-only service within NHS England—is now being turned into the Health and Social Care Information Centre, which is UK-wide. We already have the information and statistics division in Scotland, so changing the ability of the Secretary of State to change arm’s length bodies may indeed affect what happens in the devolved health systems. Reference is made to the Human Fertilisation and Embryology Authority and the Human Tissue Authority simply to respect that those health services are under the control of the Welsh and Scottish Parliaments and the Northern Ireland Executive, but decisions made here will have an impact on them.

I welcome the Minister saying that NICE would not be forced on Scotland—we have the Scottish Medicines Consortium, and the Care Inspectorate rather than the Care Quality Commission. However, that is people’s fear because it is not explicit here—either through consultation or consent—that bodies that have been set up for almost two decades, that are integrated with our health system and functioning well, could suddenly be rolled over. It is important that the Minister points out that clause 89(6) is merely consequential. It increases anxiety that the Minister here can, simply through regulations, revoke, repeal and amend Acts of the Scottish and Welsh Parliaments without consent or even consultation.

I do not see an issue with a name change, but there is an issue with a Bill of this size and complexity being published and Ministers in the devolved Administrations seeing it only the day before. That does not show respect between the Governments. That is something that I hope, as the provision is taken into regulations, will change. I do not plan to push the amendment to a vote because the Minister said that he is consulting the Scottish and Welsh Cabinet Secretaries, but it should not have come to this. Respect for devolution should have been implicit in the Bill from the start.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume with you in the Chair, Ms Elliott, and to move on to part 3. Of the various parts, it has possibly had the least impact on my mailbag, but it is important. I am a little troubled by some of the provisions and want to probe them a bit.

The Minister gave a good and characteristically cogent explanation of what is in the Bill, but not of why it is there. That explanation was much shorter, so I want to come back to that because I do not think it is clear what problem the Government are seeking to solve. Has a significant risk to the health and wellbeing of the nation been caused by the Secretary of Secretary’s inability to remove functions from one organisation to another more quickly? I do not think that is the case. The Minister made the point about a rather fractured service and the need to be able to act more swiftly. I will revisit those points shortly.

Clause 86 specifies the organisations that the Secretary of State can delegate or transfer functions to: Health Education England, the Health and Social Care Information Centre, the Health Research Authority, the Human Fertilisation and Embryology Authority, the Human Tissue Authority and NHS England. I was surprised not to see the UK Health Security Agency in that list and I hope the Minister will come back to that.

Clause 87 allows the Secretary of State to move functions between the organisations, and clause 88 provides for the Secretary of State to permit them to exercise functions on the Secretary of State’s behalf. Are we really saying that there are not decent, appropriate and effective ways to do that already? For example, the UK Health Security Agency is a relatively new body and it will take time for it to settle in and find its level. Do we really believe that there are no mechanisms to ensure that it can exercise functions on the Department’s behalf, or that there might be a public health information function currently exercised by NHS England that the agency might be better able to deliver in the future, but cannot because it is not covered by this legislation? I find that hard to believe. Are we saying that there will be an alternative route for that? I cannot understand why there would be a different way of doing that.

If that is really necessary, why is the Government’s instinct to do it by regulation? If there are problems today that perhaps the past challenging 18 months have revealed, we have got primary legislation here, so we could make whatever changes the Secretary of State wishes to make to the organisations on the face of the Bill. Obviously, that would not help with new and emerging problems, but what are they? What examples have happened recently? It feels as though we have a solution in search of a problem to solve.

Clause 87(3) basically prevents the Secretary of State from abolishing NHS England. Well, we would hope so—that seems wise—but what of the other agencies? The Health and Social Care Information Centre was formed by the Health and Social Care Act 2012; the Health Research Authority and Health Education England were created by the Care Act 2014; the Human Fertilisation and Embryology Authority was formed by its own Act in 1990; and the Human Tissue Authority was created by the Human Tissue Act 2004. Are we really saying that we need a more direct ministerial route to dissolve or amend these bodies?

We have recent precedent for this: over the course of the past couple of weeks, or certainly over the past few months, the Government have taken Public Health England apart, taking some functions for themselves and creating a new organisation with the remaining ones. They were perfectly able to do it in that case, which would seem to me to be a very drastic case. Now, we think that was a very bad thing to do—I will continue to make that argument—but what I cannot understand is why, if the Government were able to do that then, they would not pursue the same routes in the future.

I would not argue the case against clauses 88 to 91, which form the blueprint for these powers, but I would argue against the rationale for them existing at all. Amendments 68 to 72 again seek to protect the devolved settlement: as the Minister has said, clause 92 provides for devolved nations to be consulted on changes that are within their legislative competence, but I am concerned that that consultation might not go far enough. If we consider a policy area as a devolved matter, that surely requires consent. I have heard some response to that point from the Minister, but we may well hear a little bit more.

Clause 92 lists who the Secretary of State “must consult”. As well as devolved nations, it includes the organisation in question and then anyone else the Secretary of State wishes to consult. That list does not expressly include the public or experts in the relevant discipline, for example, and I do not think that is sufficient. In reality, the decision over Public Health England was a rash one, made in its early stages by individuals who are not really involved anymore. In all honesty, nobody would have made the decision that was made: it was a situation in which, despite our desperate attempts to give the Government room to do so, they never quite managed to climb down. However, talking to the public and to experts would have helped the Government make a much better decision in that case, and I am surprised not to see those groups included on the face of the Bill. I hope that we will get an assurance that at least in the Minister’s mind, “anyone else the Secretary of State wishes to consult” would involve some experts, if not the public. I very much hope it would.

To conclude, we have gone back and forth on this topic in recent days, and we cannot support the provisions in this part of the Bill. They are Executive overreach, and there are recent examples of why these powers are unnecessary, because the Government can already do these things. During the proceedings on the Bill, the Minister has frequently told us that our amendments are not necessary because they are already covered elsewhere. I am going to gently turn the tables and suggest that these powers exist elsewhere, and therefore these provisions are not necessary.

[Edward Argar]

I am grateful to colleagues for their comments and contributions. The short answer to the shadow Minister, the hon. Member for Nottingham North, is that comparing the UK Health Security Agency, for example, to what we are discussing here is in a sense comparing apples with pears. This is about non-departmental public bodies. UKHSA is an Executive agency, so it is already directly under the power of the Secretary of State, hence why the Secretary of State was able to make those changes. This is about the different categorisation of two subordinate bodies of the Department—NDPB versus Executive agency—which is why this section of the Bill deals with NDPBs, for which that power is currently not the same as it is for an Executive agency such as UKHSA. It is a technical point, but hopefully that gives the hon. Gentleman some explanation of the difference in approach.

Health and Care Bill (Seventeenth sitting)

Alex Norris Excerpts

Committee stage
Tuesday 26th October 2021 Public Bill Committees

Regulation of local authority functions relating to adult social care

[Alex Norris (Nottingham North) (Lab/Co-op)]

I beg to move amendment 145, in clause 121, page 102, line 40, at end insert—

“(11A) When conducting a review under subsection (1), the Commission must ensure the direct involvement of both users and providers of services.”

This amendment creates an explicit requirement for service users’ and providers’ involvement in the reviews and assessments that the new Part 46A creates.

[The Chair]

With this it will be convenient to discuss the following:

Government new clause 60—Default powers of Secretary of State in relation to adult social care.

Government new clause 61—Care Quality Commission’s powers in relation to local authority failings.

Clause stand part.

[Alex Norris]

We have been at this now for the best part of a couple of months. This is our 16th session. Some of the faces have changed but largely it is the same group of people. We have reached clause 121 of the Health and Care Bill and we have finally found the bit that is about care. It is amazing—you had to not blink or you might have missed it. But I would not get too excited; it is only two clauses, and neither comes anywhere near addressing the problems we face in our nation’s social care.

The national Government’s cuts to local authorities over the past decade have had a devastating impact, particularly around social care. They have led to rationed care and poor quality care. They have led to care being devalued as a profession and to providers being unable to retain their staff. As a result, we see short visits and a constant changing cast of carers, and we know that is bad for all those individuals receiving support. That is the story across all our communities, and it is worsening as we go.

Clause 121 proposes that the Care Quality Commission will now make a general assessment of the quality of a local authority’s offering for those needing care. Once those reports start coming back, I have no doubt they will make very difficult reading for many parts of the country, if not all, because they will lay bare the issues that I talk about. I do not have any problem with inspection and public assessment of the quality of care services. I do not have any problem understanding this at a local authority level rather than provider by provider. My constituents, and people across the country, deserve excellent services, and I can see how these things work in support of that goal. What I do worry about is that this will be just another way for the Government to passport blame to hard-pressed local authorities that are doing their best but are simply not adequately funded to do their job. That is the reality in this country today.

Amendment 145 seeks to improve clause 121 a little, in line with our broader efforts throughout the Bill, because we want to see service users at the heart of the health and care system as genuine shapers of what happens to them in their lives and their community. We want to make sure that those with the greatest stake and the greatest expertise by experience have the chance to be part of the process, as set out in clause 121, and to talk about their experiences in their community and about how things might be done better, because they hold so many of the answers to the challenges we face. That is a moderate but important ask and I hope the Minister will support it in the Bill or make a commitment that it will follow in the guidance that will be issued to the Care Quality Commission.

Similarly, we should seek the voice of providers, for a couple of reasons. First, they know what the successes and challenges are in their local system, and they know about the hard conversations they have with commissioners, which ought to be conversations about an individual’s needs but are, inevitably, rationing decisions. Secondly, and this them gives a special insight, many if not most—probably the vast majority—of these providers work across multiple local authorities, giving them a rich picture of the differences in approach, availability of care and similar. That is a rich contribution. We strongly think that those two voices should be heard, and the amendment is a good way of doing that.

Turning to Government new clauses 60 and 61, I express my gratitude to the Minister for his correspondence on them to give the Committee a sense of where the Government seek to go, but he was not quite able to provide comfort. New clause 60 is a mess constitutionally. It allows the Secretary of State for Health and Social Care greater powers over local authority social care functions, including giving him powers to talk about failures and directions. First, local authority accountability is to its public. We know that, every four years, we have elections. Beyond that, exceptionally and rarely, the Secretary of State who leads for local government—I know they have taken “local government” out of the name, but there is still one in whatever the Department is calling itself now—can take action in instances where the local authority is deemed to be failing in its duties to its population. The Secretary of State can put in directions, support and, as we have seen, even commissioners. That is a well-established process, but the clause inserts the Secretary of State for Health and Social and Care into this arrangement, which is a considerable overreach. It gives the Secretary of State a power to impose themselves on local authorities in a way that I do not think is welcome. At the bare minimum, it ought to be something that is exercised by the colleague of the Secretary of State who leads on local government in ways that are already well established, rather than creating another actor in the piece.

That leads us to the continued pattern that we have seen throughout the Bill. I am afraid that integration is a bit of a myth, but where there is any, it is largely that the health service ought to have more power and, more importantly, that the Secretary of State ought to have more power over telling local government what to do. There is no equivalent or supporting ability for local authorities to impact on the decisions taken by the Secretary of State. That creates a mismatch, which is really undesirable. I am keen to hear from the Minister why it was decided that the Secretary of State needed direct access to do that, when they could perhaps have worked better through their colleague, who does it more conventionally on a day-by-day basis.

New clause 61 dispenses with the Care Quality Commission’s ability to issue a notice of failure to a local authority in England. Again, when taken with new clause 60, my suspicion is that that is because the Secretary of State is in charge now. The commissioners and inspectors may be there to give some helpful evidence but, in reality, it is the Secretary of State who will command and control the system. That might be deemed adequate by the Government with regards to the health service, but I do not think it is adequate in local government, given the mandate that our councillors get from their population.

We cannot support the new clauses. We will not oppose clause 121, because there needs to be some oversight in the new environment that the Government are seeking to create, but I have no doubt that we will have to find a better way to do that in years to come. In the meantime, I hope that we can at least enhance that with amendment 145.

[Dr Whitford]

I rise to support amendment 145 but also to echo the comments of the Labour Front Bench about how far we have to go into the Bill, which is called a Health and Care Bill, before we hear anything about care. I think that all of us with any interest in social care have recognised the challenges within the sector over the past 18 months, which have been laid bare by the pandemic. What needs to come out is a much more radical approach to social care, including closing what is thought to be between a £6 billion and £8 billion funding gap in England every year.

In Scotland, we spend over 43% more per head on social care than in England, and that provides free personal care to people who are resident in Scotland. We fund the real living wage, which helps to begin to tackle the workforce issues, but the deeper issue facing all four nations is that we need a different approach to social care. The Feeley review, which the Scottish Government commissioned last autumn, highlighted the fact that we constantly talk about social care as a burden, and about how much it costs, instead of realising that almost half of those receiving care are people of working age. We must recognise the importance of social care for both younger and older people, recognise it as a human rights issue, and recognise it as funding to allow people to participate in the society in which they live. We need to turn that around, which means that we need to change the approach to the staff who deliver it.

Workforce is the biggest single problem. It is unfortunately much worse since we left the EU—certainly in parts of rural Scotland, where up to 30% of care workers were European citizens. We need to develop care as a profession. It is a registered profession in Scotland, but the staff need to be treated as professionals with career development, so that people come into social care for a lifetime, not just until they get a job on the checkout in Tesco. I appreciate clause 121, but it is not remotely radical enough. In something called the Health and Care Bill it is very small considering the mountain that has to be climbed.

[Edward Argar]

I do not think it is an entirely fair reflection to ask why it is taking so long to get to social care reform. We have already had debates about integrated care systems, integrate care partnerships and the integrated care board; a key element of that was about local government working with the NHS in the social care space, so that is a slightly unfair characterisation. Members will have heard the Prime Minister set out his ambitious plan to fix social care and waiting lists, with more to follow.

Clause 121 inserts proposed new section 46A into the Health and Social Care Act 2008, introducing a new legal duty for the CQC to review and make an assessment of the performance of local authorities in exercising certain regulated care functions related to adult social care. As part of the new legal duty, the commission will be required to publish a report of its assessment. The specific regulated care functions that local authorities will be assessed against will be set out in secondary legislation. These reviews will be informed by objectives and priorities set by the Secretary of State and will reflect indicators of quality and methodology devised by the commission and approved by the Secretary of State.

The commission may choose to revise the quality indicators and the statement describing the methodology periodically, or do so under the Secretary of State’s direction. In order to provide transparency, the commission must publish the objectives and priorities, the quality indicators that will inform assessments, and the statement describing the methodology. This new duty is crucial in increasing assurance and transparency about how local authorities are delivering critical adult social care responsibilities, on which so many people rely.

Amendment 145 would alter the proposed duty under proposed new section 46A of the Health and Social Care Act 2008, to require the Care Quality Commission directly to involve service users and providers when undertaking reviews of local authorities’ regulated care functions. I understand the spirit behind this amendment and sympathise with its aims. It is our intention that reviews by the CQC should draw upon a wide range of information and perspectives from the sector, including from providers and service users.

However, I do not feel this cause is best advanced through acceptance of this amendment. The views of people who use services, and the providers of those services, are already central to the way in which the CQC regulates. The CQC has a proven record of hearing a wide range of views since its creation over 10 years ago, both when it develops its methodology and when it assesses quality and safety in services. That is supported by section 4 of the Health and Social Care Act 2008, which places a duty on the CQC when performing its functions to have regard to views expressed by or on behalf of members of the public about health and social care services, and to the experiences of people who use health and social care services, and their families and friends.

Reviews under proposed new section 46A are not due to commence until 2023-24. As the CQC designs its approach to reviewing local authority performance before then, it will work closely with people who use health and social care services, their families, health and social care providers and the organisations that represent them, as well as other key stakeholders to ensure that its regulation is properly informed by a diverse range of views.

More detailed information on how local authorities’ reviews will be undertaken will be provided in a method statement, which the CQC must develop and the Secretary of State will approve. Section 46A(8) requires the CQC to produce a method statement outlining the method that it proposes to use in reviewing local authorities. This statement is a more appropriate place to set out operational details such as when and how providers and service users will be involved—the shadow Minister made a point about whether it would be guidance and whether it should be in the legislation.

I would like to further reassure right hon. and hon. Members, given the CQC’s publication of its new strategy, “The world of health and social care is changing. So are we” and “A new strategy for the changing world of health and social care” in May this year. That sets out a bold new approach to regulation, underpinned by a focus on what good and outstanding person-centred care looks like, and smarter use of data and intelligence. The CQC consulted on the strategy earlier this year, receiving more than 790 responses from people who use services, the public and voluntary groups and almost 400 from commissioning bodies and service providers. For the reasons that I have given, I would encourage the shadow Minister to consider withdrawing his amendment.

Let me turn to the relevant clause. Demographic change has resulted in more people having care and support needs, and we expect that trend to continue for the foreseeable future. As social care affects a greater number of people at some point during their lives, it is important that there is a transparent system through which local authorities can be held to account by their populations for delivering the right kind of care—I take the point, which I think the hon. Member for Nottingham North was making, about democratic elections, essentially, forming a key part of that; I do not disagree, but I believe it is important that there is a mechanism to assess quality of care in this context, and the best outcomes within the resources available. The measure delivers on that aim by requiring that assessment of how local authorities are delivering critical adult social care functions.

I believe that this new level of insight will support local authorities to understand what they are doing well and what they could do better. It will also help the Department to understand what is happening, forming an overarching national picture alongside the local-level assessments. I do not believe it challenges the parallel strands, which we have talked about before—the different approaches in a national health service versus local authority social care provision. I do not believe it threatens democratic oversight, either.

Turning to Government new clauses 60 and 61, new clause 60 provides the Secretary of State with powers to intervene where local authorities are failing to discharge their functions under part 1 of the Care Act 2014 to an acceptable standard. This will form one part of a new approach to assurance and support for local authorities, which will underpin our efforts to improve outcomes for people receiving care and support. Our new power of intervention will sit alongside this statutory CQC assurance framework. Where issues are identified, our priority will be to support local authorities to lead their own improvement. However, where CQC assessment identifies a persistent and serious risk to people’s wellbeing and local authorities are unable to lead their own improvement, it is right that the Government have powers to step in and help secure that improvement.

We will intervene using the most proportionate and appropriate tools available. That might include requiring local authorities to report to an improvement panel or co-operate with improvement advisers nominated by the Department of Health and Social Care. We have ruled out the use of independent trusts, whereby services are removed from local authority control and transferred to an independent charity or a commercial organisation. We will of course engage partners in the sector to finalise our approach, with additional detail to be set out in the forthcoming White Paper. Where necessary, the new clause gives the Secretary of State, or an individual nominated by the Secretary of State, power to take over the exercise of specified adult social care functions of a local authority.

In the light of our new approach to assurance and support, we are making changes to section 50 of the Health and Social Care Act 2008 through new clause 61. Where the CQC identifies failure, it may make recommendations to local authorities. It must also notify the Secretary of State of the failure and advise him on possible next steps to secure improvement. Because we are creating bespoke powers relating to adult social care services, we are taking adult social care functions under part 1 of the Care Act out of the scope of the existing powers of intervention under section 7D of the Local Authority Social Services Act 1970.

Our intervention amendments are key to ensuring that people can expect high-quality care, regardless of where they live; without clause 121, we would continue to lack a strong understanding of local authority performance, good practice and pioneering approaches that can support local authorities to meet the needs of those who rely on them for social care. I therefore commend the clause and the Government new clauses to the Committee.

[Alex Norris]

I am grateful for the contribution from the hon. Member for Central Ayrshire. I completely agreed with her point that, fundamentally, the No. 1 basic issue is a complete lack of investment, as we have seen over the last decade. Everything else after that becomes just tinkering around the edges, and there has been too much of that in this legislation. I share the hon. Member’s enthusiasm for taking a different approach—to stop treating social care as a burden and to understand our responsibility to working-age adults, but also to older people, and the investment and the national good of investing to ensure that those people can live independent lives and can reach their potential and do what they want to do. That we do not prioritise that in this country is a profound sadness.

Perhaps I was a little glib in the point that I made about the two clauses, and I am conscious that the Minister thinks that was unfair. He talked about other examples in which carers feature in the Bill. The reality is that each time it is about how care affects and reflects on the national health service. It is never about social care; it is about what the health service needs with regard to social care. Those two things are not the same. The point is that the Bill, for better or worse—we are not very enthusiastic about it—has 120-odd clauses about reforming the national health service and two clauses about reforming social care.

The problem is that for 11 years, or certainly for my entire four and a half years in Parliament, the Government have been promising a social care Green Paper that never comes. It is in a desk. It has supposedly been written for many years, but it never sees the light of day. Our failure adequately to grasp social care is really bad for society and terrible for the health service. That is why I made that point. How many more health service Acts do we have to see before someone finally tries to grab hold of social care? The reality is that we will have to see a change of Government for that to happen meaningfully.

The Minister’s comments on amendment 145 provided great comfort, so I will not press it to a Division. On the point that he made about needing a mechanism in cases where a local authority fails, in the most exceptional cases I agree with that, but what do we do when national Government fails? National Government have failed on that point for 11 years. The answer is that we wait until the next general election and try to persuade people. We have failed to do that three times in that period. That is right, but it also applies to local government, so I would not want to see that overused. I think I have made my point on Government new clauses 60 and 61, so I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Edward Argar]

I beg to move amendment 147, in clause 121, page 102, line 46, leave out “or”.

This amendment is consequential on NC59.

--- Later in debate ---

Over the coming year, the CQC will use its significant experience as an independent regulator to develop and pilot a methodology for reviewing ICSs, in line with its strategy to provide independent assurance to the public of the quality of care in their area. We expect that that will build and expand on the thematic reviews of health and care that the CQC has already undertaken, such as its local system reviews in 2018 of how health and social care services are working together within a system to support older people. We expect the CQC to develop that methodology in collaboration with NHS England and other relevant system partners, which goes back to the point made by my hon. Friend the Member for Eddisbury. That should ensure that the methodology does not duplicate or conflict with existing system oversight roles. The Secretary of State will also be required to approve CQC’s methodology before the reviews can commence. Once again, I thank the Health and Social Care Committee for its work on this matter and for its recommendation, which we are happy to take forward with this amendment.

[Alex Norris]

I am glad to see this change added to the Bill. Since the publication of the White Paper, we have called for greater oversight of integrated care systems. We offered options in previous sittings around democratic accountability, which would be our preference, but we may have to settle for this change, which does represent progress. Integrated care systems—in particular integrated care boards, which will be the system in reality—will be powerful. They will hold billions of pounds in funds, and will author and manage care for the entire population—a lot of people. The quality of their work will go a long way to deciding the quality of local healthcare provision and, indeed, health outcomes in their communities.

It is right to have oversight of that work, to have a way to hold systems up against each other and understand where there is success and where there are greater challenges, and to use an established overseer with reputation, experience and a degree of independence—one that the public know how to engage with and contact. It represents the first bulwark against the system working in its own interests, rather than in the interest of population health, which is good news.

I have a couple of specific questions, but before asking them I want to make a general point to the Minister. I hope we do not lose one of the best things that local government does, and does much better than the health service, which is sector-led improvement. The idea is that as we have however many—150—local authority areas in England, they will develop an awful lot of great experience over time and can share it among them. I do not mean, “Here, read our manifesto—we’re wonderful,” but in a day-to-day supportive and developing way, which is better than just waiting for an inspection every four years.

Before I was elected to this place, I was a member peer, and I helped those in other health footprints on the exact point of integration, so I know that established people are already working in this field. I recall that it was at one of these sector-led, improvement-type activities that I first met my hon. Friend the Member for Ellesmere Port and Neston. That was eight or nine years ago, when we were the future once in local government, or perhaps in politics in general—and look at us now! Nevertheless, the point is that there is loads of really good work going on in the LGA, and I really hope to hear from the Minister that that will be seen as an asset, and could now be developed for all these systems as something that would really complement an inspection regime.

I will make two quick points about the inspection regime itself. Proposed new section 46B(3)(a) in new clause 59 says that the CQC will have to establish indicators. Will the Minister clarify what he means by that? Is it about things we would conventionally understand —outstanding, good, requires improvement, adequate—or similar? Again, this needs to be something the public can easily understand, and we need to be able to understand what it is trying to tell us.

Under proposed new section 46B(6)(a)(i), it would be left to the CQC to determine the frequency of inspection. I feel that that is rather a function for the Department, as it commissions the inspector, than for the inspector itself. I seek at least a sense from the Minister of the frequency we are talking about. I understand that it might be different for different footprints—I think it was the hon. Member for Eddisbury who mentioned Ofsted—depending on how their ICSs are doing at a certain point, but what at least is the broad frequency we are talking about?

Those are important details, and I hope to hear greater clarity on them, but the basic principle that there is oversight is one we are supporting.

[Edward Argar]

I will be relatively brief. I am grateful to the shadow Minister, and I think that on this we are in broad agreement. He raised a few specific points, about which I hope I can reassure him. On local authority sector-led improvement, I entirely share his view; I think it is an asset. We are in the business not of excluding ways to improve, but of creating new ways to improve. If we have something that—he is absolutely right—does add value, I would hope it is looked to as an asset to draw on, rather than pushed to one side.

Let me discuss the hon. Gentleman’s other points. On indicators, yes, I entirely agree with him. While we must wait for subsequent developments to assess exactly how we characterise those—we will be doing a system assessment rather than an individual provider assessment, with complex moving parts—I entirely agree with his underlying point, which is that the indicators ideally need to be consistent with extant ones, to be easily understandable and to convey a clear message on performance—be it outstanding, good or whatever—as something that is meaningful to all our voters and to those using the systems.

On the hon. Gentleman’s final point about frequency, I may disappoint him a little in not being able to give quite such a clear answer. I am being cautious because I think it is right that the CQC—when it is given this power, subject to the passage of the legislation through Parliament—can take a step back and consider what it thinks. The ICSs will be at different stages of development in different parts of the country; some will be very much advanced because of where they are now, and some will not be.

It would wrong at this stage to be prescriptive about that frequency. I suppose I would say—we have seen this with Ofsted—that some are inspected very regularly because there is clearly a problem that needs to be addressed, but others that are doing quite well will be assessed at regular, but less frequent, intervals. That does not give the hon. Gentleman a clear statistical answer, but I would expect regular routine assessments, obviously with the facility for the CQC to do more frequent assessments where it thinks something needs bottoming out or where it needs to support such improvement. I hope that that, to a degree, answers the points he made, all of which are valid and important.

Amendment 147 agreed to.

Amendment made: 148, in clause 121, page 103, line 3, leave out “or”.—(Edward Argar.)

This amendment is consequential on NC59.

Clause 121, as amended, ordered to stand part of the Bill.

Clause 122

Provision of social care services: financial assistance

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

[Edward Argar]

I will be relatively brief. The clause will expand the Secretary of State’s powers under the Health and Social Care Act 2008 so that payments can be made to all providers delivering social care services. It will also allow the Secretary of State to delegate the new power to special health authorities via directions.

The power in the 2008 Act excludes providers that operate for profit. Given that social care in England is largely delivered by private providers operating on a profit-making basis, the Secretary of State is unable to make direct payments to much of the sector under the existing power. Crucially, the power can be used only by financial assistance bodies engaged in providing social care services or services connected with social care services.

The coronavirus pandemic has demonstrated the need for speed and flexibility in providing support to the care sector. Without the clause, our only means to deliver financial assistance to social care providers is via local authorities. We are clear that the power will not be used to amend or replace the existing system of funding for adult social care, whereby funding for state provision is funded via local authorities, largely through local income and supplemented by Government grant.

The new power will allow the Secretary of State to react to unforeseen and changing circumstances by directing financial assistance social care providers with greater speed and in a more targeted manner. That is one of the learnings that we are seeking to implement as a result of what has happened during the recent pandemic. I therefore commend the clause to the Committee.

[Alex Norris]

I will be very brief, not least because we will not divide the Committee. However, I could not let us go past the clause without mentioning the heading. I must read it from the Bill because it gives me so much pleasure: “Provision of social care services: financial assistance”. Wouldn’t that be something in this country?

It is quite something to see the Government seeking to establish a mechanism to fund social care because we have been waiting 11 years for them to do so. During tomorrow’s Budget, we will listen with interest for news of support for social care. Given that most of the Budget has been leaked already, I dare say we will be disappointed. I feel a little as though the clause is the parliamentary equivalent of being threatened with a good time.

We do not have any issue with the establishment of such a mechanism, although our preference would be for that to be done by the Department that leads on local government, rather than by the Secretary of State for Health and Social Care, because we think that that is confusing. However, we do not oppose the principle behind the clause.

I can foresee the scenario in which this power would be desirable, but I would like the Minister to reiterate on the record that it will not lead to the routine commissioning of private providers outside the commissioning plans of the local authority. Each local authority puts incredible efforts into commissioning services in its community. The last thing local authorities want is someone doing a sideline arrangement on a different matter. To be clear, this is an exceptional power—almost an emergency power—and not one that we would expect to be used frequently.

[Edward Argar]

I think I can give the shadow Minister that reassurance. The clause is intended to reflect some of the learning from the pandemic. There are occasions when such intervention is necessary, but there is no intention, as I said in my remarks, to in any way go round or replace the current commissioning functions of the local authority. I have had discussions with the Local Government Association on exactly that point, so I hope I can give him the reassurance he seeks.

Question put and agreed to.

Clause 122 accordingly ordered to stand part of the Bill.

Clause 123

Regulation of health care and associated professions

--- Later in debate ---

[Dr Whitford]

Basically, clause 125 is just schedule 16 —there is nothing very much in clause 125. I sat on the Health and Social Care Committee when we talked about trying to tackle obesity, which is a growing harm across the UK, giving rise to heart disease, diabetes and so on, and the difficulties of trying to regulate the advertising of unhealthy foods, particularly foods with high fat, salt and sugar. I welcome the fact that there is an attempt to tackle that issue in broadcasting, streaming and particularly online.

I have concerns that the exemption for small and medium-sized enterprises could be worked into a loophole at a later date by large companies simply employing multiple small advertisers or restructuring themselves to get away with still advertising. I would be grateful if the Minister could explain that exemption, because unhealthy food is just as unhealthy whether made by a small or a big company.

Broadcasting and online regulation are clearly reserved matters, and I totally respect that, but public health is devolved, so I would welcome clarification from the Minister on exactly how the devolved Ministers will be involved, how their public health policies will be respected, and how they will be consulted.

Proposed new section 368Z20(3) of the Communications Act 2003 gives power to amend by regulation Acts of the devolved Parliaments, and proposed new subsection (4) states that the Secretary of State can consult who they think appropriate. I am surprised that at that point there is no mention of consulting the devolved Governments. I totally accept that it would not be a matter of consent, but yet again there is absolutely no mention of consultation with or involvement of the Public Health Ministers in the devolved nations.

[Alex Norris]

It is a pleasure to speak to this important clause, which sets out restrictions on advertising less healthy food and drink. I echo what the hon. Member for Central Ayrshire said about its importance and the general commitment to it across the House. Importantly, it also gives me an opportunity to put on the record a message of thanks to the hon. Member for Bury St Edmunds (Jo Churchill) for all the work she did in this area while a Health Minister. She has moved to a new post during the Bill’s consideration, but she championed this provision for a long time and fought very hard for it, so I have no doubt that she will be glad to see it included in the Bill.

These measures form part of the Government’s obesity strategy, which is coming through the system bit by bit. The strategy has largely come through in secondary measures, so I welcome the fact that this provision has been included in the Bill, because it gives us an opportunity to propose improving amendments. Is the Minister able to explain why other provisions in the strategy have not been brought forward in this way? For example, we have considered a statutory instrument on showing calories on menus, which I dare say all Members will have received something about in their mailbags, because it is a contentious and emotive topic, with many shades of grey. That provision would have been improved if we had had a chance to amend it, so I am sad that we instead got a “take it or leave it” measure. I do wonder why the entire obesity strategy was not put through in this way.

Turning to what is before us, ensuring that we do not see the aggressive promotion of products high in fat, sugar and salt, particularly to our nation’s children, is an important step in reducing the obesogenic environment we live in. We know that one in three of our children leave primary school overweight and one in five are obese, and we know the lifelong impact that that has on physical and mental health, such as the links to diabetes, musculoskeletal ailments and depression. We also know the impact on children’s education, as they go to secondary school and beyond, and on their prospects in the world of work.

It is a well-established and long-standing precedent in this country that we try to protect children from exposure via the television by using a watershed, so it makes sense to consider these products within that scope. Of course, the nature of the content we all consume—children are no exception—has changed beyond all recognition in my lifetime. The explosion of the internet and its pre-eminence in our lives has provided new advertising space for traditional means—banner ads, pop-up ads and similar—but there is also a much broader platform. Today is probably not the day, certainly not in the witching hour of this Committee, to get into the influence of culture and how the entertainment landscape is changing—not least because I feel woefully underqualified to talk about it—but the point is that there are extraordinarily novel ways of connecting with people, especially young people. It is therefore right that we in Parliament enter this space to try to create the safest possible environment.

I will say, alongside this, that I am surprised that we have not yet seen the online harms legislation—it seems to have been coming through the system for a very long time indeed—because it would sit very neatly with this. I hope there will be a sense of trying to weave this in with that in due course.

The Government’s answer here goes beyond a watershed and into full prohibition. I hope that the Minister will take us through how that decision was reached. I understand from my conversations with industry, particularly those working in digital media, that they have offered a solution that would act as a de facto ban for children without being an outright ban. Given that we genuinely lay claim to being world leading in advertising in general, and in digital media in particular, we ought to listen if there are more elegant ways of doing that. I hope the Minister can cover the conversations being had with the sector and why this approach was chosen, not a slightly more nuanced one. Perhaps it was considered too complicated, but we need to know that.

As the hon. Member for Central Ayrshire says, clause 125 inserts schedule 16 into the Bill. As that is where the meat is, I want to probe the Minister on a couple of points. First, on the fines regime, what are the sanctions in the Government’s mind? Secondly, the schedule provides for regulations to follow. I suspect we will see a full regime, but when are we likely to see it? How far along are we, and what sort of consultation will there be? Thirdly—again, this will be a matter for regulations, but I hope the Minister might be drawn on it now as a concept—who does the burden fall on? Is it the advertiser or the platform? It might be both, and obviously it could not be neither. That will be a very important point going forwards.

Adding to the case the hon. Member made about small and medium-sized enterprises, we supported that conceptually in the statutory instrument on calories on menus because there was agreement that it was reasonable to say that these things would be a significant burden for a small operator, which might have only one or two members of staff. I do not think that applies in the advertising space. Again, we would be keen to understand how the Minister and his colleagues reached the conclusion they did.

Amendments 139 and 141 deal with alcohol. One of the few parts of the obesity strategy where we have departed from the Government’s view is the curious decision to remove alcohol, particularly with regard to calories and labels. We all know that alcohol is a less healthy product—I may well be the billboard for that, certainly when it comes to weight—so why has it been left out? Our amendments are more probing than an attempt to actually change the Bill, because I hope that alcohol has already been covered. However, in the obesity strategy in general, it seems to have disappeared, which seems very odd. I hope that the Minister can explain his thinking on that.

New clause 55 seeks to protect the nutrient profiling model. According to gov.uk, the NPM

“was developed by the Food Standards Agency in 2004-2005 as a tool to help Ofcom differentiate foods and improve the balance of television advertising to children. Ofcom introduced controls which restricted the advertising of HFSS foods in order to encourage the promotion of healthier alternatives.”

So far, so good. We would say that that principle is sound today and will be sound going forward; that is why we are keen to see it in the Bill. It is crucial that we continue to uphold those standards, but we know that foods change. We know that our understanding of what different nutrients mean for us or our children changes over time. We know that the biggest prize in this space is about reformulation, as much as it is about anything else, which would put more stresses on the NPM. I am keen to hear a full commitment from the Minister today that before meaningful changes are made to the NPM, they will be put out to proper consultation and that industry and consumer groups will be properly engaged, along with anyone else who may have an interest.

I will finish with amendment 113, in the name of the hon. Member for Central Ayrshire. I have made the arguments around engagement through consent, mutual good faith and co-operation from Ministers multiple times, and I hope to hear that in closing.

Clause 125 is very important, and we would like to know a bit more about schedule 16. I would be keen to hear that the issues raised in our amendments are covered elsewhere or at least to have a commitment to that. Finally, I would like to hear a bit about the nutrient profiling model.

[Edward Timpson]

Briefly, on clause 125 and schedule 16 in particular, I want to pick up where the hon. Member for Nottingham North left us, on the issue of obesity. I think we all share concerns that a rising number of children continue to leave primary school either overweight or obese. Much of the answer to tackling that lies in making physical education and sport part of the core curriculum in schools, but we need to look at all measures, including on what children look at and are exposed to in the changing and more digital age in which we live. I welcome measures to tackle that head on, particularly in primary legislation, although I recognise that regulation will flow from that.

--- Later in debate ---

[Dr Whitford]

I do not plan to press my amendment to a Division, but I encourage the Minister to put in the Bill the consultation that is required. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 125 ordered to stand part of the Bill.

Schedule 16 agreed to.

Clause 126

Hospital food standards

[Alex Norris]

I beg to move amendment 137, in clause 126, page 107, line 18, leave out “hospital”.

This amendment would make the power to impose food standards applicable to all premises within the remit of the Care Quality Commission, rather than just hospitals.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 138, in clause 126, page 107, line 28, leave out paragraph (c).

This amendment is consequential on Amendment 137.

Clause stand part.

[Alex Norris]

It is a pleasure to speak on the important topic of hospital food standards. We very much support the substance of the clause, and its inclusion in the Bill. What we consume before, during and after we engage with a hospital can have a profound impact and long-lasting effects on the ailment that brought us there, and affects our experience while we are there.

Even prior to being in hospital, malnutrition is a feature in many people’s lives. It affects about 3 million people in the UK, and health and social care expenditure on malnutrition is estimated at more than £23 billion a year across the UK. Around one in 10, or 1.3 million, older people are malnourished or at risk of malnutrition, and older people are disproportionately represented in malnourished groups. Of course, malnutrition plays a significant role in hospital admissions; around one in three patients admitted to hospital are malnourished, or at risk of becoming so.

This is the right time to act on this issue. We ought to expect that a person’s time in hospital will be used as well as possible, and what a person consumes while they are there should be seen as part of their care, reablement and rehabilitation. It is a good idea to make sure that our hospitals promote that view, and we therefore support the clause. Our amendments 137 and 138 would improve it, and I hope to find the Minister in listening mode on this.

The whole point of the Bill is that while hospitals are one element of our health and social care system, there are many other places in the system that people are more likely to find themselves in. They may be in community-based care facilities, in step-up or step-down care, or a care home, which could be their permanent home. We argue that anything within the purview of the Care Quality Commission ought to adhere to the standards set out in the clause. The evidence bears that out. Somewhere between a third and 40% of patients admitted to care homes, and one in five patients admitted to a mental health unit, are at risk of malnutrition, so clearly they would need this sort of support.

For those in long-term care settings, nutrition is a vital part of their care. Research has shown the importance of good nutrition to people with dementia; it slows the loss of independence or functional decline. Research shows that nearly 30% of dementia patients experience malnutrition, and that is associated with a much more rapid functional decline over five years. It is really important that we make sure this provision is in place for them; it is fundamental to their life and their future.

Of course, the issue with the two amendments and the clause is resourcing. I am interested to hear from the Minister how the Government intend to resource the clause, because we do not want pressure on hospital settings—and settings in the community, if our amendments are accepted—to make cuts elsewhere. It would be a pyrrhic victory if the clause led to better nutrition but worse care. We need to see the measures as not only the right thing to do—of course, it is what individuals should expect when in the care of the state—but a good investment that will bring us a good return. This is an important issue, and I look forward to hearing the Minister’s response.

[Edward Argar]

As matters stand, the enforcement of standards for food and drink in hospital is not on a statutory footing. That has resulted in variance in compliance across the sector. The clause will grant the Secretary of State the power to make regulations imposing requirements and improved standards for food and drink provided and sold on NHS hospital premises in England to patients, staff, visitors or anyone else on the premises. As the hon. Gentleman set out, providing good-quality, nutritious food is a cornerstone of patient care, and placing these requirements on a statutory footing will ensure a level playing field when it comes to compliance across the sector with nutritional standards in hospitals.

The Care Quality Commission will ensure that any requirements in regulations made under the clause are fulfilled, pursuant to its existing statutory powers of enforcement under the Health and Social Care Act 2008. The clause demonstrates that we are committed to acting on a key recommendation from the independent review of NHS hospital food, published in October 2020, to ensure that hospital food standards are enshrined in law and sufficiently enforced .

To address amendments 137 and 138, as I have set out, the clause has been drafted specifically in response to the independent review of NHS hospital food, which was published on 26 October 2020. That independent review was announced in August 2019, following the deaths of six people linked to an outbreak of listeria in contaminated food in hospitals. The review’s aims were to improve public confidence in hospital food by setting out clear ambitions for delivering high-quality food to patients and the public. The review was intentionally limited to hospitals only because specific issues had been identified in relation to hospital foods that necessitated a prompt and meaningful response by the Government.

The report was prepared following considerable research, investigation, hospital visits and expert advice from within and outside the NHS specifically in relation to the provision of hospital food. The review recommended that ambitious NHS food and drink standards for patients, staff and visitors be put on a statutory footing. We support that recommendation and have included the clause in the Bill because we believe that giving the Secretary of State powers to place hospital food standards on a statutory footing sends a clear message about the importance of standards for the provision of good hydration and nutrition in the NHS. Covid-19 has highlighted the importance of good nutrition in recovery and rehabilitation, were such a reminder needed.

I reassure hon. Members that the Government are committed to the health and wellbeing of patients in all healthcare settings. Each setting presents unique issues and challenges. Although there may be some common themes, if the clause were to be broadened beyond hospitals, the provision of food in other healthcare settings would need to be researched, investigated and carefully considered in the context of those individual settings and in consultation with their service users and stakeholders to ensure that the legislation was fit for purpose and met their individual needs. Challenges affecting the provision of food in other healthcare settings were not considered as part of the scope for the independent review of hospital food. Therefore, although there are common themes, we cannot be sure that the amendment would adequately and fully meet their needs and requirements.

The recommendations from the review, and the introduction of the clause, form a key part of our policy to improve public confidence in hospital food. I commend the intention behind the amendments to expand the clause to capture all premises within the remit of the Care Quality Commission.

The CQC already has some important powers over other healthcare settings. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provide the CQC with powers to prosecute providers that do not provide people in their care with nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment. That power ensures that basic nutrition standards are provided.

The clause goes further and is not about basic provision. The root-and-branch independent review made recommendations on how NHS trusts could prioritise food safety and provide more nutritious meals to staff and patients. The clause is a key component of our plan to fulfil the recommendations of the review. I reassure hon. Members that the CQC remains vigilant about the provision of nutrition and hydration in other healthcare settings, as evidenced by the CQC’s powers.

For these reasons, I urge the hon. Member for Nottingham North not to press the amendments. Ultimately, the clause cements the Government’s commitment to patients in this regard and sends a clear message about the role that food plays in patient care and recovery. I commend it to the Committee.

[Alex Norris]

I appreciate the Minister’s response. I understand that the genesis of the clause was a hospital setting. The case that the Minister mentioned was exceptionally serious, and it is right that action was taken, but I feel that there is a slight lack of ambition to say that the activity must stop at hospitals—it is a slightly blinkered approach. I heard the point that extending the provision to broader care settings would take research and careful consideration. I probably support that principle, but I would like to have heard that that process is under way, and I did not hear that.

At the end of the day, the goalposts do not move that much. Basic nutritional and hydration standards are either being met or they are not. Taking the learning from hospital settings should have made it easier to widen the process, rather than harder. The point that the CQC inspects those settings is true and fair. It is also true of hospital settings. Setting some standards would probably have been prudent. I will not press the amendment, but I think we will return to the issue at some point. I hope the Minister and his officials will reflect on the opportunity to go further with the provision .

[Edward Argar]

I am always happy to reflect on the sensible suggestions made by the hon. Gentleman.

[Alex Norris]

I am grateful for that and, on that basis, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 126 ordered to stand part of the Bill.

Clause 127

Food information for consumers: power to amend retained EU law 

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

[Edward Argar]

I can reassure the Committee that I will be a little briefer than in my remarks on clause 125.

Clause 127 amends the Food Safety Act 1990 to make provision for domestic legislation to modify retained EU regulation 1169/2011 concerning the labelling, marketing, presentation or advertising of food and the descriptions that may be applied to food. The current powers to amend the regulation are limited in scope. This power will afford the Government an additional necessary lever to introduce domestic changes that better suit and support consumer needs and priorities for food information. We know that consumers want transparency and clear information about the food and drink that they are buying, and such information can inform people’s choices. Scientific information and evidence on labelling and consumer needs continue to evolve. We want the ability to respond quickly to those changes and that changing evidence base as and when required.

Retained EU regulation 1169/2011 sets requirements on labelling and food information in the UK. It was designed to apply to EU member states. Now that we have left the EU, primary legislation is required to modify the retained legislation. Clause 127 will help us to settle this issue by conferring powers on the Secretary of State in England, and Ministers in Scotland and Wales, to modify requirements on food labelling using regulations. The regulations made under this power will be subject to the affirmative procedure, which will ensure that any changes introduced are debated and actively approved before implementation.

The clause will be vital in supporting the Government to deliver on a range of policies being developed as part of our obesity strategy, which includes commitments to consult on front-of-pack nutrition labelling and whether to mandate alcohol calorie labelling. The power will enable us to make improvements to food and drink information more effectively while retaining a level of scrutiny on any proposed changes. The clause can also help us to deliver on wider Government objectives, including options for the forthcoming food strategy White Paper, which sets Government ambitions and direction for food system transformation. I commend clause 127 to the Committee.

[Alex Norris]

The Minister and I have had these Brexit-type statutory instruments time and time again, so I am not going to get too involved in the conversations that we have had. As we said in the discussion on clause 146, we would like to see greater safeguards. We are glad about the use of the affirmative procedure but we do not think that there is a strong mandate for Ministers to march across the statute book. I hope to hear that this power will be used to the minimum extent necessary to implement the decisions that we have taken.

[Edward Timpson]

I want to put on record my support for the clause and for the opportunity that it presents for our domestic market and the promotion of locally grown produce, the high standards of animal welfare across the UK and our eco credentials. We do not want to make labelling too complicated for people––we want to make it accessible and simple to decipher––but this power is a chance to put that to the forefront so that consumers get produce that is good for them but also good for the UK market.

--- Later in debate ---

[Alex Norris]

I beg to move amendment 149, in clause 128, page 108, line 22, at end insert—

“(za) in subsection (3)(a)(i), after “Secretary of State” insert “or relevant local authority”;”

The Bill removes the ability of local authorities to commence fluoridation schemes and gives that ability to the Secretary of State. This amendment, together with Amendment 150, seeks to allow local authorities to commence schemes as well as the Secretary of State.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 150, in clause 128, page 108, line 26, after “Secretary of State” insert “or relevant local authority”.

See explanatory statement to Amendment 149.

Amendment 151, in clause 128, page 108, leave out lines 33 to 36.

This amendment would remove the ability of the Secretary of State to pass the cost of fluoridation onto another public body.

Clause stand part.

Clause 129 stand part.

[Alex Norris]

I am really pleased that we have reached clauses 128 and 129, on fluoridation of water supplies. This is something that I am personally very enthusiastic about, so I want to make a few points on it. Fluoridation is a very important venture. Oral ill health can be a hidden and very personal but insidious ailment. It is the single biggest reason for hospital admission among our children. A 2015 review of children’s dental health found that a quarter of five-year-olds have decayed teeth, with an average of 3.4 per child.

[Dr Whitford]

I wonder whether the hon. Member, like me, is surprised that the opportunity offered by this Bill has not been used to introduce a child dental health programme in England similar to Childsmile, which has existed in Scotland since 2007, or the scheme that Wales has had since 2011. Although there was agreement a couple of years ago to establish pilot sites across England, data on the impact in Scotland, where many areas had significantly poor dental health, has been available for four years. I am just surprised that something like that has not been included in this Bill, when we are talking improving the dental health of children and addressing the fact that, as the hon. Member mentioned, dental clearance—the removal of significant numbers of teeth—is the commonest reason to administer a general anaesthetic to a child. That is quite a shocking indictment.

[Alex Norris]

I am grateful for that intervention; I was going to turn to that issue next. Not only have opportunities been missed over the last decade to invest in oral health, but we are actually going backwards. Supervised tooth brushing and other high-quality evidence-based interventions, such as the models that the hon. Member mentioned, have disappeared because of this Government’s cuts to the public health budget. Of course, the savings from those cuts are hoovered up very quickly by the costs that they generate elsewhere in the system. It is very sad, it results in a lot of pain and lost potential for the individual, and it is bad for the collective.

Fluoridation is one element in trying to put that right. Putting fluoride in our water is a really good, evidence-based intervention that is proven to work. For every pound spent in deprived communities, there are savings of nearly £13 within just five years, and of course every independent review of fluoridation has affirmed its safety. As a nation, we ought to be creating new fluoridation schemes targeted at the communities that would benefit the most. The current system does not work, as I remember well from my time in Nottingham. Currently, a local authority has to decide to enter into this space, build support, and then, with support from Public Health England and the Secretary of State, move to implementation. However, that generally fails for two reasons.

First, our political boundaries do not match up very accurately with our water boundaries, so where we would physically tip in the bag of fluoride does not fit with our political geographies. That creates issues between authorities such as mine, where the case would be very strong because of our oral health outcomes, and bordering authorities that would have less interest because they have better oral health outcomes. Secondly, this issue is contentious. Local authorities have an awful lot on, and it is very hard for a local council to make this the one totemic fight in its four-year term. There are only so many big things that a council can take on at once, and fluoridation gets beyond the bandwidth of local authorities.

We support the principle behind clause 128; bringing the Secretary of State into this is a very good idea. The position of the Secretary of State, once removed from the entire country, can make different geographic decisions sensibly align with water boundaries. He is perhaps also in a stronger position to help with some of the political issues, so in concept we support that.

Amendments 149 and 150 are a pair. Why are the Government keen to swap the current local system for one that is nationally driven, when we could have both? As I have said, we support adding the heft of the Secretary of State to the local expertise of our councils, but why remove councils from the process? Although clause 128 gives new powers to the Secretary of State, our argument is that local authorities should be able to retain their powers in the event that they might want to use them. This is a cost-free proposal. It merely expands the range of possible approaches and paths towards fluoridation, and it promotes local decision making.

Clause 128(2)(d), which inserts new subsection (6B) into section 87 of the Water Industry Act 1991, is a little bit naughty, and amendment 150 seeks to address it. According to page 43 of the Government’s community water fluoridation toolkit, if a local community can successfully get itself together to get a scheme going, Public Health England is required to meet the reasonable capital and operating costs. I presume that that responsibility ported to the new Office for Health Improvement and Disparities when it came into force at the beginning of this month. However, subsection (6B) removes that provision and instead allows the Secretary of State to direct another body—I presume it will be the local authority—to pay for the scheme. Therefore, instead of being paid for nationally, the scheme will be paid for by a body chosen by the Secretary of State. That will be a barrier to the creation of a scheme.

I think that local authorities will be less keen to engage with the Secretary of State in implementing a scheme if they feel that they will have to pay for it. Their budgets are exceptionally stretched—I suspect they will not get much support tomorrow—and the benefits do not generally go back to local authorities. Of course, the benefit goes to the community in general, but in terms of organisations and cashable benefits, they would be health service benefits rather than local authority benefits. I do not think that the proposal promotes integrated thinking. The amendment seeks to address that, and I hope that the Minister will reflect on it. As I have said, I think that, broadly speaking, the clauses do the right thing, but their current effect will be to replace a locally led system with a nationally led one, when actually we could just have both.

To conclude, over the past year we have stood shoulder to shoulder with the Government in expressing to communities up and down the country that vaccines are not only safe but necessary. The objections that we receive come from those who argue in the face of evidence or who rely on conspiracy theories. The same is true of arguments against fluoridation. It is an evidence-based, safe and highly effective intervention. That is not to say that it is easy to do. It does not require behaviour change but it has a remarkable impact, so I am keen to hear from the Minister not only that the Government want to put this in the Bill, but that they want to get on with doing it in communities such as mine, which will benefit. If they do that, we will stand shoulder to shoulder with them again, and I think it will be an exceptionally important breakthrough in oral health in this country.

[Edward Argar]

The hon. Gentleman is absolutely right in the points he makes about fluoridation and the parallels he draws with the vaccine. Although there have been times over the past 20 months when he and I, and our respective Front-Bench teams, have not necessarily agreed on every aspect of the response to the pandemic—that is appropriate, as the Opposition seek to challenge and question the Government—may I pay tribute to him and his colleagues in the shadow health team for what they have done to highlight the importance of the vaccine and to counter the misinformation that some have spread about it?

I will speak to amendments 149 and 150 together, as the former is consequential on the latter. They would allow for local authorities to bring forward proposals for new fluoridation schemes and to enter into arrangements with water companies. As has been set out, tooth decay is a significant, yet largely preventable, public health problem. In 2019-20, more than 35,000 people aged 19 or under were admitted to hospital for the extraction of decaying teeth. In the same year, the cost of hospital admissions for tooth extractions among that age group was estimated to be £54.6 million.

As we know, fluoride is a naturally occurring mineral found in water and some foods, and at the right levels it has been shown to reduce tooth decay. If five-year-olds in England with low levels of fluoride drank water containing at least 0.7 mg of fluoride per litre, the number experiencing decay would fall by 28% in the most deprived areas, and the number of hospital admissions for tooth extractions due to decay would reduce by up to 68%.

We have seen no new water fluoridation schemes implemented for the past 40 years. Both major parties in the House must accept our responsibility for that. That is not a fault of the NHS or local government, but because responsibility in our view has sat fundamentally at the wrong level for driving forward such a health intervention. Local authorities currently have the responsibility to initiate new water fluoridation schemes or to propose that existing schemes are varied or terminated. We have heard their frustration with the overly burdensome and complex processes in place for initiation and variation of schemes. The steps we are proposing to take through the Bill are intended to make it simpler to expand schemes. We all share the same ambition.

Transferring responsibility to central Government will allow us, for the first time, to move away from the limitations of local authority boundaries and to look more strategically across the country, to where oral health is the poorest. Subject to funding being agreed, we will be able to expand schemes across larger areas to make an impact on a bigger scale. We know it is less cost-efficient to operate schemes across individual local areas.Allowing local authorities to continue to bring forward schemes and to enter into arrangements with water companies separately would run counter to our ambitions to manage expansion at a higher level, again adding extra complexity, which we are eeking to remove.

We understand that some local authorities have begun the process to bring forward schemes, and we appreciate that they are passionate about their schemes and the benefits that they would bring to the populations they serve. I want to provide assurance that we share the ambition to expand schemes so that more of the population can benefit from water fluoridation, which we know is both safe and effective.

Any plans to expand schemes will of course take into account oral health across the country as well as areas that have already began to progress schemes. We want to engage and listen to local areas so that together we can make the biggest impact on oral health improvement that we know fluoridation will provide. For those reasons, I ask the hon. Member for Nottingham North to consider withdrawing his amendment.

On amendment 151, we are taking powers in the Bill to remove the operational burden associated with bringing forward new schemes. Prior to 2013, both the NHS and local authorities had, at different times, responsibility for funding both revenue and the capital cost associated with fluoridation schemes. There are no current proposals for cost sharing, but given the cycle of legislation and the infrequency with which such opportunities present themselves, we have taken the decision to include such measures in the Bill.

We have discussed the provisions with both NHS England and NHS Improvement and the Local Government Association, and I can assure the Committee that should we bring forward any plans to cost share in the future, we would seek to fully engage with relevant groups at the earliest opportunity. Under the Bill, any plans to cost share with public sector bodies would be subject to regulations on which there is a requirement to consult.

A precedent has been set over the decades for the funding of water fluoridation schemes. We believe that, to move forward, it would be best to have the flexibility to work collaboratively across industry and the public sector to effect what could be the most significant improvements in oral health that we have seen to date. For those reasons, I ask the hon. Member for Nottingham North to consider not pressing the amendment to a Division.

Clause 128 would transfer the power to initiate, vary or terminate water fluoridation schemes to the Secretary of State. The clause also allows for the Secretary of State to make regulations that will enable the sharing of costs for fluoridation schemes with water undertakers and/or public sector bodies that may receive benefit from such schemes. However, before making any such regulations, the clause imposes a duty on the Secretary of State to consult. The clause also requires the Secretary of State to consult water undertakers on whether any proposal for new fluoridation schemes, or whether any termination or variation of an existing scheme, is operable and efficient prior to undertaking any public consultation, for which there will also continue to be a duty.

The clause requires us to set out in regulations the process for consulting the public, for example on any new proposed schemes. That will ensure that those affected will continue to have a voice. In September, the chief medical officers for England, Scotland, Wales and Northern Ireland made a joint statement confirming that water fluoridation is an effective public health intervention for improving the oral health of adults and children. Such schemes have been in operation for more than 60 years, and no credible evidence that they cause health harms has emerged. It is time we take action that will enable us to reduce the oral health inequalities across the country, and I commend clause 128 to the Committee.

I turn briefly, and finally, to clause 129. We have a number of existing water fluoridation schemes across England that have been in place for decades. We want to ensure that those existing arrangements can be treated in the same way as any new schemes created using the powers in clause 128. Clause 129 simply provides for the existing arrangements to be treated as if they were made under the new statutory regime for fluoridation. The clause also provides that all previous England fluoridation arrangements shall be treated as if they were entered into between the Secretary of State and the water undertaker. The Secretary of State has the power to modify the detail of these existing arrangements to give effect to this, provided he first seeks to agree the modifications with the water undertaker.

I therefore commend these clauses to the Committee.

[Alex Norris]

I take the Minister’s point about current powers. I agree that they are clearly at the wrong level, because these schemes simply are not coming through, so the system is obviously not working. As I say, I would rather we added what we are putting in the Bill today to what we already have, but I have probably made my point, so I do not intend to press amendments 149 or 150 to a Division.

The Minister has made the point that there are currently no schemes in the system. I hope that when it decides which schemes to prioritise or pilot, the Department might at least look fondly on local authorities—such as the city of Nottingham—that have made such commitments in their council plans.

Finally, on amendment 151, I have heard what the Minister said about cost sharing. That gave me some comfort, so I will not press that amendment to a Division either. I beg to ask leave to withdraw amendment 149.

Amendment, by leave, withdrawn.

Clauses 128 and 129 ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Steve Double.)

Health and Care Bill (Eighteenth sitting)

Alex Norris Excerpts

Committee stage
Wednesday 27th October 2021 Public Bill Committees

[Edward Argar]

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

New clause 62 adds to section 164 of the National Health Service Act 2006, enabling regulations to be made that would allow further products to be centrally stocked and supplied free of charge to community pharmacies without the need for reimbursement under the standard NHS arrangements. This would allow Ministers to create limited additional exemptions to the exemptions that can already be created by the regulation-making power introduced in 2017 for unlicensed medicines, more commonly known as “specials”.

As was recognised in 2017, the legislative framework for pharmaceutical remuneration established by section 164 is predicated on the basis that community pharmacies will be reimbursed for the products they supply. Unique conditions required the unlicensed specials medicines amendment to be tabled in 2017 due to an unconventional supply chain. Unusually, there was no competition and, therefore, no incentive for community pharmacies to seek value for money for unlicensed medicines.

Under normal conditions, a virtuous competitive circle would encourage community pharmacies to try to source the lowest cost product and, in doing so, force overall prices down. The 2017 amendment allowed for regulations to be made so that the process of sourcing the relevant products could be by central procurement and subsequently there could be direct supply to community pharmacies. No such regulations have yet been made, but the matter remains under review.

The amendment only seeks to further add, in a limited way, to the current powers to make regulations to provide for an exemption from the ordinary requirement to reimburse. The only products that it will cover are vaccines, pandemic treatments, and associated products such as diluents and syringes. There are various reasons why we may seek to procure centrally vaccines or products used to treat a pandemic, for example when the typical competitive supply chain and reimbursement arrangements cannot be relied on, because pressures from global demand mean that central purchasing and direct supply to community pharmacies is critical to maintaining continuity of supply for UK patients.

In those circumstances, if centrally purchased products, rather than being supplied directly to pharmacies, were sold to wholesalers, that would risk wholesalers exporting or selling the stock at a much higher price than is usually paid, thereby playing the market. In this example, that would defeat the original purpose of the central stockpile.

When supplying products directly to pharmacies free of charge, we do not want to reimburse pharmacies as well as purchasing the stock, as that would mean the Government or taxpayer paying twice. Currently, as I have indicated, the legislative framework only makes provision for the reimbursement price of specials to be set at zero. We are restricting those to vaccinations and immunisations, medicinal products used for the prevention or treatment of disease in a pandemic, and associated products. By carving out these niche, critical—but understandable, I hope—exceptions in the legislation in that way, we recognise the importance of not undermining the supply and reimbursement arrangements more generally and broadly across the piece. Furthermore, the legislation will also ensure that in the case of pandemic treatments, once the disease is no longer a pandemic, the appropriate arrangements will be put in place to transition back to normal supply and payment arrangements.

The new clause is important to ensure that centrally purchased stock of essential medicines intended for patients in England can be distributed to community pharmacies to meet clinical need and support patient access, whether that applies to a vaccination or treatment in connection with a pandemic. For those reasons, I ask the Committee to support the new clause.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to serve again with you in the Chair, Mrs Murray. As I said yesterday, we are grateful for the Minister writing with his explanation of this and the other new clauses ahead of time. That was helpful.

As the Minister explained in his letter, the new clause will simplify and safeguard the process of remuneration where the Government centrally procures vaccines, immunisations or products used to treat a pandemic, as well as other listed products, replacing “special medicinal products” under the previous legislation, in particular when there is significant international demand. That is very topical and we have a rich understanding of it given the events of the past 18 months, so it makes sense to the Opposition and we will not dwell on it long, nor will we press the new clause to a division. However, I seek clarity from the Minister on a couple of issues.

In the Minister’s letter, he cited the risk of wholesalers exporting the products or selling them at a much higher price if they were fed into the conventional supply chain. He characterised that as market failure. Community pharmacies would then be claiming reimbursement from the NHS based on the drug tariff determinations. I do not doubt the risk of that, and it is a foreseeable one, but am keen to hear from the Minister whether he is able to quantify the risk or demonstrate examples in either case. For example, during this pandemic, did that happen at the beginning? What was the cost if that took place? Have there been examples of profiteering preventing necessary products from reaching the patients for which they were intended?

In a second point, I am curious about the arrangements put in place to transition back to normal payment arrangements, once the disease in question is no longer pandemic or at risk of becoming pandemic. Again, I think we would always want restoration of normal circumstances at the first appropriate moment. In his letter, the Minister describes the arrangements as “appropriate”, while the new clause reads:

“Where…the Secretary of State considers that the disease to which it relates is no longer a pandemic disease or at risk of becoming a pandemic disease, the Secretary of State must revoke that provision within such period as the Secretary of State considers reasonable”.

Given that section 164 of the National Health Service Act 2006 also allows the Secretary of State to determine remuneration, that feels a little like the Secretary of State being allowed to mark their own homework. It could leave such measures in place for as long as suits them, rather than for as long as necessary, because the only determination of their need sits with that person. Will the Minister offer some reassurance that the power is for an emergency and is exceptionally limited, and give the Committee some comfort about the oversight and how Parliament perhaps will be given the chance to challenge the Secretary of State, so that the measures are not kept in place for any longer than necessary?

[Dr Whitford]

I have a small comment following on from the hon. Gentleman, who was asking for evidence of profiteering on specials. I was on the Committee considering the Health Service Medical Supplies (Costs) Act 2017 and brought the issue of specials before the Committee. These are often personalised medicines. In Scotland, they are produced centrally by the NHS, but there is certainly huge evidence of profiteering on them within NHS England, with hundreds of pounds being charged for simple ointments. While we may not have evidence on vaccines, evidence of profiteering on specials is long standing.

[Edward Argar]

I am grateful to the hon. Lady for helping to reduce the number of the shadow Minister’s questions that I need to answer. The hon. Lady makes her point well. We saw early on in the pandemic the challenges of a globally competitive market and the incentives and disincentives that can create around supply. I will not go into other aspects of supplies purchased for the NHS during the pandemic, but we have seen what happens when a market becomes super-saturated with demand versus a very limited supply, hence why we believe the steps in the new clause are prudent.

The shadow Minister will be familiar with approach in the new clause; it was used, for example, for covid vaccines, which were centrally secured and supplied directly to pharmacies. While we felt that supply could be justified on the basis of conventions of statutory interpretation that allowed us necessary flexibility in those exceptional circumstances, we think it is appropriate that we put such measures on a proper legal footing—through debate and, if necessary, Division in the House—to future-proof our arrangements. We are not trying to radically alter NHS pharmaceutical service provision or the payment mechanism. The aim is actually to strengthen the legal basis, and indeed the democratic oversight of that legal basis, through this debate in this Committee, for scenarios in which usual supply routes need to be bypassed.

The shadow Minister also raised a couple of other points, mainly about the Secretary of State’s power and Parliament’s role going forward, if I may paraphrase it in that way. I take his point. Judgments will obviously be based on advice from officials and legal and scientific advisers, but to a degree it is in the nature of ministerial accountability that there is an element of subjectivity when the Secretary of State is obliged to make a judgment. I appreciate the point, which I echoed in my remarks, on the need to turn these arrangements off or transition out of them as swiftly as possible, but we can see this pandemic declining and coming back at various times—that is the nature of the lifecycle of a pandemic; there are ups and downs before it finally burns itself out—and therefore the Secretary of State will ultimately need a degree of discretion and subjectivity in their judgment about the right moment, although obviously they will take advice.

On the House’s ability to challenge that, as the shadow Minister will possibly expect me to say, he and his colleagues and other Members will have ample opportunity, not only at Question Time but also, as I have discovered, through urgent questions, which I have answered on behalf of colleagues in the Government on occasion. There are plenty of opportunities for Members to summon Ministers to the Dispatch Box, or through written questions, to challenge and to probe and hold Ministers to account. I hope that hon. Members feel that this is a pragmatic and proportionate measure to address something we have identified in the course of the pandemic as needing resolution, and in so doing to put it on a surer and clearer statutory footing.

Question put and agreed to.

New clause 62 accordingly read a Second time, and added to the Bill.

New Clause 1

Prohibition of virginity testing

“(1) A person is guilty of an offence if they attempt to establish that another person is a virgin by making physical contact with their genitalia.

(2) A person is guilty of an offence if they provide another person with a product intended for the purpose, or purported purpose, of establishing whether another person is a virgin.

(3) A person is guilty of an offence if they aid, abet, counsel or procure a person to establish that another person is a virgin by making physical contact with their genitalia.

(4) No offence is committed by an approved person who performs—

(a) a surgical operation on a person which is necessary for their physical or mental health; or

(b) a surgical operation on a female who is in any stage of labour, or has just given birth, for purposes connected with the labour or birth.

(5) The following are approved persons—

(a) in relation to an operation falling within subsection (4)(a), a registered medical practitioner; and

(b) in relation to an operation falling within subsection (5)(b), a registered medical practitioner, a registered midwife or a person undergoing a course of training with a view to becoming such a practitioner or midwife.

(6) There is also no offence committed by a person who—

(a) performs a surgical operation falling within subsection (4)(a) or (b) outside the United Kingdom; and

(b) in relation to such an operation exercises functions corresponding to those of an approved person.

(7) For the purpose of determining whether an operation is necessary for the mental health of a girl it is immaterial whether she or any other person believes that the operation is required as a matter of custom or ritual.

(8) This section applies to any act done outside the United Kingdom by a United Kingdom national or resident.

(9) A person who is guilty of an offence under this section is liable, on summary conviction, to imprisonment for a term not exceeding 12 months, to a fine, or to both.

(10) The court must refer the case of any person guilty of an offence under this section who is subject to statutory professional regulation for investigation by the relevant regulator.”.—(Alex Norris.)

Brought up, and read the First time.

[Alex Norris]

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

[The Chair]

With this it will be convenient to discuss new clause 2—Prohibition of hymenoplasty—

“(1) A person is guilty of an offence if they undertake a surgical procedure for the purpose of re-attaching membrane tissue, creating scar tissue or otherwise attempting to re-create the hymen in the vagina of a patient.

(2) A person is guilty of an offence if they advertise the service of hymenoplasty or any service that purports to ‘re-virginise’ or otherwise re-create or re-attach the hymen of a patient by way of surgical procedure.

(3) A person is guilty of an offence if they aid, abet, counsel or procure a person to undertake a surgical procedure for the purpose of re-attaching membrane tissue, creating scar tissue or otherwise attempting to or re-creating the hymen in the vagina of a patient.

(4) This section applies to any act done outside the United Kingdom by a United Kingdom national or resident.

(5) A person who is guilty of an offence under this section is liable, on conviction, to imprisonment for a term not exceeding 5 years.

(6) The court must refer the case of any person guilty of an offence under this section who is subject to statutory professional regulation for investigation by the relevant regulator.”.

[Alex Norris]

I want to speak to new clause 1 in my name and seemingly in the name of half the House. With pleasure, we have reached the new clauses. A central theme runs through the new clauses that my colleagues and I have tabled. If the Government are adamant that now is the time for this Bill, and we have well-established issues with that, then given the significant and growing challenges facing health and social care in this country we really ought to put things in the Bill that will make a difference. Too much of what we have discussed over the previous 18 sessions—give or take—has been about structures and moving things around; this is fundamentally likely to make little to no difference on the frontlines to practitioners or the people that we work for. These new clauses, and the new clauses in general, seek to try and redress that balance and put things in the Bill that will make an impact in this country.

--- Later in debate ---

I hope that I have given the Committee a clear rationale for why, although we are entirely aligned on the new clause’s policy objectives and intent, there are a number of drafting and other factors that we need to work on a little. However, I am hopeful that in short order we will be able to bring forward legislation and clauses that will be satisfactory to both sides of the House.

[Alex Norris]

Let me come back briefly on a couple of issues. First, I am grateful for the contribution of the hon. Member for Central Ayrshire and, in particular, her point about non-medical practices dressed up as medical practices. That is a particularly insidious way to inflict abuse on another person, and I completely agree with her that that is an absolute violation—it is as totemic as that.

We will all have taken great encouragement from the Minister’s response. I am grateful for that. I associate myself with the comments he made about the hon. Member for North West Durham—I should have said that in opening. Between us, we will ensure that he sees a copy of the proceedings, and he can take great encouragement from what the Minister said.

It was particularly welcome to hear that the Government intend to legislate in this space, with the intent for that to be at the earliest opportunity. That is good news, and the Opposition will support them in that process. I gently say—I know he enjoys these exchanges—that we are currently considering primary legislation, so this is definitely the earliest opportunity. If there are moments for the Government to revisit this issue on Report or in the other place, he will find colleagues very welcoming of that.

I do not want to shatter the consensus that has grown by dividing the Committee, so I do not intend to press either new clause to a Division. However, on new clause 2, we will look at what the expert panel says. I will be interested to see the divisions in opinion—I have not been able to find them. We look at these things on their merit, but the commitment to see the report before Christmas was welcome and will give great heart to campaigners in this space. The Opposition look forward to seeing the proposals and will be keen to support them if they can achieve the goals that we seek. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 3

Annual parity of esteem report: spending on mental health and mental illness

“Within six weeks of the end of each financial year, the Secretary of State must lay before each House of Parliament a report on the ways in which the allotment made to NHS England for that financial year contributed to the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of mental illness.”—(Justin Madders.)

This new clause would require the Secretary of State for Health and Social Care to make an annual statement on how the funding received by mental health services that year from the overall annual allotment has contributed to the improvement of mental health and the prevention, diagnosis and treatment of mental illness.

Brought up, and read the First time.

[Justin Madders]

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

The Minister referred to my longevity in post, which gives me the advantage of having had this debate with him previously. That does not make it any less important; in fact, the subject has only risen in importance in the intervening period. That is why the Opposition were pleased to put our name to the new clause, which was tabled by the hon. Member for Newton Abbot (Anne Marie Morris).

In March, the Centre for Mental Health reported:

“There are…many areas where parity of esteem has not yet been realised. Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”

Parity of esteem is the principle by which mental health must be given equal priority to physical health. Many of us assumed that it had always been there, but debates have gone on over the years and, as that figure suggests, it is still some way from being achieved. The founding National Health Service Act 1946 spoke of a comprehensive health service, securing the improvement of both physical and mental health, and the National Health Service Act 2006 said the same. That principle was enshrined in the Health and Social Care Act 2012—at least, the parts of it that remain.

In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through the NHS mandate. However, there are reports that this requirement falls down at a local level. Certainly as a constituency MP, I have a whole range of stories of people not being able to access treatment in a timely manner, or being pushed around the system with very little effect and discharged from care before it was appropriate, with consequences we can all imagine. It is difficult to overestimate how challenging that is, not just for the individuals, but for the local commissioners when they face competing pressures.

We are not suggesting that the 20% to 30% gap should be closed entirely, but we should be looking to at least get on the road towards delivering true parity. There was a missed opportunity earlier in this Bill when we suggested that one of the mandated positions on the integrated care board should be a mental health representative. Should that have been accepted, the ambitions behind the new clause would have been much easier to achieve. It is about not just getting on the road to financial parity, but actually changing the culture so that disparities can be addressed. It does sometimes seem that mental health is the Cinderella service: the one that gets cut first at the expense of the more visible services where people, understandably, can see if a particular service is shut down.

It should go without saying that it is part of the Secretary of State’s normal duties to promote mental health care, but that is something that has been sadly missing. While we do not want to get into an exact science on spending, we do think that much more can be done in terms of delivery and outcomes. Looking at some of the hard facts, it is clear how far we have to travel. One in four mental health beds has been cut since 2010; just last year, 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic, and I am sure most Members will have similar stories from their own constituencies of people in desperate need of help—young people whose entire lives could change by getting the right help at the right time, but who are not able to access services despite there being an obvious clinical need.

That must change. We need parity to mean something in practical terms. We hope that the new clause would create a shift in culture by requiring the Secretary of State to lay a report before Parliament addressing whether the aim of parity of esteem has been delivered.

--- Later in debate ---

[Justin Madders]

I am grateful for the Minister’s comments. If the investment standard is being met across the board, perhaps it is the investment standard that needs looking at rather than the services themselves. We are all aware that there is a lot more to do in this area. As the Minister rightly says, no doubt we will return to it, so I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 5

Support provided by the NHS to victims of domestic abuse

“(1) Each Integrated Care Board must—

(a) assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services;

(b) prepare and publish a strategy for the provision of such support in its area;

(c) monitor and evaluate the effectiveness of the strategy;

(d) designate a domestic abuse and sexual violence lead; and

(e) publish an annual report on how it has discharged its duties relating to the provision of services to victims of domestic violence under the Care Act 2014.

(2) An Integrated Care Board that publishes a strategy under this section must, in carrying out its functions, give effect to the strategy.

(3) Before publishing a strategy under this section, an Integrated Care Board must consult—

(a) any local authority for an area within the relevant Integrated Care Board’s area;

(b) the domestic abuse local partnership board appointed by the local authority for an area within the relevant clinical commissioning group’s area under section 58 of the Domestic Abuse Act 2021; and

(c) such other persons as the relevant local authority considers appropriate.

(4) For the purposes of subsection (4), “local authority” means—

(a) a county council or district council in England; or

(b) a London borough council.

(5) An Integrated Care Board that publishes a strategy under this section—

(a) must keep the strategy under review;

(b) may alter or replace the strategy; and

(c) must publish any altered or replacement strategy.

(6) The Secretary of State may by regulations make provision about the preparation and publication of strategies under this section.

(7) The power to make regulations under subsection (7) may, in particular, be exercised to make provision about—

(a) the procedure to be followed by an Integrated Care Board in preparing a strategy;

(b) matters to which an Integrated Care Board must have regard in preparing a strategy;

(c) how an Integrated Care Board must publish a strategy;

(d) the date by which an Integrated Care Board must first publish a strategy; and

(e) the frequency with which an Integrated Care Board must review its strategy or any effect of the strategy on the provision of other provision in its area.

(8) Before making regulations under this section, the Secretary of State must consult—

(a) all Integrated Care Boards; and

(b) such other persons as the Secretary of State considers appropriate.”—(Alex Norris.)

This new clause would require Integrated Care Boards to publish a strategy for the provision of support for victims of domestic abuse using their services and designate a domestic abuse and sexual violence lead.

Brought up, and read the First time.

[Alex Norris]

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

For Opposition Members in Committees of this type, as we assemble the issues that we prioritise in proceedings, we have to be a bit of a magpie and pinch things along the way, so I want to recognise that this new clause is pinched from the hon. Member for Newton Abbot. I am grateful to her for tabling this and for the level of thought that she put into the amendment, which is a very good one.

Earlier in the proceedings, we discussed integrated care board plans and their responsibility to engage with the Domestic Abuse Commissioner. I was grateful for the commitments that the Minister made. There was a common understanding that the health and social care system has a crucial role in both preventing and tackling domestic abuse and in supporting victims and survivors. That sounds self-evident, but we are not in that position in this country yet, and we could do much better. I hope we can build on that consensus with the new clause, which requires integrated care boards to publish a strategy for the provision of support for victims of domestic abuse using their services and to designate a domestic abuse and sexual violence lead.

I will not repeat the arguments that I made earlier regarding the scale of domestic abuse, but it is worth reiterating top lines, particularly the global statistics from the World Health Organisation, which show that 30% of women have experienced some form of physical and/or sexual violence by an intimate partner in their lifetime. In this country it is one in four, so it is of a similar order of magnitude. The Government’s own estimate is that it costs health services £2.3 billion annually. A common refrain from the sector, with which I meet a lot, as I did before coming to this place, concerns the impact it could make with a fraction of that money if it was put into statutory services or the services that it provides. We should think about that investment model.

In discussing the new clause, I want to take the opportunity to cover something that we have not previously considered, namely domestic abuse, which tends to be against women but also concerns people with disabilities. According to Stay Safe East, disabled people and, most specifically again, disabled women, experience higher rates of domestic abuse than those who do not have disabilities. Abuse against women with disabilities is likely to be more violent and to happen over a longer period before the victim discloses it or can access help. The really sad thing is that if the victim––who is living with a disability––is not heard, there is a significant risk that they will then be sent home by the system to be cared for, in the very loosest sense, by their abuser. None of us would want that but it is the sort of thing that happens at the moment because we do not have a strong enough grip. I hope that we can use the new clause and the Bill generally to take more active steps to address that problem.

There is clearly a significant need for specialist domestic abuse services, which are crucial to enable women’s recovery in particular. Often, such services take on the work of statutory services and provide vital advocacy for women facing health exclusion, particularly in respect of services supporting black and minoritised women. It came out strongly in the debate on what is now the Domestic Abuse Act 2021 that we need specific and specialised services for those who are at greatest risk of being excluded. We did not quite get there in those provisions. I confess to using every legislative and parliamentary opportunity to keep pushing at this because it is really important and we can do much better.

We know that medical staff receive some training in adult safeguarding and, in a few hospitals, even on domestic abuse and sexual violence. But the skills and time to communicate with people with, say, learning disabilities or cognitive issues, with deaf survivors or with very elderly people who might be less likely to disclose personal information are not always available, and certainly not universally. The new clause seeks to put the onus on the integrated care system to get organised around this, to specialise and to prioritise it. It should be a priority across the system.

[Dr Whitford]

Does the hon. Gentleman think that we also have a job to do socially in reducing the stigma? I have worked in casualty departments and as a surgeon facing women who had clearly been abused but were standing or lying there making excuses for their abuser and saying why it was their own fault. As well as women with disability, there are women with insecure immigration status or insecure financial status who have no money of their own and feel that they have nowhere to go. I support the principle here, but we have a much bigger job to do around domestic abuse, which is endemic across the UK.

[Alex Norris]

I am very grateful to the hon. Lady for that intervention and completely agree with everything she said. For my part, and that of many of our colleagues, our way to tackle all those different barriers is to seek to put this in every bit of legislation. Most domestic legislation touches on these issues.

What is pertinent to this debate is thinking about the barriers to reporting. One barrier is the fear of not being believed. Of course, there is a bigger fear around prosecutions, which the Minister took a personal interest in when he was a Justice Minister, but it is clear from the evidence that we are not making enough progress. We have heard lots of positive sounds from the Government but no concrete proposals for change. We could do much better there.

On the barrier of not being believed, one way to create a better environment for a survivor to disclose what has happened to them is by their knowing that the person they are talking to in that healthcare setting has had training and works in a system that prioritises the safe disclosure of abuse. That would do a lot to build confidence. On the hon. Lady’s point about migration status, it is important that we talk about that. It was a key theme in the Domestic Abuse Act. There must be safeguards in place so that the disclosure of abuse trumps immigration status. The practitioner that they work with must be someone whose role is to help them address those issues, not someone who will be speaking to the Home Office. That first knock on the door will be someone trying to help them deal with the abuse and its impact on their life; it will not be from someone trying to resolve their migration status. That is an important principle.

Returning to the new clause, meeting with a professional social worker who ought be trained in assessing risks, including domestic abuse, might be the significant moment that an older or disabled person discloses domestic or other abuse. If given time and asked skilful questions in a safe environment, the person may disclose or express their fears, knowing they can do so in a protect manner. But across the country, such interventions are not falling into place on their own.

Women’s Aid’s data shows that in 2019-20, no refuge services responding to its survey were commissioned by their CCG, and just 10% of community-based services were. This is a multi-agency issue. I fought very hard to persuade the hon. Member for South Derbyshire (Mrs Wheeler) when she was Housing Minister that there ought to be investment and support going into the services through local government. She took that on, which was a good thing. Local authorities alone cannot tackle this issue. The picture that emerges from the evidence is that health agencies are not delivering as they ought to.

To be clear on what our modest ask is, subsection (1) states that each board must

“assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services”.

That is pretty basic. Following that, it must prepare a strategy, monitor that strategy and have an annual report on it, but particularly, under paragraph (d), it must

“designate a domestic abuse and sexual violence lead”,

because we know that in organisations such as the police or health organisations, where they have designated such a person, that person has been impactful. Those are pretty basic requirements. On many occasions the Minister has said that the point of the system is to be a permissive one and to let local areas shape services in the interests of their population, depending on the challenges they face; but the reality is that this problem is in every community, and we ought to be clear to ICBs that we expect this kind of activity. Subsection (3) includes a modest ask for consultation, which is reasonable and desirable.

Women in particular, and all our communities, desperately need this issue to be given deliberate focused attention. There is a high degree of consensus on it, but that does not lead to action frequently enough. The appointment of a Domestic Abuse Commissioner, which we have discussed, was a welcome step, but from a health and social care perspective we need to do more in the system. At the moment, that is not happening. That is not because I think that commissioners, leaders and decision makers do not think it is important, but they have an awful lot on. This can be a hidden crime that goes on behind closed doors, and as such drops down the list of priorities because of the urgent pressures on them; but we cannot let it go. As well as the leadership that we try to display on a national scale, we must do more to encourage this on a local scale. In this case, that is in the strategies and plans of the ICBs. We should make sure that happens.

To conclude—this is in the same vein as what I said when we debated new clauses 1 and 2—we should in our remaining time seek to put in the Bill things that will change people’s health outcomes, and outcomes in life more generally. New clause 5 is one of those things, so I hope the Government are in listening mode.

[Edward Argar]

I put on record my gratitude to my hon. Friend the Member for Newton Abbot and to the hon. Member for Nottingham North for enabling this discussion to take place in Committee today. I find myself in deep agreement with the idea that the NHS can play a vital role in protecting vulnerable people and, as part of that, it must have strategies and processes in place for supporting victims of domestic abuse, sexual violence and other forms of harm.

The hon. Gentleman was kind to refer to my stint at the Ministry of Justice, when as Victims Minister I took a close interest in this issue with Dame Vera Baird, the former Member for Redcar, in her role as Victims’ Commissioner—I pay tribute to her—and with the Minister of State, Ministry of Justice, my hon. Friend the Member for Louth and Horncastle (Victoria Atkins). My hon. Friend and I worked on the early stages of the Domestic Abuse Act 2021, and she saw that work through—I had moved to this role by then—before receiving a well-deserved promotion. I took a close interest in this issue when I was in the MOJ, and hon. Members from across the House will have found that it is not forgotten or left behind; we always reflect on it and see how we can continue to play a part when in other roles.

The hon. Member for Central Ayrshire was right to highlight the challenges that many people feel. The stigmas are completely unjustified, but people feel them because of the nature of the abuse and the controlling and coercive behaviour to which they have been subjected. When I was at the MOJ, I discovered the limitations of legislation in this space. We can and should legislate in certain areas, but a lot of this is about how services work on the ground, how we talk about this as a society, and how we break down the stigmas. One of the key things that I took away from my time at the MOJ was that tackling domestic violence and abuse is not just the responsibility of the justice system or the NHS; it is our responsibility as a society. I hope I can reassure the shadow Minister. On some areas, we tend to find ourselves in agreement rather more than is perhaps good for either of our political careers, but on this I entirely share his sentiments.

Turning to new clause 5, I hope to reassure the Committee that placing in the Bill a formal duty on ICBs to develop a separate strategy is unnecessary and not the best approach, but I hope the Committee will allow me to expand on my reasoning. There are already several duties on CCGs to consider the needs of victims of violence, including victims of domestic abuse, through the joint strategic needs assessment process. CCGs must respond to identified needs through health and wellbeing strategies. The duties will be transferred to and continue to apply to ICBs once CCGs are abolished, and will be further strengthened by the requirement on ICBs to develop system level commissioning plans. Through the Government’s landmark new Domestic Abuse Act 2021—it would be churlish of me not to recognise the Opposition’s work on it—local healthcare systems will be required to contribute to domestic abuse local partnership boards.

I slightly caution against requiring ICBs to create further additional strategies and plans, separate from those already in the Bill. I recognise the impulse to require NHS bodies to do this, because the theory is that a separate strategy will attract particular attention. My note of caution is because in doing so, we are saying, “We will put that over there, in that strategy” rather than having it as a thread that runs through all the strategies, underpinning strategic documents and plans of the local NHS and the ICB. We risk separating it and putting it in a different compartment from the wider span of integrated responsibilities, which is where it should sit.

The new clause also places a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we believe we can do that effectively through existing legislation and guidance. As set out in the Government’s recent violence against women and girls strategy, the Department of Health and Social Care will be engaging with integrated care systems and providing guidance to promote best practice in addressing violence against women and girls, domestic abuse and sexual violence. That could well include advice on designated leads and those internal structures and processes.

Beyond ICBs, I see a huge opportunity for integrated care partnerships to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnership working. I am sure we have all undertaken visits to women’s refuges or to other charities that support women who are victims of domestic abuse. I should just say that it is, of course, true that men and women can be victims of domestic abuse. I refer to women in this context because an overwhelming number of victims are women, but it can happen to anyone, irrespective of gender.

In my previous role, I had the privilege of meeting survivors of domestic abuse, who were willing to talk to me about what had happened and their recovery from and survival of domestic abuse. In those conversations, people would often say, “I dealt with one agency, but it did not talk to this agency and this bit did not join up.” There is a real opportunity for the ICPs to work with housing providers, local authorities, the NHS and other voluntary and third sector organisations to help to bring together a more coherent and joined-up approach.

More broadly, I assure the Committee that the NHS will be at the forefront of stepping up to its responsibility to play its part in tackling domestic abuse, sexual violence and violence against women and girls. NHS England is developing enhanced trauma-informed mental health support for victims with the most complex needs within the sexual assault and abuse pathway. The DHSC’s new office for health promotion will work with the newly merged NHS England to review and build on workforce policies to ensure safe, effective processes are in place to support staff affected by domestic violence and sexual violence.

I hope I have reassured the Committee that we take this issue extremely seriously. Although we do not think that the approach proposed in the new clause is the right one, I am open-minded and happy to work across the aisle to see if there is more we can do in this space, in keeping with the strategy set out by my hon. Friend the Member for Louth and Horncastle when she was at the Home Office, and to see if there are other ways to achieve essentially the same objective.

[Alex Norris]

I have listened carefully to what the Minister has said, and I agree with significant elements of it. I take the point about existing duties on CCGs, and I am very mindful of those. The reality is that they do not work, or they certainly have not worked to date. I have no confidence that anything will change if current arrangements are just ported over to integrated care boards, which is what will happen. I do not think anything will change. I cannot imagine what will have changed in that moment to make it different, and I cannot therefore agree with the characterisation that the new clause is unnecessary.

I accept that we would not want to see a proliferation of further strategies. By making it a requirement, the new clause seeks to put the treatment, assessment and care of domestic abuse on the same footing in integrated care as elective care or major diseases. It should have that status, and at the moment it does not. It needs to be elevated to that level. I do not disagree at all with the Minister’s point about domestic abuse being a thread that runs through all policies. The reality is that we have been saying that for a really long time. What actually happens is that it is in everything and, as a result, it is in nothing, and things do not change. Certainly, they are not changing quickly enough in the health space.

Finally, on the point about integrated care partnerships, I hoped that the Minister would not say what he did, because that is the problem. The fundamental issue is that those who are making the direct daily decisions about health and care in our communities are downgrading the issue by considering what they do not as operational, daily, immediate, crucial decisions—in the way they would with elective care or cancer care—but instead as partnership work.

I would never talk down the pledges that we sign or the awareness days we do. I have signed all the pledges and gone to all the awareness days, and I will keep doing that because it is an important way of keeping the pot boiling. However, I am not convinced that they have done enough to make my constituents safer or give them a better health service. I have seen no evidence of that yet. This is not partnership work, but daily, crucial work that ought to be done by system decision makers, who ought to be prioritising it every day, but I do not think that is the case.

[Edward Argar]

If I was unclear, I apologise; that was not the intention of what I was saying. I sought to say that that partnership work brings together organisations that, I believe, do focus on the issue day to day and have it as an operational priority, but often still operate in silos. In some of the best partnerships in the best local authority areas, those silos are much less evident. My point about the ICP was not as an alternative to making this front and centre, and asking “What are you doing in your operational decision making?”—be it about elective care, cancer or domestic abuse, and treating them the same—but that often it operates in a way that is internal to those organisations, rather than across them.

That was the point I was trying to make about partnership: not only do we need that internal process and urgency—I totally share the hon. Gentleman’s view on that—but we need the ICPs to offer an opportunity to do that by bridging organisations. I hope that adds a little clarity, if I was unclear.

[Alex Norris]

It does, and of course I would not want to misrepresent what the Minister said. My point is that, while of course we should seek to work across the partnership and have a cross-partnership approach to tackling this issue in our communities—that is a very good thing to do—the problem currently is that that means we are not doing enough in the health and care space. There has to be something that says to health leaders, “Yes, work in partnership, but there are bits that you have to do yourselves that at the moment you are not doing well enough, so please do them.” This is my “something”. That was my logic in tabling this new clause, and it is why I intend to push it to a Division.

Question put, That the clause be read a Second time.

Health and Care Bill (Nineteeth sitting)

Alex Norris Excerpts

Committee stage
Wednesday 27th October 2021 Public Bill Committees

When I was Science Minister, healthcare research was an afterthought. It sat separately from BEIS. Let us make sure that it is a priority, right at the forefront of the Secretary of State’s mind. That is why I am keen for the Minister to reflect on this. It would be a strong signal if the Government adopted the amendment. It would curry favour with the Prime Minister to demonstrate that he, as a Minister, has taken forward the Prime Minister’s message on delivering a science superpower. I am sure that he will be keen to do so. Let us put R&D on a statutory footing in the healthcare service for the first time in 70-something years. It is long overdue and this is the time to make it happen.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume with you in the Chair, Mr McCabe. I commend the right hon. Member for Kingswood for his new clause and for the persuasive case that he made for it. I will cover much of what he said in my contribution, but I highlight his point about long-term certainty, because I was not going to cover that. Those points were very well made. If we want to embed a culture of research in this country and to be world-leading, as surely we do, we must give our researchers that long-term certainty.

I am going to start with the National Institute for Health Research, which was, of course, established by the previous Labour Government in 2006. We are very proud of that, and since then, in partnership with NICE and other organisations, it has delivered on its mission to improve on the health and wealth of the nation through research. I refer any colleagues who have not had a chance to look at it to the 2016 RAND report, which identifies 100 examples of positive change resulting from the institute’s research. You may be pleased, Mr McCabe, to hear me say that I do not intend to read out all 100, but I do want to highlight the role that it has played since in fighting covid-19 by funding, enabling and delivering lifesaving research throughout the pandemic and now in this current phase. I will not list all the ways in which that has been done, but I will highlight the recovery trial that discovered dexamethasone. That was the first drug to reduce covid-19 mortality in hospitalised patients, cutting deaths by one third, and it was funded and supported by the NIHR. It is a great organisation, which we should be backing and should be very proud of.

On research more generally, there is a shared vision and a shared ambition across this place: the UK should be at the very forefront in science more generally, and particularly in research on health and care. We have all the assets to do that, if we link everything up and invest in it, and to make the UK the destination of choice for clinical research. The new clause offers the Government the chance to put that on a statutory footing, and to make good that commitment, ringfencing funding and mandating the Secretary of State’s support and interest in leadership. As the right hon. Member for Kingswood said, we would expect the Secretary of State to make many things a personal priority. We would argue that this is one of those things.

As in many of our proceedings, we are tidying up on the Health and Social Care Act 2012, and this is a good opportunity to do so again. The Minister smiles; I am always here to offer those opportunities. My hon. Friend and I have been ever so accommodating in that regard. The 2012 Act only included the duty for clinical commissioning groups to promote research. I would direct colleagues to the cross-sector written evidence headed up by the Academy of Medical Sciences, which said that the NHS’s lack of ability

“to prioritise the resourcing and delivery of research has been a major impediment to improving the UK’s clinical research environment over the last decade.”

According to that submission, that has subsequently been a contributing factor to wide-ranging disparities in opportunities for patients to engage in research. When it talks about that, we should listen. As with so many things, we have chance to right that wrong in the 2012 Act and to show in the Bill that we want an active research culture in the NHS, building on the last 18 months.

Evidence shows that a strengthened research mandate would bring many benefits. First, patients treated in research-active NHS organisations have improved outcomes. They have lower mortality rates and higher confidence in the care they receive, which really is a big prize. Secondly, at a time when the NHS is dealing with many work force issues, this increases job satisfaction, with most doctors surveyed by the Royal College of Physicians wanting to be more involved in research and two thirds more likely to apply for a role with dedicated research time. We know it is what our excellent clinicians want too. Thirdly, it brings economic investment into this country; £2.7 billion was generated by NIHR clinical research network-supported activity in 2018-19, making the NHS around £350 million from life science companies. So we win here both coming and going; it is better for our patients, better for clinicians and better for our economy.

There really is a lot in this very good new clause with regard to both the NIHR itself and research more generally. I hope that the Minister will look favourably on the new clause. If he does not, I hope that he will give the Committee comfort on how this will be not just a broad priority for the entire system, where it is not quite clear who is responsible, but something that he as a Minister, and the Secretary of State, will be driving personally and taking as a personal responsibility. As I say, the prizes are very great indeed.

[Dr Whitford]

Although this would obviously apply in England and not Scotland, and the NIHR does not generally fund a lot of clinical research that comes from Scotland, I absolutely support the principle. When I was lead clinician in the west of Scotland, we put trial support staff into all 13 breast cancer units around the west of Scotland. That drove up participation in trials, which, as the hon. Gentleman just said, is what generates confidence among patients and results in better outcomes. Most trials come with a lot of bureaucracy, and people working in very busy clinical jobs in district generals often do not engage because of that. Putting trial staff out in district generals can actually mean that, instead of research being within academic units, it is suddenly available to all patients. That is really important.

Having a questioning mind should be part of being any doctor. All junior doctors are encouraged to develop auditing and clinical ideas as an approach. The hon. Gentleman—I have forgotten the constituency, I am afraid.

[Alex Norris]

Nottingham North.

[Dr Whitford]

I was going to guess some other city and get it wrong, but it is somewhere north. The hon. Member said that having access to research time as a clinician, which the right hon. Member for Kingswood mentioned is a way of retaining staff, is quite important. My local health board now employs younger, as opposed to older, doctors as clinical fellows, and they have a day a week as part of their contract. It is not just one or two doctors; the board are doing it as a standard approach. It has become really popular and has certainly helped with our workforce issues in Ayrshire and on Arran. It is important to see laboratory and trials research and frontline outcome audit and clinical ideas research from all young clinicians, and we should encourage that. The money is great, but we then have to work out how the money feeds into the health service to generate the biggest impact.

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Brought up, and read the First time.

[Alex Norris]

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

[The Chair]

With this it will be convenient to discuss new clause 15—Regulation of the public display of imported cadavers—

“The Human Tissue Act 2004 is amended as follows—

In subsections (5)(a), (6)(a) and (6)(b) of section 1 (authorisation of activities for scheduled purposes) after “imported” insert “other than for the purpose of public display”.”

[Alex Norris]

In speaking to these new clauses, I stand on the shoulders of the inestimable work done in this place by my hon. Friend the Member for St Helens South and Whiston (Ms Rimmer) and in the other place by the noble Lord Hunt of Kings Heath, who is with us for a little while longer before he has an oral question to dispose of in the other place. I note my thanks to them for their leadership. I hope that we can move this important issue on as part of our consideration of the Bill.

In this country, since April, around 2,000 people have received an organ transplant. A person voluntarily deciding to give an organ in life or after their death gives the most precious gift of all. It is an incredibly selfless act that allows another person to live. It is a wonderful thing. We should be very proud of Britain’s record on organ donation over the years, of the research and development in that area and the work that I have no doubt we will yet do.

However, there is a sinister underside to organ donation that I ask the Committee to consider with these two new clauses. In some parts of the world organs are not given freely but are taken by force. Extensive research has shown organ harvesting to be prevalent particularly in China, where the number of organs transplanted swamps the official number of voluntary donations. The organs are generally destined for high-paying customers and come from people such as political dissidents, prisoners of conscience and ethnic minorities.

The Chinese Government say that it does not happen. The World Health Organisation has backed that up, based on a self-assessment made by the Chinese Government, which I did not find very credible. What I do find credible is that, in 2020, the independent China Tribunal found that forced organ harvesting has been committed for years throughout China, on a significant scale. Falun Gong practitioners have been one source—probably the main source—of organ supply. Victims include both the dead and the living. There are whistleblower reports of corneas being harvested.

In January we made progress on the issue through the Medicines and Medical Devices Act 2021—I am sure the hon. Member for Central Ayrshire remembers the exchanges fondly. That opened the door to further regulation of human tissues and I hope that we can move further in this Bill.

Existing legislation does not deal with British citizens who travel abroad. New clause 14 attempts to close that loophole by making it a crime for British citizens, residents and other specified people to be involved in the kill-to-order organ trade. It would end the opportunity for someone to travel to pay for black market organs from a prisoner of conscience and to return to the UK for NHS-funded anti-rejection medication. We must make it clear that involvement in this trade is reprehensible and unacceptable. I think that is a point of consensus across the House, but I am yet to hear what the mechanism is to close the loophole—I think new clause 14 presents a very good one.

New clause 15 deals with the display of human bodies. I used the word “grim” earlier in proceedings, and this is very grim indeed. Regrettably, this is not a theoretical conversation. In 2018 the Real Bodies exhibition took place in Birmingham. Adults and children paid to look at deceased corpses that had been injected with silicon and transformed into real-life mannequins. The bodies were sourced from a lab in Dalian in China. The bodies were able to be displayed without any documents or proven consent, and from a lab that we know receives bodies from the Chinese police.

Whether that sort of exhibition counts as entertainment is a matter for individuals—it is certainly not my sort of entertainment. New clause 15 would ensure that the trade is tightly regulated, so that something like that could not happen again. It would prevent the display of dead bodies of political prisoners and guarantee that proper consent has been received, ensuring dignity and respect for the deceased and their families. I think this is a matter of interest to the Committee, which is why I am seeking to put it in the Bill. It is also of significant interest in the other place. I know there will be conversations on the issue as the Bill progresses.

I am keen to hear from the Minister on these two points. I do not doubt that we are of one mind on the matter. What I would like to know now is what the Government are going to do about it, because these are pressing issues and need action now.

[Edward Argar]

I can certainly tell the hon. Gentleman that I think there is a consensus across the Committee, and indeed across both Houses, condemning the reprehensible behaviours and practices that he has highlighted. As he says, the challenge is the mechanism, particularly given the concept of extraterritoriality that applies here, so I will talk about that a little bit. I fear we may have to return to this; I suspect, given the complexities, that it may well be their lordships’ House that grapples with it a little further. Although it is not normally the done thing to recognise those in the Public Gallery, as they are not in the Chamber, were there to be a distinguished Peer in the Public Gallery, I would also pay tribute to their work on this. I hope that just about keeps me in order, Mr McCabe.

New clause 14 seeks to extend the provisions in section 32 of the Human Tissue Act 2004, which prohibit commercial dealings in human material for transplantation. The amendment would make it an offence for someone to travel outside the UK to receive such material without free, informed, and specific consent or in exchange for a financial gain or comparable advantage.

We believe that much, albeit not all, of what the clause seeks to achieve is already covered by different aspects of existing legislation. I will talk first about those travelling from the UK, forcibly or otherwise, and the protections available for them from having their organs harvested, and then I will turn to those travelling from the UK to receive organs.

Provisions in the Modern Slavery Act 2015 make it an offence to arrange or facilitate another person’s travel, including travel outside the UK, for the purposes of their exploitation in any part of the world. Travelling covers the arrival or departure from any country, or within any country, and exploitation includes the supply of organs for reward. The Modern Slavery Act applies to the activities of UK nationals regardless of where the travel or the arrangements for it take place.

A person found guilty of that offence could be liable for life imprisonment, and those guilty of aiding, abetting, counselling or procuring it are liable for up to 10 years’ imprisonment. This means that existing extraterritorial legislation already makes it an offence for a UK citizen to purchase an organ for transplant overseas, provided that the purchase involves arranging or facilitating a person’s travel for the purpose of the removal of their organ for sale.

Furthermore, section 32 of the Human Tissue Act already prohibits the giving of a reward for the supply, or for an offer to supply, any controlled material. If a substantial part of an illicit transaction takes place in England, Wales or Northern Ireland, it will constitute an offence under this provision. It could, for example, be an offence to arrange a purchase and pay for an organ from a UK bank account and, likewise, it could be deemed against the law if somebody were to take steps in the UK to find someone who would sell them an organ overseas.

By adding an explicitly extraterritorial offence, as this amendment seeks to do, the interpretation of the existing provisions could be restricted, thereby potentially weakening our existing tools under those two pieces of legislation. As this amendment would prohibit travel outside the UK to receive an organ without the specific consent of the donor or next of kin, there is a chance that it could also inadvertently make it an offence for someone from the UK to receive an organ in a country with deemed rather than explicit consent provisions. This is at odds with our domestic position, where deemed consent is accepted as an appropriate form of consent for organ donation.

There is also the possibility of an unintended consequence of criminalising the recipient, as opposed to the supplier and buyer, of a trafficked organ. It is not difficult to imagine a case of a vulnerable person receiving a transplant abroad, perhaps through arrangements made by relatives, and having been misled as to the provenance of their organ. Under these circumstances, we believe that those who made the arrangements to purchase and supply the organ should be prosecuted and deemed liable, as they already can be under the Human Tissue Act and the Modern Slavery Act.

--- Later in debate ---

It is for those reasons that I ask the hon. Member for Nottingham North to consider not pressing the new clauses to a Division. However, I believe that more thought can be done in this space. I think that Members on both sides of the Committee, and of the House, seek the same outcomes. I would prefer to see that work done through the existing legislation covering those loopholes. However, if there are gaps and loopholes, I am happy to reflect further on what more might be possible in this space. I hope that is helpful to the hon. Gentleman.

[Alex Norris]

I am grateful to the Minister for his full reply. I do not intend to stress the consensus we have by dividing the Committee. He has given others who may want to look at this at a later stage quite a bit to go at. On resolving the point made in new clause 14, I heard what the Minister said about the scattering of the different parts across the statute book, but a judgment may have to be made about whether that is an effective way to organise the powers. Perhaps creating a consolidated offence would be a more practical and meaningful approach. That is my personal view, but as I have said, there will be lots to go at elsewhere.

I got quite a bit of satisfaction from the Minister’s response to new clause 15. I will go away and look at the Human Tissue Authority’s work. Obviously, primary legislation is always best, but I will see whether that is effective.

[Edward Argar]

In that context, may I make the hon. Gentleman an offer? If he thinks there is anything specific that my officials could provide to assist him in his reflections, could he let me know and I will be very happy to facilitate it?

[Alex Norris]

That is a very kind offer and I am almost certainly going to avail myself of it. On that basis, I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 16

Licensing of beauty and aesthetics treatments

“(1) No person may carry on an activity to which this subsection applies—

(a) except under the authority of a licence for the purposes of this section, and

(b) other than in accordance with specified training.

(2) Subsection (1) applies to an activity relating to the provision of beauty or aesthetics treatments which is specified for the purposes of the subsection by regulations made by the Secretary of State.

(3) A person commits an offence if that person contravenes subsection (1).

(4) The Secretary of State may by regulations make provision about licences and conditions for the purposes of this section.

(5) Before making regulations under this section, the Secretary of State must consult the representatives of any interests concerned which the Secretary of State considers appropriate.

(6) Regulations may, in particular—

(a) require a licensing authority not to grant a licence unless satisfied as to a matter specified in the regulations; and

(b) require a licensing authority to have regard, in deciding whether to grant a licence, to a matter specified in the regulations.”—(Justin Madders.)

This new clause gives the Secretary of State the power to introduce a licensing regime for cosmetic treatments and makes it an offence for someone to practise without a licence. The list of treatments, detailed conditions and training requirements would be set out in regulations after consultation with relevant stakeholders.

Brought up, and read the First time.

[Justin Madders]

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

It will be noted that new clause 16 has attracted considerable support from a wide range of Members across the House. I pay tribute to the beauty, aesthetics and wellbeing all-party parliamentary group, whose work in the area has been influential in producing the new clause. Many of the Members who put their name to it are also members of that group. I pay tribute to a constituent of my right hon. Friend the Member for North Durham (Mr Jones), Dawn Knight, who has been assiduous in this area, as has my right hon. Friend himself. Their tireless campaigning, which I suspect will continue for some time, has been vital so far. This is such an important area and it needs an awful lot of attention. We know there is a lot more to be done.

As we know, cosmetic treatments can include a wide range of procedures aimed at enhancing or altering appearance. Many common treatments are offered on the high street and include lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and—one that we are more familiar with—tattoos. Perhaps one day the Minister will show us all of his. If the Minister wants to respond on that point, he is more than welcome to.

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[Alex Norris]

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

The past 18 months have made clearer than ever the health risks that our health workers face at work, as they have dealt with unprecedented pressures during the pandemic. Occupational health is a multidisciplinary approach to maintaining the wellbeing of those employed in a workplace, preventing and removing ill health and developing solutions to keep staff with health issues at work, the most common problems being mental health and musculoskeletal issues.

Occupational health services occupy a unique position as neither the employer nor the employee. I remember in my time as a union official helping NHS staff with issues at work, and we would howl at times at things that occupational health came up with. Then we met management and realised that they were howling about it too, so we realised that the occupational health practitioner was probably in the right place. That is a very specific and special place, in the NHS and beyond, and we should want our wonderful NHS staff to have proper access to it.

Currently, the NHS provides access to occupational health services to the vast majority of staff in acute trusts, but the policy is inconsistent. While NHS England is making efforts to expand access through the growing OH programme, those efforts need to be accelerated and supported, which is what the new clause would do.

In secondary care, the provision of services tends to depend on legal requirements on safety, for example checking for blood-borne viruses in advance of performing surgical or other procedures that could pose a risk to patients from the infected clinician, rather than occupational health provision that supports individuals to remain at work based on other needs they might have.

Similarly, the co-ordination of occupational health services in primary care has suffered since the abolition of primary care trusts in the Health and Social Care Act 2012. As a result, there is far less provision in primary community care settings. Some of the funds previously allocated to PCTs in support of occupational health services were diverted to the practitioner health programme—PHP— which provides mental health support for NHS staff. While that is valuable, the PHP is not a replacement for specialist occupational health services that are ready to work with both employer and employee on issues beyond mental health. That means that key parts of the NHS workforce—GPs, practice nurses and pharmacists—lack full access to occupational health services, and that has real implications. We worry about burnout in all those groups, especially after the 18 months we have just had. For some of our staff, A&E is the only avenue for treatment, in cases of exposure to infectious disease or a needle stick, for example. That is unsuitable and we could do much better than that.

We think it is vital for NHS staff wellbeing and staff retention that all NHS workers have access to occupational health services when they need them. We are not asking for something extra or beyond the scope of current conception. In 2016, NHS England introduced a commitment for OH services to be provided across the NHS, stating its intention to achieve

“a nationally standardised Occupational Health Service…that is equitable and accessible.”

That is a very good commitment, but five years on it remains unfulfilled. The new clause would put that on a statutory footing and get it going.

The Secretary of State already has several duties to NHS staff, in relation to education and training, for example, under the 2012 Act. The new clause would fulfil the 2016 commitment and meet the needs of NHS staff by requiring the Secretary of State to meet any reasonable OH requirements for anyone employed by the NHS directly or indirectly. It would be really good for our staff and, in turn, for the health service and those it serves. I hope that the Minister will give it positive consideration.

[Edward Argar]

As the hon. Member for Nottingham North set out, the new clause seeks to legislate for an additional duty on the Secretary of State to provide access to occupational health services to NHS staff.

The NHS is what it is thanks only to the hard work of its staff. The Government and Members of Parliament on both sides of the Chamber are immensely grateful to them. Caring for people throughout the pandemic has required a phenomenal effort from so many people, ranging from students and trainees to new recruits, established staff and those returning to the workforce. The dedication and resilience of NHS staff has been incredible—indeed, humbling—to witness. They have consistently placed the needs of patients before themselves, as indeed they do year in, year out, but they have done so in particularly challenging circumstances over the past year and a half or so.

If healthcare staff are to provide excellent care to patients, they need to receive excellent support themselves. Occupational health services play an important role in ensuring that staff get the support that they need to do their jobs and to flourish in them. Throughout the pandemic, we have placed a strong emphasis on supporting staff wellbeing. In July 2020, we published the NHS “People Plan”, which prioritises staff health and wellbeing. That was supported by the roll-out of a comprehensive national health and wellbeing support offer, which has been accessed by staff across the NHS.

The past 18 months have seen many NHS organisations respond with empathy and agility to the pandemic, and occupational health teams have developed innovative ways of supporting their colleagues. As we move towards, or into, the recovery phase, there is a great need to build on that focus and momentum, to ensure a healthy, sustainable workforce going forward. As we look to the same workforce who have taken us through the pandemic to tackle the waiting lists and waiting times, we must recognise, and be open with those who watch our proceedings and listen to us, that that task of rebuilding and getting the waiting lists down will be challenging. We owe it to the staff to be clear about that, because they are the same staff. They are physically and emotionally exhausted, and we have a duty of care to them, and must enable them to rebuild their physical and emotional strength after what they have been through over the past year and a half.

That is why the NHS priorities and operational planning guidance, published in March 2021, puts staff wellbeing and the recovery of the workforce right at the top of the list of priorities for the NHS. To support that, NHS England and NHS Improvement have launched a new programme to strengthen and improve occupational health across the NHS. That will look at how we can improve occupational health services, grow the occupational health workforce, develop their capability, empower local leadership and bring a strengthened focus on proactive and preventive care. It will build on best practice across the country and will inform future blueprints for potential service delivery models, with the aim of having a five-year service improvement strategy for occupational health in the NHS. It is being developed with the support of Dr Steve Boorman and the Faculty of Occupational Medicine, the Society of Occupational Medicine, the Council for Work and Health and the NHS Health at Work network, as national occupational health partners that both represent the voice of and link directly with occupational health professionals. That work, and the broader programme of work through the NHS “People Plan” to transform the NHS as a place to work, demonstrates our strong commitment to supporting staff health and wellbeing in the NHS.

As a result, we do not believe that this new clause is necessary, although we appreciate the sentiment, objective and aims sitting behind it. Our concern is that drawing out occupational health over and above other aspects of health and wellbeing support does not necessarily help to drive forward the other work done, which I have alluded to and which provides staff with a more comprehensive package that can be tailored to individual or group staff needs. There is a risk, though I suspect it is a small one, that occupational health could become a tick-box exercise to comply with, which would detract from the full journey of health and wellbeing support. Occupational health is part—indeed, a vital part—of that, but it is not the solution in and of itself, alone.

For the reasons that I have set out, I ask the hon. Gentleman to consider not pressing the new clause to a Division at this point.

[Alex Norris]

I am grateful for that response. I do not intend to push this new clause to a Division. I have made my case about the importance of occupational health, and I understand what the Minister said about the broader range of interventions. Of course, we would support those, too, but particularly here, we really need to get to the point of having full coverage. Only NHS England has committed to that. I hope that today we have at least sounded the signal that the pace is too slow, and that we ought to get on with it. I hope that the Minister will keep the matter under consideration. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 23

Cap on private charges

‘(1) Section 43 of the National Health Service Act 2006 is amended as follows.

(2) Leave out subsection (2A) and insert—

“(2A) An NHS foundation trust does not fulfil its primary purpose if the proportion of the total income of the NHS foundation trust in any financial year derived from private charges is greater than the proportion of the total income of the NHS trust derived from such charges in the financial year ending 31 March 2022.

(2B) For the purposes of subsections (2A) and (2C) “private charges” means charges imposed in respect of goods and services provided to patients other than patients being provided with goods and services for the purposes of the health service.

(2C) An NHS foundation trust does not fulfil its principal purpose if in any year the proportion of the total income derived from private charges is greater than the proportion of the total income of the NHS trust derived from such charges in the previous financial year unless—

(a) the appropriate integrated care boards and integrated care partnerships have been notified of the intention that this increase will occur;

(b) that intention has been published with a statement of the reasons why it is considered to benefit the NHS;

(c) the appropriate integrated care boards and integrated care partnerships have used reasonable endeavours to consider any responses to the publication mentioned in (b); and

(d) any integrated care board which has commissioned services from the trust, and the integrated care partnership for the board, have informed the NHS foundation trust that the proposed increase is justified.”’—(Justin Madders.)

This new clause would prevent NHS foundation trusts increasing their income from private patients year on year unless the conditions set in subsection (2C) are met.

Brought up, and read the First time.

--- Later in debate ---

[Alex Norris]

I congratulate the right hon. Member for Kingswood on his excellent new clauses and the case that he has made for them. We strongly agree that the training and development of staff ought to be to the fore. We must take the opportunity of understanding that we have a workforce crisis at a time of significant technological development.

Take cancer services, for example. We are all concerned about gaps in cancer provision. We need to take the opportunity to turbo-leap forward, rather than trying to restore services to where they were pre-pandemic, when targets were being missed, and had been missed for a number of years. Let us train and develop our staff to use new and innovative approaches, such as new radiotherapies. There is real opportunity there. With respect to new clause 27, the right hon. Gentleman makes a strong case for harnessing the ability of our universities and colleges, and putting that together with our workforce to develop and improve our services.

On new clause 28, the right hon. Gentleman mentioned the paradox of us having profound workforce shortages—in August, there were about 94,000 vacancies, including for nearly 40,000 nurses—while 14,000 applicants were not accepted on to nursing courses in 2018. I understand that there was a significant increase in 2019, but it was not big enough to meet our shortfalls, so that is a real paradox. Our services are not sustainable until and unless we take deliberate action to increase capacity. I know that the right hon. Gentleman does not intend to push the new clause to a Division, but I hope to hear from the Minister about what conscious decisions are being taken. This concerns not just those big courses either, but smaller ones, such as paramedic science and radiography. University Alliance members have reported 1,000 applications for 40 to 50 places, so there is demand. Of course, they cannot just take everybody and there has to be a filtering process, but it feels very over-geared to have 20 or 25 times the applicants per place.

I will not repeat the right hon. Gentleman’s arguments about GPs, but they were good. We should use this moment to change our approach to how we grow our GPs. What do we know about GPs? We know that we do not have enough of them, and that we certainly will not have enough of them in five or 10 years’ time. We know that certain communities find it particularly hard to attract GPs, but also that GPs tend to stay where they train or, if not, they are more likely to go back to where they grew up. As part of any so-called levelling up, we need to focus on growing our own GPs in poorer communities such as mine, and similar midlands communities—perhaps you share some of that vision, Mr McCabe—but we do not quite put this together.

Many of my constituents tend to enter education quite a way behind; they really close the gap over their 14 years of formal education, but fall just short of those very high standards that are needed at the age of 18 to go on to university. Should we be writing off those young people? Could we be doing better at getting them on courses to be GPs? I suspect that we would be able to retain them in Nottingham, or at least attract them back there, and to the surrounding towns, which desperately need GPs. Similarly—this is not a long-term answer, but it is certainly one for the short term—one of my foundational moments in my views on migration came from working in a shop the year after finishing school and before going to university. I was often on the rota with a man from Iraq, who was a trained civil engineer in Iraq, but could not afford to convert his qualification. He could not work in that field and instead worked with me in that shop. It always seemed to me like a significant waste of his skills.

I will take this moment to plug a wonderful project in Nottingham called the phoenix programme, in which students at the University of Nottingham School of Medicine work with migrants to this country who have medical qualifications at home but cannot practise because they need to convert the qualifications and often cannot afford to. Those medical students are working on language, functional skills and all the different aspects of the exams that those individuals will take, in order to help those people become doctors in this country. What a wonderful thing to do.

If we think about however many hundreds of thousands it costs to train a GP in this country, we realise what a saving they are making for us, too. I think that is a wonderful thing. We need that level of creativity on workforce in order to deal with our gap.

I will make no further points—I do not want to repeat what the right hon. Member for Kingswood said—but if those are not going to be the answers, I hope we hear from the Minister what the answer is. If we go for more of the same, we will just see growing workforce gaps and we really will have profound problems in our health service.

[Edward Argar]

I am grateful for the opportunity to address new clauses 27 and 28 together. First, new clause 27 seeks to place a specific duty on the Secretary of State to support the transformation of the health and social care workforce for integrated care systems by working with universities and colleges to train the future workforce through investment in technological and inter-professional innovation.

I take on board the broader points made by my right hon. Friend the Member for Kingswood, but we do not believe that the new clause is necessary, as that work is already covered by section 1F of the NHS Act 2006, which the new clause seeks to amend. Section 1F(1) sets out that the Secretary of State has a duty

“to secure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in…the health service”.

Discharge of the duty under section 1F(1) is largely delegated to Health Education England through section 97 of the Care Act 2014. To meet its statutory duties and to ensure that an effective education and training system is in place, HEE undertakes a variety of work, including with further and higher education providers and regulators. Part of that work includes the curriculums for the healthcare professions. Those curriculums are set by approved education providers at an institutional level. HEE can influence the content by representing the employer voice to ensure that the training that individuals receive is relevant and remains up to date.

As part of that work, HEE is particularly keen to ensure that technological and medical advances are included in teaching, alongside new ways of working. Those measures would support newly qualified professionals to be suitably prepared to launch their careers in the NHS. To support that work and engagement with universities, HEE commissioned the Topol review, published in February 2019—probably in association with my right hon. Friend in one of his previous ministerial roles—on how to prepare the healthcare workforce to deliver the digital future.

That review made recommendations that will enable NHS staff to make the most of innovative technologies such as genomics, digital medicines, artificial intelligence and robotics to improve services. The recommendations support the aims of the NHS long-term plan and the workforce implementation plan, helping to ensure a sustainable NHS. The progress report was published by HEE in 2020 and, as part of the implementation report, HEE has launched a digital readiness programme to continue to lead on developments in preparing the workforce to deliver the digital future.

On inter-professional working, we want a workforce that is less siloed and more flexible and adaptable, and work is ongoing to take that forward in England. For example, at the national level, we are looking at new skill mixes to meet new service models. Those new mixes could include upskilling existing staff, so that more staff are able to do things that have traditionally been limited to a smaller group of professionals—for example, prescribing—or making better use of the wide range of skills and contacts available to reduce duplication.

At ICS level, national guidance on the ICS people function also set out the expectation that the ICB, working with the ICP, will have responsibility for enabling workforce transformation across the health and care system, including through the use of technology and innovation, as well as for work with educational institutions to develop the local future workforce. Nationally, arm’s length bodies will support and enable ICBs to deliver those responsibilities at a local level. I hope that that highlights some of the work being done under the existing statutory duty in section 1F of the 2006 Act.

Secondly, new clause 28 seeks to place three new statutory duties on the Secretary of State. That, in a sense, is at the heart of what my right hon. Friend the Member for Kingswood was getting at. They are: a duty to ensure a sufficient number of clinical placements for the number of students; a duty to ensure innovation—his new clause outlines greater interdisciplinary working, digital technology and simulation as three examples—is supported and funded in the education and training system; and a duty to consult universities and others on clinical placement availability.

We have carefully considered my right hon. Friend’s new clause, but we do not feel that those additional specific statutory duties are necessary, in addition to the existing statutory duty on the Secretary of State in section 1F of the 2006 Act, which my right hon. Friend seeks to amend. Section 1F sets out that the Secretary of State has a duty to ensure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in the health service. Discharging the duty under 1F(1) is largely delegated to HEE through section 97 of the Care Act 2014.

As the hon. Member for Central Ayrshire said, clinical placements are a vital part of healthcare students’ education and training. Good experience during a placement can lead a student to seek employment at their placement provider. As a result, ensuring that there is sufficient placement capacity remains a priority for HEE in order to meet its statutory duties and ensure that an effective education and training system is in place.

Health and Care Bill (Twentieth sitting)

Alex Norris Excerpts

Committee stage
Thursday 28th October 2021 Public Bill Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Obviously, smoking has increased during covid, particularly during the lockdowns, which is quite depressing after some of the progress made in recent decades. This array of new clauses tries to tackle the issue from different angles. New clauses 32 and 38 relate to the age at which someone can purchase, along with other point-of-sale policies. Those issues are all under devolved control, so I have not got involved in those. However, the policy decisions around manufacturing, flavourings, packaging and so on are all reserved, and all four nations of the UK would agree that the biggest single favour anyone can do for their own health is to give up smoking.

As older people and people who have smoked for many years sadly succumb to the diseases we know are caused by smoking, such as heart disease, stroke and cancer, it is incumbent on tobacco companies to recruit a new generation. That is what ornate packaging and childish flavourings are clearly aimed at doing, and they are therefore completely counter to the policies of the UK Government and the devolved Governments.

This is an opportunity to stake the point, move forward and take action to prevent the recruitment of young smokers into cigarette smoking, which will inevitably cost the NHS—indeed the four NHSs—more, as they deal with the health issues over a number of decades, than is raised by tobacco duty. The Government need to stop looking at what they earn from cigarettes and focus on minimising their use. That is the Government’s stated policy, and these new clauses would take that forward.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume proceedings with you in the Chair, Mr Bone. I commend my hon. Friend the Member for City of Durham for her new clauses and the powerful case she made for them, but also for her leadership in the all-party parliamentary group on smoking and health, alongside the hon. Member for Harrow East (Bob Blackman). I know it is a truly impactful APPG and I have always been grateful for my opportunities to go to its sessions to contribute or to listen, as I know Ministers have as well. Reducing smoking and being smoke free by 2030 is a major public health prize. It was a bit disappointing and surprising that there were no tobacco control elements on the face of the Bill, so it is right that we spend a little time trying to change that.

Successive Governments have rightly taken real pride in the reductions in smoking over the past 20 to 25 years. Those reductions have not happened by accident, but through concrete interventions that were sometimes controversial and often challenging at the time, such as the smoking ban, plain packaging and packet warnings—things that we soon afterwards realised were very impactful, and very much the right thing to do. Of course, as the hon. Member for Central Ayrshire says, we have to view this in the context of covid, and there has perhaps been a bit of backsliding on that progress, but that should drive us not to despair, but to redouble our efforts. I hope we can move things forward in the spirit that my hon. Friend the Member for City of Durham suggested.

We have to understand that the gains we have made in recent years come with a caveat. Most of the quitting has been done by people from better-off communities, and the benefits have largely accrued to those communities. We are now at the point where smoking accounts for 50% of health inequalities between the poorest and the best-off communities. If we really are serious about levelling up or whatever we want to call it, health is surely a crucial part of that. We know that smoking accounts for half of that difference, so we really ought to be focusing on it.

Reducing smoking ought to be a major project for any Government, because poorer smokers are just as likely to want to quit as their better-off counterparts, and just as able to do so if they have access to good services. However, we have spent a decade cutting those services in general, but particularly in the poorest communities, so high-quality smoking cessation services—which are so effective—have withered on the vine in many of the places that need them the most.

I will now turn to the new clauses tabled by my hon. Friend the Member for City of Durham, beginning with new clause 29. About one in seven adults smokes. That is about 7 million people, and while health warnings have been displayed on smoking packages for well over a decade, there is evidence that the impact of warnings such as those wane over time. However, the dangers of smoking remain high—between 2016 and 2018, there were 1,167 deaths attributable to smoking in my city of Nottingham alone—so we need to build on the techniques that have worked, with new ones to refresh our under-standing of the dangers of cigarettes to smokers.

There is evidence that dissuasive cigarettes can make smoking less attractive to younger people and non-smokers, and the inclusion of warnings on individual cigarettes, as proposed by new clause 29, is one key way of doing that. Such warnings are already being considered around the world: an in-depth study from France found that warnings on cigarettes increased negative health perceptions, reduced positive smoker image and the perceived pleasure of smoking, decreased the desire to start smoking, and increased the desire to quit. There are therefore signs that such a policy would be impactful.

New clause 30 deals with cigarette pack inserts. Inserting leaflets that contain health information and information about quitting is an effective and cheap way to target existing smokers and help them get support to quit. Those inserts are easy and cheap to implement and, moreover, while the reading of cigarette pack warnings decreases over time, the reading of inserts increases. In Canada, package inserts have been a legal requirement since 2000, and a survey of smokers in Canada found that between one quarter and one third of respondents had read pack inserts at least once in the prior month, and those intending to quit or having recently tried to do so were significantly more likely to have read them. Pack inserts will support and reinforce the impact of other measures that will require more significant investment campaigns to go with them, such as behaviour change campaigns and stop smoking services. They are a really good evidence-based, low-cost addition to such campaigns.

New clause 31 relates to the packaging and labelling of nicotine products. Over the decades, regulation has transformed traditional cigarette packaging, plastering it with warnings and preventing tobacco companies from selling a desirable image of smoking. However, regulations have not kept pace with the less traditional nicotine products, such as e-cigarettes and nicotine pouches. Tobacco companies are still able to sell e-cigarettes adorned with bright colours, cartoon characters and attractive images, as we have heard from my hon. Friend the Member for City of Durham and the hon. Member for Central Ayrshire, and I know that e-cigarette shops in my constituency offer vape liquids branded as vanilla ice cream, slushies and cookie dough, all of which appear targeted at young people, and children in particular.

I am enthusiastic about vaping—it still feels like that is an unfashionable thing to say, but I stand by it. I think vaping is a really good way to help people quit smoking and stay quit, and it is a really important part of a smoke-free 2030. However, it should be regulated properly to help make being smoke free a reality. Data shows that restrictions on the branding of e-cigarettes and refills reduce the appeal of vaping to young people, particularly children, while having little impact on adult smokers’ interest in using these products to quit smoking, so, again, it is cost-free.

[Dr Whitford]

I assume from the hon. Gentleman’s comments that he shares my concern that although vaping is considerably safer than traditional tobacco, as Public Health England reports on vaping show, vaping products still contain nicotine, which is a vascularly active substance. Therefore, we should still be concerned about non-smoking children being recruited on to vaping. We have no idea what decades of nicotine vaping will do to someone.

[Alex Norris]

I do share that view, particularly around children. Our preference would be for them to never start. There should not be packages with cartoons and child-friendly descriptors to develop a market among children. I think there would be a high level of consensus on that.

In that spirit, new clause 32 addresses an incredible loophole, which I cannot believe anybody thinks is a good idea. If the Minister is not going to accept new clause 32, I hope he will say when the issue will be resolved. The idea that you cannot sell e-cigarettes to children but that you can give them out as free samples to under-18s is quite hard to understand. It is time for us to get hold of this simple loophole, which goes against the spirit of the legislation, which is designed to protect children against nicotine addiction. I hope we can get some clarity, either because the Minister accepts the new clause or gives us a clear picture that we will see action very soon.

On new clause 33, about flavoured tobacco products, it again feels like the market is not acting in the spirit of the laws that have been passed. Flavoured tobacco is designed to make products more appealing, especially to younger people. In May 2020, we banned the sale of tobacco with a characterising flavour such as vanilla, spices and menthol. However, companies have adapted to this legal change with new innovations that skirt the law and provide smoking experiences that replicate flavoured tobacco. I can go to supermarket websites and find “green” branded cigarettes being sold, with many reviews stating how similar the flavour is to menthol cigarettes. I do not think that is in the spirit of the law.

In the year from May 2020, Japan Tobacco made over £91 million in profits from menthol brands. Clearly, the law has not worked as we want it to. Moreover, between January 2020 and 2021, a survey of smokers showed that the smoking of menthol cigarettes has not declined, despite the apparent ban, so I do not think the law is working. This new clause would do a good job of closing that legal loophole. If the Minister is not minded to accept it, I would be keen to know what the Government intend to do instead, because I cannot believe that they want laws that they passed, in possession of full facts, to be worked around in that way.

I will take new clauses 34 to 37 as a group, because they create the same thing: a tobacco control fund, paid for by manufacturers, combined with the regulation of tobacco companies’ profits. As my hon. Friend the Member for City of Durham said, when the Government announced their smoke-free 2030 ambition, they promised to consider a US-style “polluter pays” levy on the manufacturers, and included an ultimatum for industry to make smoked tobacco obsolete by 2030. My hon. Friend’s APPG has published a very strong option for how to do that. Ministers could lift and shift that very happily and get on with this. There are real benefits to that.

Action on Smoking and Health do some wonderful work, and I am grateful for its support in my work. It estimates that a comprehensive national, regional and local tobacco control programme—in many ways, we have lost that in recent years—to deliver a smoke-free 2030 would cost the UK about £315 million. That would involve adding back lost services. ASH’s estimate for a levy, based on the model the APPG talks about, is £700 million. This could be a “polluter pays” model, and we would have plenty left over to overturn all those poor public health budget cut decisions taken over the last decade. If the spirit of yesterday’s Budget was to try to rewind and erase the lost decade that we have had in this country, this would be a really good place to do that, and I think that is a good deal.

Of course, the EU tobacco tax directive is no longer a blocking factor, so we have complete agency to act in this area and it is in the gift of the Government, so I am very interested to know how far along the Minister or his colleagues are in the consideration, as they said, of this matter, and when we will see some proposals. Similarly, when will we see another tobacco control plan? That is something that everybody, from local government, public services, the private sector, community and voluntary services and all of us in this place, can organise around. The 2030 goal is a common goal. Pretty much everything that we have said in the new clauses are things that we are of one mind on. We can do something really good for the health of the nation, and I hope to find the Minister in action mode on that.

I will finish by referencing new clause 38, also tabled by my hon. Friend the Member for City of Durham, because I do not want it to look like I have ducked the question. It is important that we actively look at that and consider the evidence. I am perhaps not ready to say that it should be in the Bill, but it should be part of an active conversation in this area and part of a tobacco control plan. I think the Minister may be in a similar place on that, because we know that it is an effective part of the armoury. There are loads of really great things to go at in this set of new clauses, and I hope that he feels the same way.

[The Minister for Health (Edward Argar)]

It is a pleasure, as ever, to serve under your chairmanship, Mr Bone. I am grateful to the hon. Member for City of Durham for giving us an opportunity to debate the new clauses. I had the privilege and pleasure, I think almost a year and a half or two years ago, when I was standing in for the Public Health Minister, of responding to a debate in the House on this subject—I think she was in Westminster Hall responding to another debate. I therefore had the pleasure of listening to hon. Members speaking about the work of the APPG, and this issue more broadly, on that occasion. It seems like an age ago. I suspect that it was only about a year ago, but that is what the last year and a half has done for many of us.

New clause 29 seeks to provide powers for the Secretary of State to impose a requirement for tobacco manufacturers to print health warnings on individual cigarettes and cigarette rolling papers. That requirement is intended to further strengthen the current public health messaging and encourage smokers to quit. The Government are sympathetic to the aims of the new clause. We strongly support measures to stop people smoking and to educate smokers of its dangers, as we have done through warnings on cigarette packs. However, we believe that we need to conduct some further research and build a more robust evidence base in support of such additional measures before introducing them. If evidence shows that that requirement would not be effective, there is a risk that the power would not be used. As hon. Members will be aware—the hon. Lady was right in the point that she made—health is a devolved matter. Therefore such a measure would need to be considered in partnership with the devolved Administrations.

We are currently in the process of developing our new tobacco control plan. When the hon. Lady winds up the debate on this group of new clauses, she may say, “All well and good, but we’ve been in that place for a while. When will I see it?” I would be surprised were she not to do so. We continue to work on the plan at pace. She will be aware that the events of the last year and a half have, in a number of areas, knocked the existing timelines for producing plans slightly sideways, but we continue to work actively on that. As part of the tobacco control plan that we are working on, we are exploring a broad range of new regulatory measures to support our ambition to be smoke free by 2030. We are reviewing this specific proposal as part of that work, in considering the options for a package of legislative measures.

New clause 30 seeks to provide a power for the Secretary of State to introduce a requirement for manufacturers to insert leaflets containing health information and information about smoking cessation services inside cigarette packaging. We believe that that power is not strictly necessary as the Department could legislate to do that already under the Children and Families Act 2014, as inserts could be required for public health messaging through amendments to the Standardised Packaging of Tobacco Products Regulations 2015. It is also important to note that we already have strong graphic images and warnings of the health harms of smoking on the outside of cigarette packs, and the NHS website provides advice for people seeking to quit smoking. That website address is required on packaging under the Tobacco and Related Products Regulations 2016.

The current regulations, the Standardised Packaging of Tobacco Products Regulations 2015, prohibit the use of inserts, as there was limited evidence during the development of those regulations that placing public health messaging inserts inside cigarette packets was more effective than the messaging on the outside of packs. A post-implementation review of SPOT—if I may refer to the regulations in that way to save a little time—is currently under way. It is seeking to assess whether the regulations have met their objectives, and will identify whether there is a need to strengthen them in any way or to revisit any aspect of them, such as the one that the hon. Member for Central Ayrshire mentions. We aim to publish the post-implementation review before the end of this year.

If we were to introduce inserts through regulations, we would need to conduct further research on that. We would need to establish the public health benefit, costs to businesses, impact on the environment from litter and practicalities around enforcement, and crucially build a robust evidence base in support of such measures and their efficacy, along with, obviously, public consultation on them. This is something that we will consider as part of the Smokefree 2030 regulatory plans, but we will wait and see what, in the next couple of months, the published post-implementation review says. Health, as I have mentioned, is devolved, so it is something on which we would need to work with our friends and partners in the Scottish Government and other devolved Administrations.

New clause 31 seeks to enable legislation that would make provision about the retail packaging and labelling of electronic cigarettes and other novel nicotine products. That would include requirements for health warnings and the prohibition of branding elements that are attractive to children. I pay tribute to the work that the shadow Minister, the hon. Member for Nottingham North, has done in this space. I know that this is not just an issue of shadow ministerial concern for him, but something in which he has taken an interest as an individual Member of Parliament, so I recognise his expertise and knowledge in this area.

We are currently undertaking a post-implementation review of the Tobacco and Related Products Regulations 2016 as well. The current regulations include requirements on the packaging and labelling of e-cigarettes, along with restrictions on marketing, and they prohibit advertising on mainstream media such as TV and radio for e-cigarettes. Again, we will publish that review this year.

We want to encourage smokers to quit smoking using nicotine replacement therapy and by switching to less harmful products such as e-cigarettes. I take the point made by the hon. Members for Nottingham North and for Central Ayrshire. I share the shadow Minister’s view that if there is a choice between a conventional cigarette and an e-cigarette, I would much prefer people to be smoking an e-cigarette, because it is less harmful. But I absolutely take the point made by the hon. Member for Central Ayrshire, who is, as we know, an eminent clinician, that even if it is less harmful, it is still harmful. The ideal would be that people use neither product, but if it is a choice between the two and a question of getting someone to change their habit, I would much prefer to see them using an e-cigarette than a conventional cigarette. I think that there is consensus on that point across the two Front Benches and, indeed, the SNP Front Bench.

However, we need to ensure that our regulatory framework continues to protect young people and non-smokers from using e-cigarettes. That is the point about the degree of harm: although less, it is still there. Regular youth use of e-cigarettes does, on current evidence, remain very low, at about 2% of 11 to 15-year olds. That figure dates back to 2018, so it is slightly dated, but it gives us a useful data point. However, I do not believe that that should induce complacency in any of us. We need to continue looking at the matter very carefully.

Again, the Government are sympathetic to the aims of the new clause and strongly support measures to protect young people. Again, I point to the timing and the need for the post-implementation reviews and for further research and consideration in the light of those when they come forward in the next few months.

New clause 32 seeks to give powers to the Secretary of State to make regulations to prohibit the free distribution or sale of any nicotine products to anyone under 18, with the exception of the sale or distribution of nicotine replacement therapy licensed for use by under-18s. There is already in place, as the shadow Minister alluded to, legislation that prohibits the sale of tobacco and e-cigarettes to under-18s; that includes proxy sales. There are also existing powers in the Children and Families Act 2014 to extend the age-of-sale restrictions to include any nicotine products such as nicotine pouches. Therefore, as he said, the new clause is not needed in relation to sales.

New clause 32 seeks to further protect young people from the distribution of free nicotine products to under-18s, but again, we do not have a firm or robust evidence base at present to suggest that that is a widespread problem. The recent post-implementation review of the Nicotine Inhaling Products (Age of Sale and Proxy Purchasing) Regulations 2015, published earlier this year, did not raise that as a concern. I suspect the hon. Member for Nottingham North will say, “Why not get ahead of the game, anyway, with a pragmatic measure?”, and I have some sympathy with that point.

--- Later in debate ---

[Alex Norris]

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

I welcome the Government’s commitment to bring forth a consultation on introducing calorie labelling on alcohol products, for which we have been calling for some time, but I do not think there is a need to wait for this to be introduced in order for alcohol products to display the chief medical officer’s low-risk drinking guidelines, health warnings, ingredients and nutritional information, which is what the new clause asks for, mirroring what clause 127 does for food.

As it stands, there are no legal requirements for alcohol products to include health warnings, calorie information or even basic information such as ingredients. I am aware of the research by the Portman Group, which says that nearly half choose to do so. However, it is not quite cutting through. Consumers have a right to know what they are consuming and the associated risks, but many people are unaware of the calorie content in alcohol. About 80% of people are unable to identify the number of calories in a large glass of wine. Furthermore, beyond the most obvious risks of drinking alcohol, many people are unaware of the broader risks. Only a quarter of people are aware that alcohol is linked to breast cancer.

Similarly, despite alcohol’s link to worse pregnancy outcomes and serious lifelong impacts on a baby, one in three people are unaware that it is safest not to drink while pregnant, and it is estimated that 41% of women consume alcohol during pregnancy. That is a serious matter, and the issue of foetal alcohol spectrum disorder is not well known enough in this country. Especially in communities such as mine, I suspect that it has a profound impact on child development, which I know we will talk about shortly. My predecessor, Graham Allen, was a very strong proponent of a national study into FAS, and I echo his call. I really hope that might be something the Minister addresses, because it would have profound outcomes for child development and some of the care services that we might need in communities such as mine.

The public have a right to know what is in what they drink and eat and to make informed choices. I will not go round the bars snatching bottles of beer or glasses of wine out of people’s hands—I could not credibly do that, but I also have not inclination to do that. However, people should have a free and full understanding of the impacts of drinking alcohol and make their own judgments based on that. A recent survey conducted by YouGov found that 75% of people want the number of units in a product on the label, 61% want calorie information and 53% want the amount of sugar to be displayed. Again, this is what people want. Notwithstanding the research on some of the good things that the industry is doing voluntarily, which I pointed to earlier, we are still in a situation whereby that is not happening enough.

The Alcohol Health Alliance did a review of 424 alcohol product labels in London, the south-east and north-east of England, Wales and Scotland, which revealed that 71% of labels did not include the chief medical officer’s low-risk drinking guidelines. More than one quarter of labels included incorrect or misleading information that was either out of date or from other countries, 72% of labels did not list the ingredients and a majority had no nutritional information. Just 7% of labels displayed full nutritional information including calories, which is what we called for.

[Dr Whitford]

Many of the labels simply say, “Drink responsibly” or, “Drink aware”, but, as the hon. Gentleman is highlighting, the lack of information on labels introduces quite a complex step of that person having to go and look up the risk of harm or the unit measures. Yet we have just been debating the need to have warnings on cigarettes. Alcohol introduces harm both to the individual and, if they are heavy drinkers, to those around them, and therefore we should be taking this seriously. We have tried to do so in Scotland with measures such as minimum unit pricing, but information to the consumer is the first step.

[Alex Norris]

I am grateful for that intervention. I would certainly not talk down including the very broad messages that the hon. Lady mentions; I know that in an overwhelming number of cases that is available, but, as she says, that is not enough. People are conscious of that message and we should keep reinforcing it, but the jump-off point is, “So what? What am I going to do differently, or what do I need to understand differently?” At the moment, we are not helping them in that process.

This new clause, mirroring clause 127, asks the Secretary of State to introduce secondary legislation to compel the inclusion of this sort of information on products. It is a relatively modest ask, but it promotes informed choice, which in this area would be a very good thing. I do not think we should miss the opportunity to put it in the Bill.

[Edward Argar]

As has been set out, this new clause would make provision to ensure that alcoholic drinks display the chief medical officer’s low-risk drinking guidelines, a warning intended to inform the public of the danger of alcohol consumption, a warning intended to inform the public of the danger of alcohol consumption particularly when pregnant, a warning intended to inform the public of the direct link between alcohol and cancer, and a full list of ingredients and nutritional information.

First, let me say that alcohol labelling is an important part of the UK Government’s overall work on reducing alcohol harm. We believe that people have a right to accurate information and clear advice about alcohol and its health risks to enable them to make informed choices for themselves about their drinking. However, we feel that the new clause is unnecessary, because the Government are about to launch a consultation on these matters.

As part of our tackling obesity strategy, published in July last year, the Government committed to consulting on whether mandatory calorie labelling should be introduced on all pre-packaged alcohol, as well as alcoholic drinks sold in the out-of-home sector. The Government have worked with the alcohol industry to ensure that labels on pre-packaged alcohol reflect the UK chief medical officer’s low-risk drinking guidelines, and the industry has made some progress towards achieving that.

To make further progress, as part of our public consultation on alcohol calorie labelling we will also seek views on whether provision of the chief medical officer’s low-risk drinking guidelines, which include the various specific warnings that the hon. Gentleman mentioned, such as drinking in pregnancy and the drink-drive warning, should be mandatory or should continue on a voluntary basis. Respondents to the consultation will be able to provide suggestions for additional labelling requirements that they would like the Government to consider, such as nutritional information. As I said, that consultation will be launched shortly.

Clause 127 confers a power on the Secretary of State in England, and on Ministers in the devolved Administrations in Scotland and Wales, to make improvements to and amend or repeal articles of European Union Regulation 1169/2011. This EU regulation currently prohibits mandatory calorie labelling on pre-packaged alcohol that is 1.2% alcohol by volume and above. The passage of this legislation will therefore enable Governments to introduce changes such as mandatory calorie labelling on pre-packaged alcohol labels through regulations.

If a decision is made to mandate those labelling requirements following the consultation, the Bill will support the Government in being able to make the necessary changes through a new power in the Food Safety Act 1990. Consistent with the Government’s obligation to consult on matters concerning food law, before any regulations are made, a consultation with interested stakeholders must take place. Therefore, as there is a statutory duty to consult on introducing mandatory labelling requirements and as work on improving alcohol labelling is under way, we do not believe that a separate clause in the Bill is necessary at this time. I encourage the shadow Minister to be reassured by what I have said and to consider not pressing his new clause to a vote.

[Alex Norris]

I am grateful to the Minister for his response. Any measure, as with that in the new clause moved by my hon. Friend the Member for City of Durham, again relies on us waiting for consultation. It feels like an awful lot of consultation, which is of course an important part of doing the process right, but we should never confuse it with action. We have spent an awful lot of time in this space, and it feels as if there is a danger that we are into soft-pedalling territory, rather than action territory. Nevertheless, I heard what the Minister said, that it is an active process, so on that basis I will not press for a Division. We will reflect on the issue on the Labour Benches but, widely among those interested in the area, there is a growing sense of impatience. I hope that us giving the Minister and the Government space to continue the process is not confused with us being content that we are going quickly enough—I feel strongly that we are not. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 43

Annual report on alcohol treatment services: assessment of outcomes

“(1) The Secretary of State must lay before each House of Parliament at the start of each financial year a report on—

(a) the ways in which alcohol treatment providers have been supported in tackling excess mortality, alcohol related hospital admissions, and the burden of disease resulting from alcohol consumption, and

(b) the number of people identified as requiring support who are receiving treatment.

(2) Alongside the publication of the report, the Secretary of State must publish an assessment of the impact of the level of funding for alcohol treatment providers on their ability to deliver a high-quality service that enables patient choice.”—(Alex Norris.)

This new clause would require the Secretary of State for Health and Social Care to make an annual statement on how the funding received by alcohol treatment providers has supported their work to improve treatment and reduce harm.

Brought up, and read the First time.

[Alex Norris]

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

The new clause would put a duty on the Secretary of State to make an annual statement on the spend on, and impact of, alcohol treatment services. Each day in the UK, 70 people die of alcohol-related causes. Alcohol is linked to 200 different diseases and injuries and costs the NHS £3.5 billion each year. Good alcohol treatment is essential to support those with alcohol dependence towards recovery. That is important for individuals and for the collective, because it reduces emergency services call-outs, unnecessary hospital admissions and avoidable deaths.

Despite the importance of treatment, even going into the pandemic, only one in five dependent drinkers were believed to be in treatment—that is 80% lacking healthcare. The incomprehensible and frustrating picture in this country in recent years, between 2016 and 2018, is that more than two thirds of local authorities in England cut their alcohol-treatment budgets, and in 17 of them those cuts were greater than 50%.

Having been a local councillor in that period, responsible for public health in my community, I know that no colleague did that because they thought it was the right thing to do for their community; they did it because the public health grant in this country has been run down over the past decade, which has been an absolute tragedy. Those are the sorts of services that we have lost.

A very visible example comes from St Mungo’s—we all know its wonderful work—which estimates that funding cuts have meant that 12,000 fewer rough sleepers accessed support in 2018-19 than would have done had funding remained at 2010 levels. The covid pandemic has only worsened the situation, leading to significant and sustained increases in the rate of unplanned admissions for alcoholic liver disease. This issue is very important now, in the very immediate term. We need to act.

Owing to resource cuts, however, many alcohol treatment providers have been forced to reduce their offer. A lack of outreach resources leads to people with some of the most complex needs missing out on support, while the reduction in capacity means that many of those at the lower levels, where an earlier intervention would be very impactful, miss out as well. Those with greater dependency are not getting specialised treatment or, in some cases, are not getting any treatment at all.

I strongly believe that the Bill needs to address the importance of alcohol treatment in terms of its funding and impact. Requiring the Secretary of State to report to Parliament on the ways in which alcohol treatment services have been supported and funded, and on the number of people requiring treatment and how that need is being met, will keep the issue at the forefront.

The Government’s own alcohol strategy states that alcohol treatment services

“offer the most immediate opportunity to reduce alcohol-related admissions and to reduce NHS costs.”

We also know that for every £1 invested in alcohol treatment £3 is yielded in return, rising to £26 over 10 years. Recovery also yields powerful dividends for families and communities affected by addiction, but at the moment we are going the wrong way in terms of our commitment to this issue. What I am asking for in the new clause, and I think it is a relatively modest ask, is for the Secretary of State to have on an annual basis an honest and candid assessment of the situation in this country, and then to account for the activity that is being taken to meet the need. It would be a very powerful statement that the Secretary of State and the Department have a grip of the issue and are committed to it, so I hope to find the Minister in listening mode.

[Edward Argar]

As ever, I am grateful to the shadow Minister for his exposition of the new clause, which would introduce a duty on the Secretary of State for Health and Social Care to publish an annual statement on how the funding received by alcohol treatment providers has supported their work to improve treatment and reduce harm. It would also introduce a duty on the Secretary of State to publish an assessment of the impact of the level of funding for alcohol treatment providers on their ability to deliver a high-quality service that enables patient choice. I join the shadow Minister in paying tribute to St Mungo’s for the work that it does, which I think we would all recognise across the House.

We do not think that a new reporting requirement introduced by the new clause is necessary as significant work is already under way in this area. Outcomes for local authority-funded alcohol treatment services are already published via the Office for Health Improvement and Disparities’ national drug treatment monitoring system. They are monthly and quarterly reports provided at a local authority level, and annual reports at a national level. The Office for Health Improvement and Disparities also publishes annual data on estimated numbers of alcohol dependent adults in each local authority in England. Health commissioners can use that resource to estimate the number of adults in their area who need specialist treatment, supporting them to appropriately plan and improve alcohol treatment services.

The Office for Health Improvement and Disparities provides a number of data tools to support local areas to compare their performance against that of other areas, and against national performance. Those tools include the public health outcomes framework, local alcohol profiles for England, and the spend and outcomes tool. With respect to spending, local authorities are currently required to report on their spend on alcohol harm prevention and alcohol treatment on an annual basis to the Department for Levelling Up, Housing and Communities. Part 2 of Dame Carol Black’s independent review of drugs was published in July 2021 and the Government, in their initial response, published on 27 July 2021, agreed to carry forward its recommendations and publish a new drugs strategy later this year.

The review recommended increased transparency and accountability from local authorities on how funding is spent. Although the subject of the review was drugs, the implementation of that recommendation will apply to both drug and alcohol treatment through mechanisms such as an improved commissioning standard, which is currently in development. I therefore encourage the shadow Minister not to press the new clause to a Division.

[Alex Norris]

I cannot quite accept that answer from the Minister. I understand the significant work that he talks about, and the different places where data is available. Those things tell us what is going on; they do not tell us why, and what we intend to do about it as a country. As a result, I do not think that is delivering for us, and we see that in the very difficult outcomes. On that basis, I am afraid I will have to press the new clause to a Division.

Question put, That the clause be read a Second time.

Health and Care Bill (Twenty First sitting)

Alex Norris Excerpts

Committee stage
Thursday 28th October 2021 Public Bill Committees

Brought up, and read the First time.

[Alex Norris (Nottingham North) (Lab/Co-op)]

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

It is a pleasure to resume our consideration with you in the Chair, Ms Elliott. The new clause is in my name and those of my colleagues. If we think about the pandemic and the last 18 months, we will have various views on all sorts of things that have gone on during that period, but I think that one thing that we would be of one mind on is how well our nation’s directors of public health have performed in this crisis. They have been incredible, pulling together the local response and bringing to bear their unique combination of training, relationships and local soft power in order to ensure that the local approaches to dealing with the pandemic in aid of the community have been strong ones. I think we would all say that they have done absolutely superbly.

The new clause seeks to codify a little more formally the place of directors of public health in the system. As we are authoring a new system in the Bill, this is no bad time to do that. The purpose of the new clause is to clarify the roles, powers and duties of directors of public health and to put them on a statutory footing. Whatever structures DPHs sit within, their major role—the reason why as a country we need them and why we invest in them as we do—is that they act as an independent advocate for the health of the population, for system leadership and for the improvement of the system for the population. They are already responsible within their area for a broad range of things, such as measurable health improvement, health protection, public health input, planning, commissioning, reducing inequalities and more. There is a strong reason to put them on a statutory footing. They of course provide an independent advisory function for a wide range of organisations, including the NHS. My local DPH is very good indeed. She often reminds colleagues that she is the system’s DPH rather than just the local authority’s. She may well be hosted by the local authority, but her remit goes much broader, and that is a very good thing. Putting DPHs on a statutory footing would recognise the system leadership role that they have.

The new clause would use a corporation sole model to ensure that directors of public health have scope for independent action; it would ensure that special arrangements are made for them, as officers of the Crown, to bring certain things to the attention of the Attorney General and the chief medical officer, and to ensure public health representation on NHS managing, regulating or commissioning bodies where necessary; and it would guarantee their professional independence in these wider functions. In the vast majority of cases across the country, most of these functions and roles are operating very well indeed, but the new clause would give statutory underpinning to that.

Together, these changes would allow DPHs to have influence across the entire place that they work for and across all policy areas, including budgetary and allocative decisions, and ensure that they have a chance to play their part across all decisions being made in the local community that impact on public health. This proposal would hardwire links between DPHs and the NHS public health workforce who enact public health policy. For place-based officials, having strong links with local and regional NHS employees is not only a benefit but a necessity. It would help to strengthen our response to health inequalities and hence the prevention of ill health—we have spoken at length about that during these proceedings—as well as enhancing relationships for emergencies, which we have seen in recent months.

Where this is done best, it is a strong model. I know that some directors of public health have consultants within their local NHS trust. That is something that the Association of Directors of Public Health is very keen on. If the Bill and the direction of travel are about an integrated system, those kinds of integrators are a very good model of doing that.

These are critical roles. We have seen that in challenging times, but in more general times, as we push on in order to have a healthcare system that is more preventive, that closes inequality gaps and which delivers excellent services to our population, directors of public health will be really key players in it, so I hope that this attempt to put them on a slightly stronger and more consistent footing will be welcome.

[The Minister for Health (Edward Argar)]

It is a pleasure to see you in the Chair once again, Ms Elliott.

My understanding, in the light of what the shadow Minister has said, is that one of the underlying aims of the new clause is to ensure that the public’s health is at the fore as we reform the health and care system. I have the utmost sympathy with that an aim

The Government recognise the importance of a robust public health system that works to improve the health and wellbeing of the nation and to prevent disease. That is why we have taken decisive steps to reshape our national public health bodies so that we are well equipped to face future challenges. Furthermore, we agree that directors of public health and their teams should have a crucial role at the heart of the new system.

The shadow Minister is absolutely right to say that although directors of public health are hosted by local authorities, they represent the whole system, and we owe them a debt of gratitude. In our past lives, he and I would have worked with DPHs in our local authority contexts, and of course, as Members of Parliament, we have all seen what our local DPHs have had to do over the past year and a half. I suspect that Members who did not know their local DPH have probably got to know them and their work in the community a lot better, which is no bad thing.

This fits naturally with the strategic emphasis on population health that we expect of integrated care systems. Both the Department of Health and Social Care and NHS England have set out in published policy and guidance documents our expectation of directors of public health having an “official role” in integrated care systems. Officials in the Department are working closely with the Association of Directors of Public Health and others to help describe further the place of these roles, the outcomes that we hope collectively to achieve, and the ways in which they can best add value to the system’s impact on health overall.

Although we entirely understand the motivation behind the new clause, I am not sure that it is strictly necessary. It seeks to clarify the roles, powers and duties of DPHs, but their roles and responsibilities are already clearly and accurately set out in legislation and current guidance. The requirement for the recruitment to the role of director of public health, for example, is already clear on professional qualifications, and the registration and regulation requirements are clearly laid out. The new clause may have the effect of reducing the flexibility of the post, although I am sure that the shadow Minister would say that that concern is unfounded.

Furthermore, the current system already provides independence and influence for directors of public health, and that is strengthened by several provisions in the Bill, which includes, for instance, a duty on ICBs to seek advice from persons with the appropriate expertise on prevention and public health, including directors of public health, complementing the existing duty, in the section 6C regulations of the National Health Service Act 2006, for local authorities to provide the NHS with public health advice.

Additionally, we do not believe it necessary to make directors of public health officers of the NHS, as the Bill already provides opportunities for DPHs to link into and influence NHS bodies in their current guise. Integrated care partnerships, for instance, must develop an integrated care strategy to which integrated care boards must have regard in drawing up their commissioning plans. The intended result is to create a plan to meet the health—including public health—and social care needs of the population within their defined geography. That will provide directors of public health with the opportunity to influence NHS commissioning plans to meet wider public health aims.

It is also possible that the new clause would create a number of undesirable consequences—I suspect that the shadow Minister will allay some of those fears in his response. Rather than bringing clarity, the new clause could create confusion and complexity in a system that is already functioning effectively with a clear understanding of the role and how it operates.

The new clause would put a host of prescriptive new requirements on DPHs, including a requirement for them to be officers of the NHS, NHS consultants in public health, and officers of the Crown, while retaining independence of thought and action.

While we certainly understand the motivation of wanting to knit together the system through an individual post, that approach would add a layer of complexity. I believe that it would be challenging for an individual holding that office to seek to balance those complex responsibilities, accountabilities and potentially competing priorities within various organisations. That would also complicate the lines of accountability

My concern is that the new clause is overly prescriptive about the status and nature of the role, which would go against the overall aims of the Bill in terms of permissiveness. Although we hope and expect that directors of public health will act as a nexus for bringing coherence to the local system’s focus on population health, we are not convinced that this level of prescription over permissiveness is appropriate. That reflects a thread of the debate throughout the passage of the legislation on where the appropriate balance should be struck.

Proposed new paragraphs (e) and (h) would weaken the ties that directors of public health have with local authorities. Since the 2012 reforms, there has been widespread consensus that local authorities are best equipped to deal with a wider range of public health matters for their population’s needs. In that context, I pay tribute to local authorities for their role in tackling the pandemic, including those in elected roles. If I recall correctly, the wife and partner of the shadow Minister, the hon. Member for Ellesmere Port and Neston, is active as an elected councillor in a local authority. Many Members of this House will have served in that role, too, and will recognise what local authority councillors and officers do in that space.

From their home in local government, DPHs have been able to maintain an independent mindset while playing a critical role in improving and protecting the public’s health. Although it may well evolve in future, that system is working, and we have a strong and solid base that is understood by all system players. I therefore encourage the shadow Minister to continue to work with me and others to make that system work, rather than seeking to press the new clause to a Division.

[Alex Norris]

I certainly did not intend to add complexity; I was hoping for clarity and consistency. Nevertheless, as the Minister says, those roles are currently functioning effectively, so I will not divide the Committee.

I would say to the Minister and his colleagues, however, that we need a real watching brief on this matter, because assuming that the Bill continues its onward journey and establishes those ICS footprints, there will be a range of different outcomes and organisational cultures. The stronger systems will be those in which the DPHs are at the heart of insight and decision making, and the reverse will be a defining characteristic in systems that are not as good. I certainly hope that we consider the Care Quality Commission reviews that were included in an earlier new clause, and any sector-led improvement, as well as the work those systems do to reflect on what they do and do not do well.

One of the criteria for both streams of improvement ought to be what the DPH does, how central they are, and how sighted they are on decision making. As I have said, in good systems that will be good, and in weak systems it will be weak. Those criteria would be a bellwether of how good the local ICS footprint is. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 45

Duty on integrated care boards to have regard to net zero commitment

“(1) The National Health Service Act 2006 is amended as follows.

(2) After section 14Z43 (inserted by section 19 of this Act) insert—

“14Z43  Duty to have regard to net zero commitment 

When procuring or commissioning goods and services on behalf of the NHS, integrated care boards must have regard to NHS England’s commitment to reach net zero by 2040.””—(Justin Madders.)

This new clause would place a duty on integrated care boards to have regard to NHS England’s commitment to reach net zero by 2040.

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 see you in the Chair, Ms Elliott. I will be brief in speaking to the new clause. What we are seeking to achieve is pretty clear: for integrated care boards procuring or commissioning goods and services on behalf of the NHS to have regard to NHS England’s commitment to reaching net zero by 2040.

We can assume that the Government fully support the commitment made by NHS England. We were all transfixed by the goings-on in Committee yesterday, so we may have missed the part in the Chancellor’s statement about investment in net zero and in the NHS, but perhaps the Minister will say a little more on that. I suspect that although he will accept that ICBs should have regard to the overall commitment, he will say that the new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs. We would say that NHS England can achieve that target only by working through ICBs, which will, of course, have the ability to commission more than £100 billion-worth of services.

We may end up yet again in the realms of the permissive versus prescriptive debate, but the power of public sector procurement is a massive issue, and there is no bigger part of the public sector than the NHS, which is the responsibility of the Minister’s Department. We should be very much on the front foot in using that to deliver the commitment to net zero.

Of course, we have yet to see what will replace the public contracts regulations in Government procurement as a whole. It is hoped that the same commitment to green issues will be in the mix somewhere, but until we know what that looks like, the new clause presents an opportunity to enshrine in law a commitment that I think most if not all Members want to see delivered.

--- Later in debate ---

[Justin Madders]

I am grateful to the Minister for his positive comments. We were probably pushing our luck with getting a formal commitment from him, but it sounds like we are probably as close as we are going to get to progress on the matter without pushing the new clause formally to a vote. We will keep a close eye on the issue and will, no doubt, come back to it if progress is not made in orderly time. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 50

Access to innovative medicines and medicinal products review

“(1) The Secretary of State must undertake and publish a review of the use by the NHS of innovative medicines and medicinal products.

(2) The review must—

(a) conclude before 31 December 2022;

(b) consider ways to improve the use of innovative medicines and medicinal products within the NHS in England.

(3) The review may consider—

(a) the creation of a specific pathway to assess medicines and medicinal products for rare and less common conditions;

(b) improvements to the way in which patient and clinical experience is accommodated when considering the adoption of new medicines and medicinal products.”—(Alex Norris.)

This new clause would require the Secretary of State to carry out a review of the assessment and use of innovative medicines and medicinal products, and to consider how to improve access to medicines and medicinal products for people with rare and less common conditions in particular.

Brought up, and read the First time.

[Alex Norris]

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

The new clause would put a helpful requirement on the Secretary of State to undertake a review of the assessment and use of innovative medicines and medicinal products, which I believe would be a positive step forward. Medical innovation, including new drugs and cutting-edge treatments, produces life-saving and life-changing results, and those benefits are particularly felt by those with rare and genetic diseases.

--- Later in debate ---

[Dr Whitford]

I wonder whether the hon. Gentleman shares my concerns after leaving the European Union about access for clinicians, and indeed their patients, to the European reference network, which helps to provide advice and treatment and has co-ordinated research, through the European Medicines Agency, into these rare, often childhood, diseases? They can be studied much more easily in a population of 500 million than one of 60 million.

[Alex Norris]

I am grateful for that contribution. It is axiomatic that, if we are talking about diseases that affect small populations in this country, growing the field of people who are affected so that we can undertake better research, trials and treatment can only be a good thing. I hope that the Minister might touch on how he is ensuring that we are not disadvantaged in that way. When we add up the nearly 8,000 diseases, we are talking about 3.5 million people—one in 17, so one person on the Committee, basically—who will in their lifetime be affected by a rare disease. So actually they are not so rare at all. It is really important that we are meeting that group of people’s needs, but access to medicines and medical devices remains a problem, which is why such reporting for rare conditions is so important.

At the moment, approved medicines are available for only 5% of rare diseases and, even where licensed treatments exist, patients can face an uphill battle in accessing them on the NHS. I am sure that most of us will have at least one case of a young constituent who desperately needs medicinal cannabis to treat epilepsy. There is a political consensus that this is the right thing to do, and we ought to do it. That has been a settled matter for at least three years now, but frustratingly it is still not getting through, and that is a pattern across rare diseases. Perhaps that points us to the conclusion that the current assessment process is not quite accounting for the unique challenges presented by rare and ultra-rare diseases.

I do not think that the Minister will want to be drawn on the National Institute for Health and Care Excellence methods review, because we are in that process. I have spoken in multiple debates about my enthusiasm for NICE, and its processes and expertise, but clearly something is missing. My working theory is around evaluation. Again, if we have a small patient population, the data is noisy and there are higher degrees of uncertainty due to the small sample sizes. That leads us nicely to the point that the hon. Member for Central Ayrshire made about trying to grow those pools. At the moment, we are unable to get first-in-class treatments in many cases, which we should want to do something about.

Herein lies the squeeze, as the medicines for rare and ultra-rare diseases are often assessed by processes that were designed for drugs with larger target populations. The statistics are a bit of an apples-to-oranges comparison, which creates a severe disadvantage. The purpose of the new clause is to get the Secretary of State to report generally on how we are ensuring that we are world leading and meeting population need, and then to drill down within that on how we are ensuring that the system for rarer conditions is fit for purpose. As I say, I am conscious that the methods review is ongoing, but I hope that the Minister might at least give us a sense of the general policy direction in this area, and what we might look to do differently in the future.

--- Later in debate ---

The Government published the new United Kingdom rare disease framework in January 2021, outlining the key priorities for rare diseases in the UK over the next five years. One priority area, identified through the national conversation on rare diseases, is to improve access to specialist care, treatments and drugs. Development of nation-specific implementation plans for this priority are under way across the four UK nations and will involve further engagement with the rare disease community. I believe these are the right steps to take, and I therefore encourage the hon. Gentleman not to press his new clause to a Division.

[Alex Norris]

I am grateful to the Minister for his full answer. He mentioned reviews around the innovative medicines fund and NICE methods, and it is probably wise for us to let those processes play out before looking at anything else, so I do not intend to press the new clause to a Division. However, I will leave the Minister with some final thoughts on NICE methods.

First, I hope there will be a parliamentary moment for us to engage with that and have those conversations. The process has independence for a very good reason, but we should still have views on its overall direction. I want to flag ahead of that—with a focus on combination therapies, particularly in the cancer space—that we are understanding better every day how different therapies used together can have an incredible aggregate impact on the individual.

I do not think it is breaking any great state secrets to say that the problem is that the way we pay for drugs in this country is an imperfect market. Do not get me wrong; it has found a balance, but one problem is that the treatments are—funnily enough—often priced to what we can afford to pay for. That is fine until we need to combine two different treatments from different providers, when it becomes really challenging to work out how to apportion that. If we are to achieve the innovations that we need, particularly in cancer, we will need a good answer to come out of that review.

I hope that the Minister has a watching brief on that review, and that when NICE has finished, we can have a good conversation about the outcome to ensure that it supports the goals that I think we all have. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 51

Duty on integrated care partnerships to prepare and deliver a Best Start for Life strategy

“(1) The Local Government and Public Involvement in Health Act 2007 is amended in accordance with subsection (2).

(2) After section 116B (substituted by section 20 of this Act) insert—

‘116C  Duty on integrated care partnerships to prepare and deliver a Best Start for Life strategy 

(1) Each integrated care partnership must—

(a) assess the needs of expectant parents, infants and young children in its area;

(b) prepare and publish a strategy to improve outcomes and reduce inequalities among expectant parents, infants and young children;

(c) consult parents and carers in the area when developing the strategy;

(d) monitor and evaluate the effectiveness of the strategy.

(2) Local authorities, NHS bodies and other relevant partners must—

(a) cooperate on delivering the strategy;

(b) have regard to the strategy when exercising their functions.’”—(Alex Norris.)

This new clause would require each Integrated Care Partnership to prepare and deliver a “Best Start for Life” strategy, in cooperation with relevant bodies.

Brought up, and read the First time.

[Alex Norris]

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

I cannot quite remember on what day this new clause was submitted; it is towards the end of the new clauses but not at the very end, so that probably carbon dates it by 10 days or so. Nevertheless, we had some news in this space from yesterday’s Budget. We are in the strange situation of having seen effective early intervention services, such as Sure Start, take a clobbering for a decade, and then getting paid back pennies on the pound and being supposed to feel grateful for it. We are not. Nevertheless, there needs to be a commitment at all levels of Government and local government—and, in this case, integrated care boards—to have a real focus on early years.

The first 1,001 days of a child’s life, from conception to age two, are crucial. Getting things right in this period can determine what kind of life a child has and their health, wellbeing, cognitive function and psychological make-up. During those early years, a baby’s brain grows rapidly, and it doubles in size within the first year of life. As is so well established, child development is influenced by early experiences and environment, which means that it is so important to ensure that little ones in our communities get what they need—care, nurture and support—while ensuring that they are protected from neglect, harm and stress.

As the Government’s strategy in this space recognises, getting things right impacts not just on the lives of our children, but on our entire society. By ensuring that children get what they need at an early age, we can target some of the big issues that we have talked about for the last two months in this Committee: physical and mental health issues, pressures on the NHS, crime and antisocial behaviour, and drug and substance abuse. So much of that leads back to the early stages in life, and this is a matter of established science. There is no doubt that in this country, we are not very good at doing something about that. Six months or maybe even a year ago—time flies—we had a fantastic Westminster Hall debate, led by the right hon. Member for South Northamptonshire (Dame Andrea Leadsom), who chaired a very good review in this space.

There is barely a leaf’s width of disagreement on this issue between right hon. and hon. Members of all political persuasions. The common diagnosis for why we have not made more progress is that we know that such things save public services money in a generation’s time, but we cannot demonstrate that in a cashable savings way that passes Treasury processes. I am afraid that I did not see anything yesterday to suggest that that fight is yet being won, and I hope the Minister and his colleagues are doing everything in their power to argue for early interventions. Frankly, I would argue that for pretty much all Members present, the bulk of the returns will come when someone else is sitting in our seats and our roles are somebody else’s dreams, but that should not stop us acting, because it is so significantly in the national interest and in the interests of our communities.

There are huge inequalities. The most basic health statistic is that a child born in my city will live for seven fewer years than one born in the City of Westminster—never mind the yawning chasm of almost twice that in healthy life expectancy. That is the result of smaller inequalities that all add up to different life paths: family income, financial stress, smoking and alcohol use, and access to care and services. We know that the 1,001 critical days from conception are the moment to offer really good-quality support. Families receive support from a wide range of services, including maternity, health visiting and early years, and perhaps children’s social care, mental health and paediatrics.

As well as the inequalities, there is complexity. I have mentioned five different organisations with five different uniforms, five different organisational plans and five different organisational cultures. Someone has to pull that together. We have been told throughout proceedings on the Bill that that is exactly what integrated care partnerships are here to do, so let us put a responsibility on them to do so, and to have a plan. I dare say—the Minister might say this himself—that they are more than likely to want to do that themselves, and that would be a very good thing, but I do not think we can allow variance. This should be important for everybody and all footprints should be doing it, so that the first 1,001 days are given priority in new health systems. That would have a significant impact on the long-term health and wellbeing of our country.

[Dr Whitford]

I rise in support of the new clause. It is important to shift the narrative from what is often a structural focus on the NHS, and catching people when they fall, to looking at wellbeing and population to allow people to be healthier and live higher-quality lives for longer.

The hon. Member for Nottingham North mentioned the slowing down of improvement in life expectancy and the variation in life expectancy, but the bigger issue is the failure to improve healthy life expectancy. The 20 years of unhealthy life expectancy faced by many across the UK, particularly in more deprived areas, put pressure on the NHS, and we have seen that come home to roost over the last decade.

A lot of those health issues, or unhealth issues, are laid down in childhood. I am vice-chair of the all-party parliamentary group for health in all policies, which conducted an inquiry into the impact of child poverty. A figure from the Faculty of Public Health that has stayed with me is that the UK loses 1,400 children a year as a direct result of poverty, including by immature birth, small birth weight, foetal alcohol syndrome, fires, road traffic accidents, alcohol and drugs, violence and suicide. That is the number of students in a large secondary school, and if the roof of a large secondary school were collapsing every single year, we would do something about it.

Often, the time to do something about that is in the 1,001 days from conception forward, as the hon. Gentleman said. That means looking at maternal health and nutrition, which is why the early years collaborative in Scotland led to the Best Start grants to mothers and children at birth, on entering nursery and on entering school.

One internationally used measure on the health of our youngest children is infant mortality—death perinatally or in the first year. In 2014, England and Scotland had the same rate of 3.6 per 1,000 live births. In Scotland, we have managed to drive the rate down to 3.2, but in England, it is currently at 3.8. In some poorer areas of the UK, the rate is worse than in parts of the global south and the developing world. That is a brutal statistic.

We talked yesterday about maternal and infant deaths, but this also relates to the attainment gap and other issues faced throughout life by those who struggle in childhood. Investing in early years saves money in the long term. That might be the pitch to the Treasury: if we gave more children a decent start in life, fewer would struggle in the education system, fewer would struggle to get jobs, and fewer would be trapped by addiction or caught in the criminal services system. Instead of picking up the pieces later through the NHS or other public services, surely we should be investing in the best start in life for all our children.

--- Later in debate ---

[Alex Norris]

The point that the hon. Member for Central Ayrshire made about the UK losing 1,400 children a year is sobering. Whatever comes out of the process that the Minister mentioned must to be different from what we have today, or we will keep repeating that mistake. I shared the hon. Lady’s view about the pitch to the Treasury, but we will have to demonstrate that planning cycles in this country are mature and flexible enough to reflect the fact that not everything can be delivered, and show immediate returns, before the next general election. It is a challenge, and we will have to do better in that space. I am grateful for the Minister’s response, and he addressed my concerns very well. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 52

Plan for implementing recommendations of the Independent Medicines and Medical Devices review

“The Secretary of State must, within six months, publish a report containing a plan for the implementation in full of the recommendations of the Independent Medicines and Medical Devices review that have hitherto not been implemented.” —(Alex Norris.)

This new clause would require the implementation of any remaining recommendations from the IMMDS report.

Brought up, and read the First time.

[Alex Norris]

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

In February 2018, the noble Baroness Cumberlege was asked to carry out the independent medicines and medical devices review into the experiences of people—generally women—who had been treated with Primodos, sodium valproate or pelvic mesh implants. In very many cases, they had to battle for decades to be heard. They were gaslit, belittled and ignored at every turn. Some of the ways in which they were treated were just astonishing, and so upsetting. However, through that report they got their deliverance. They were vindicated: what they said had happened to them had happened to them—even though they had not been believed—and it should not have done. Acknowledging the pain that had been caused to these families was a big start in helping them come to terms with what they had experienced.

The excellent review team set out nine ways in which things would be made better, or at least a little bit easier, for those people now, and to try to prevent future incidents. Those nine recommendations should have been accepted in full. Instead, we have seen from the Government a pattern of accepting things that I suspect they were already keen to do, but otherwise taking the families for a long walk when it comes to the harder and more significant things that the Government clearly do not want to do. In aggregate, it has become a refusal to do right by these families, and that is a really poor decision.

This new clause seeks to attend to that by saying that within six months, the Secretary of State must publish a report containing a plan for the implementation of the recommendations in full. Of the nine, only four are being implemented in full and, frankly, that is not good enough. I am pleased that there has been an apology, and the families were too. I was also pleased to see legislation for a patient safety commissioner. We were lucky that the Medicines and Medical Devices Act 2021 was in front of us at that time, because it gave us a moment to introduce that and a devices database, which the hon. Member for Central Ayrshire and I pursued during proceedings on that Bill. Those things have a bit further to go, but they were significant, as were the promises of cultural reforms at the Medicines and Healthcare products Regulatory Agency. We will wait to see meaningful change there. With the remaining five recommendations, there has been a mixture of in-principle acceptance, partial acceptance and, in some cases, outright denial. I do not think that is good enough, and the new clause seeks to change that.

These are the bits that we are still missing. Recommendation 3 calls for:

“A new independent Redress Agency for those harmed by medicines and medical devices”.

The Government responded that they did not accept that. The problem is that families are therefore left to rely on conventional civil and legal routes. Those are expensive and long, and who do the families sit against in the courtroom? Very big companies with very big legal teams, so there is a significant imbalance. The whole point is that, as recommendation 3 goes on to state:

“The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals.”

That would have been really significant, but we do not have that. Instead, families are left stuck in the court system for as long as they can stick at it.

Recommendation 4 states:

“Separate schemes should be set up for each intervention—HPTs, valproate and pelvic mesh—to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim.”

Again, the Government do not accept that. These families meet exceptionally challenging needs day after day. Some have lost their house; some have had failed relationships; and all struggle with mental health, or certainly distress, as a result of what has happened, and we are not doing enough to help them. This should have been done, if not on day one, at the very first possible moment for support, rather than us expecting them to fall back on the conventional system, as they did. What have they gained by their vindication?

Recommendation 5 states:

“Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy.”

The Government accept that only in part; it is particularly with regard to valproate that those affected will not get those centres. I will listen carefully to the Minister’s justification for that. I understand that valproate is different, in the sense that its use is ongoing in certain situations where that remains medically appropriate. However, the lack of specialised knowledge is a real issue. If there is not specialisation, we need a real sense that there is a universal step change in knowledge and experience in this area to give us greater comfort.

Recommendation 8 states:

“Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors”.

That is very basic. There were relationships between clinicians and big drug companies that were unknown to the families when certain treatments were suggested. The Government accept the recommendation in principle, but will not use the General Medical Council model, preferring to go practice by practice. That is big mistake. Our constituents can go to one easy, obvious place—our website—to find out our exact financial interests if they have concerns or just want to know them. We ought to be able to do the same, through the GMC, when it comes to doctors. Again, there is an unwillingness to move quickly enough to resolve these issues.

Finally, it remains surprising that the Government have not availed themselves of recommendation 9. I will listen carefully to the Minister’s response on this point. It states:

“The Government should immediately set up a task force to implement this Review’s recommendations. Its first task should be to set out a timeline for their implementation.”

Of course there should be a taskforce, including families and the broader aspects of the state, to do that. Again, the Government say they accept the recommendation in part, but the reality is that they have no plans to establish an independent taskforce. There is a patient reference group, and we of course support its work, but it is not in control; it is not at the table. The problem is that these things were done to families; they had no agency and no say. The solutions that come out of this cannot follow that same model. Once again, families are having things done to them, rather than being worked with.

I meet representatives of these groups frequently, as I know colleagues do. I like meeting them. These are good people who have been through incredible things and have extraordinary dignity and courage, not to mention that they are brilliant campaigners. They are probably sick of seeing me, and I would rather see them in happier circumstances. When I ask them what is next, they say that they are campaigning again. They campaigned over many years to be listened to, and were proven right in the most absolute terms, but they feel they have to campaign again to get the justice that should flow from that report and from their vindication. What an extraordinary demonstration of how we have let them down. They fought for too long. It is time that we stood up for them and did right by them by implementing the recommendations in full; otherwise we fail them again. I hope to hear of significant progress from the Minister.

[Dr Whitford]

I support the new clause. For a surgeon, knowing that an operation that they were trained to carry out, and performed in good faith, has caused harm is one of the worst things that can happen. I remember how I felt in the mid-1980s when we began to realise the impact of contaminated blood. It had a huge impact on how I operated. I used special diathermy techniques to avoid blood transfusion in all elective circumstances, and that is something I carried on throughout my time doing breast cancer surgery.

In this case, there may well have been doctors who were dealing with device companies and so on—that regulatory declaration is absolutely needed—but there will be a much greater number of surgeons who were using a device that was licensed and was given to them as the correct, safe device to use.

I find it shocking that although the report was commissioned by the Government, they have accepted fewer than half of its recommendations. The others directly relate to patients who have suffered harm, whether that is the women who had vaginal meshes inserted, or the mothers of children who were harmed by the use of Primodos or sodium valproate.

Sodium valproate is still an excellent anti-epileptic and will not disappear, but it is not a matter for specialist centres. It is so widely used that it is critical that within primary care and on product boxes it is made clear that women who are looking to conceive or who are of child-bearing age should not be left on Epilim; that should be discussed with them right from when they are young teenagers, so they can think about the impact later on.

The recommendations that have not been accepted are not to do with reorganising licensing, or a yellow card system; they are all recommendations that relate to women. That is really disappointing. The redress for them—the setting up of specialist centres to try to repair the damage as far as possible—is what is not being provided. The Government should look at the fact that those are the recommendations they have skirted around and not accepted. These women and the children affected have gone through enough.

--- Later in debate ---

I appreciate that the objective of the amendment is to hold the Government to account for implementation of their response. The Government have already committed to publishing an update on implementation; we intend to do that by summer 2022. I believe that significant progress on the recommendations has been made, but I am conscious that the shadow Minister, with his depth of knowledge in this area, may wish to press further in the coming months. I suspect that he will rightly continue to hold the Government to account.

[Alex Norris]

I am grateful for colleagues’ contributions. The comments of the hon. Member for Central Ayrshire presaged what the Minister said: yes, the Government have been able to do the more strategic aspects of this, but they have done half a job. The half they left out relates to people who have fought for so long just to get a little support, and recognition that they have been badly wronged in a way that significantly changed their life. They really do not ask for much—just a bit of support. It is not a nebulous or open-ended ask; it is just for what was in the report, and that does not seem too much to me.

The Government have been in defensive mode for a long period on this issue, but I desperately hope that they do not think they have done the job, because they really have not. I also hope that they do not think these women will go away, because they absolutely will not, and a lot of right hon. and hon. Members in this place want to help them and give them a platform from which their voices will be heard. A good way to act would have been through the new clause. With that in mind, I intend to press it to a Division.

Question put, That the clause be read a Second time.

--- Later in debate ---

Brought up, and read the First time.

[Alex Norris]

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

The new clause is a fitting follow-up to new clause 52, in the sense that the theme of the report was that, yes, dreadful things happened, but—as the hon. Member for Central Ayrshire said—largely with a complete lack of knowledge among clinicians, who were just following the guidelines, as they were supposed to and had been trained to. A common theme beyond that is that this happened to women, and when women tried to express their concerns, the system was not geared up to listen. Instead, the response of the system was to write them off—some of the name calling will probably not amaze us, but it should.

The new clause seeks to ensure explicitly that local care boards take into account the views of women on reproductive health. High-quality reproductive healthcare should be accessible and individualised at each stage of a woman’s life, from puberty and through the years of menstruation to the menopause and beyond. This is something that we will discuss tomorrow through the private Member’s Bill of my hon. Friend the Member for Swansea East (Carolyn Harris). She will put the case well, I have no doubt.

The system should enable women to decide whether, when and how often to have children by informing them about, and providing easy and timely access to, the full range of contraceptive methods. Maintaining good reproductive health and wellbeing has profound and positive long-term effects for women and wider society. However, at the moment, inherent system fractures in the commissioning and delivery of reproductive healthcare services mean that many women are left struggling to access basic reproductive care, including contraception and gynaecological cancer screening.

The impact of the current situation is stark. Almost half of British women have experienced poor sexual and reproductive health, and that figure should give us pause. We know that since the Health and Social Care Act 2012—again, this is something in that Act that we should want to change—reproductive healthcare has been compromised by a lack of strategic prioritisation and prevention, a deeply fragmented commissioning landscape, and of course that ongoing theme of significant cuts to public health, which in this case include a 14% real-terms reduction for sexual and reproductive health services. Again, that has been felt more by poorer communities, and all those factors have resulted in gaps in the reproductive care pathway, creating disconnected and disjointed care for women. For example, in many areas of the country, women are not able to access a fitting for an intrauterine device—one of the most effective contraceptive methods—or cervical smear tests in a similar healthcare setting, meaning that they have to go through multiple invasive exams in different settings. Of course, it is important that those tests take place, but we should seek to make it the easiest process that it can possibly be.

Women approaching the menopause are not able to access treatment for heavy menstrual bleeding at community clinics or GP practices, because many are not commissioned to provide that service or lack the funding or trained staff, resulting in those women being bounced around the system while living with obviously debilitating conditions. This Bill is an important moment to tackle long-standing structural challenges in reproductive healthcare. If we are truly moving towards greater integration and collaboration within the healthcare system, this is a really good chance to implement holistic women’s reproductive healthcare services at a regional and local level. Through listening to women and integrating care around the needs of the individual, rather than the institutions, we can deliver holistic care across the breadth of reproductive healthcare.

I know that there is a broader duty in this Bill for integrated care boards to promote the involvement of their patients and carers in decisions about the provision of health and care services, as well as having regard for inequalities. This new clause builds on that by wiring in engagement with women, because it is not happening. Again, if we just keep doing things in the same way, we will get the same outcome, so this is an opportunity to design a healthcare system for women that listens to women and builds in accountability. That will help ensure that reproductive healthcare pathways fully meet the needs of those who they are meant to serve, which would be a very positive outcome.

--- Later in debate ---

[Edward Argar]

The hon. Lady is absolutely right to raise that. We need to get across, loud and clear, to our future clinicians almost right from the start—from their training and early education—the message that everyone’s health concerns matter equally, subject, obviously, to clinical decision making. I hope and believe that HEE and others will engage with that process in the context of the women’s health strategy. We do not want it to be a document that just sits on a shelf, or want it to look at issues in a siloed way; it should look at them across the piece. Over many years, there have been strategies on particular aspects of health. In the strategy, we seek to bring together a whole range of factors, so that we can look at how women interact with the healthcare system, and how to meet their needs holistically.

We want to maximise the independence of ICBs, so that they function in the way that best suits the needs of their patients and their organisations. We are therefore keeping their legislative obligations proportionate; that brings us back to a debate that the Committee has had multiple times about the permissive nature of the legislation. I agree that appropriate representation is essential in healthcare planning. I fear that the new clause is overly specific and not necessarily in keeping with the obligations on ICBs set out in clause 19 on general functions.

The Bill already puts obligations on ICBs that will help to ensure that relevant groups are fully represented and consulted in decision making. In particular, ICBs will need to ensure that they have taken appropriate advice from a broad range of those with professional expertise. As the work of ICBs will inevitably cover reproductive health, that requirement ensures that relevant groups are included in this work. Furthermore, as we discussed in the opening sittings of the Committee, local areas will have the flexibility to determine any further membership of the ICB beyond the minimum for which we have legislated. That discretion will allow local areas to ensure appropriate representation.

On working in partnership with the non-profit sector and local community groups, I recognise the essential role that those organisations and groups play, and agree that they should be involved in strategic decision making where appropriate. Each ICB and their partner local authorities will be required to establish an integrated care partnership. We expect the ICP to bring together organisations from across health, social care and public health, and representatives from wider areas where appropriate. That could include organisations from the voluntary and community sector. The ICP will be tasked with promoting partnership arrangements and developing a plan to address the health, social care and public health needs in its area. As that will include reproductive healthcare needs, we would expect relevant local groups to be represented. The ICB and local authorities will have to have regard to that plan when making decisions. That will enable more joined-up planning and provision, both in the NHS and by local authorities, which will enhance the services that people receive.

Existing and proposed duties already address the concerns underlying the new clause and ensure effective public involvement. We have concerns about imposing additional duties on individual services. Our approach enables local NHS bodies, supported by national guidance, to decide how best to involve patients and the public in the planning of commissioning arrangements, and in developing and considering proposals to change them, so we are not convinced that the additions in the new clause in respect of reproductive healthcare are necessary.

[Alex Norris]

I am grateful for the contribution from my hon. Friend the Member for Bristol South. Many people will be looking with great interest at what happens tomorrow. She spoke about the menopause not having been on the political agenda for such a long time. I think that that has changed, and not before time, so we are all very much looking forward to what will happen.

We have tested the Minister on the permissiveness point quite a lot, so by this, the 22nd sitting of the Committee, I think it is possibly an established fact, and I do not intend to divide the Committee, but I do want to come back on what he said about the sufficiency of the duties as drawn. When we have pushed for individual plans for each ICB—say, on inequalities, on the first 1,001 days and on drugs and health—there has almost been a sense of, “Well, of course these bodies will want to do that. It will be their local decision, but of course the evidence will drive them to do that.” I do not think we can say, on women’s health, that that is an “of course”, because we know that actually, historically, it can be very much an afterthought.

The thought that I might leave colleagues with on this issue is that we are having a growing conversation in this country about misogyny, and one of the things that you will hear men say a lot—I have said this myself, because I mean it—is, “We have to hold one another to account for the things we say and the way we act.” I completely agree with that. In that spirit, we have to understand that if a lot of the basic reproductive healthcare things that we are talking about today happened to men, we would be doing them in McDonald’s drive-thrus. It is as simple as that. Therefore, if we are to have an honest conversation with one another about misogyny in this country, it is that sort of thing that we mean. It is not always about pointing fingers and blaming, or policing jokes, which I think is important; it is actually about saying that services are different because these things do not happen to us and we should be more mindful of that and should want to change. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 54

Enhanced data collection

“(1) The National Health Service Act 2006 is amended as follows.

(2) After section 14Z43 (inserted by section 19 of this Act) insert—

“14Z43A  Duty to develop data collection systems

Integrated care boards must—

(a) develop single whole-system IT systems across the whole of their integrated care system with the explicit purpose of supporting data collection and sharing;

(b) prioritise the use of those data systems for streamlining patient pathways;

(c) establish mandatory standards for patient-initiated follow ups; and

(d) use the data systems developed under paragraph (a) to report on a regular basis performance against improving patient outcomes in line with the standards established under paragraph (c).””—(Alex Norris.)

This new clause requires ICSs to develop digital data collection and sharing systems, and use them to track performance against mandatory standards, with specific regard to patient-initiated follow ups.

Brought up, and read the First time.

[Alex Norris]

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

I keep going, Ms Elliott. Again, you can perhaps file this under gluttony for punishment. I do not intend to talk for very long about this new clause. I am sure that the Minister will be able to give us comfort easily on the point of new clause 54. It is just to develop the point about data one last time before our carriages turn into pumpkins.

A specific part of the Bill deals with data, and we had some very good conversations at that point. I will not repeat any of that. I will explain what I am chancing my arm at in new clause 54. I talked previously about systems and the problems with systems talking to one another. Here, we are asking integrated care boards to develop

“single whole-system IT systems”.

That is perhaps at the top end in terms of what should be aspirational and what is in fact achievable, but I do want to pursue the point a little.

Data is critical, as we have said before, in driving improvements. NHS England’s own website talks about the need to use it to improve services and decision making, to identify trends and patterns, to draw comparisons, to predict future events and outcomes and to evaluate services. But to do that, we have to have some sense of consistency. I will not repeat the arguments around the General Data Protection Regulation—we had those at length—but that shows the challenges if we do not get it right.

Going down to ICS level, if we are going to have a system that really does harness all the information, we need systems that talk to one another. Therefore, the prescription in proposed new subsection (a) is that it is a single system. As I have said, that is the stretch target. What I am hoping to get from the Minister is a sense of where he thinks this will land. Is it the same organisations using the same systems but trying to find a new way to do them, or will there be some new, novel approach to how we support footprints to do that? It is an established fact that data is going to be really important to local systems, so we want to give them the fairest wind to make the best use of it that they can.

[Dr Whitford]

On new clause 54, I just want to speak to proposed new subsection (d)—the use of data to assess performance against outcomes. Between 2009 and 2019, there was really no significant national audit of quality of breast cancer services in England, even though some of that audit had been carried out in previous years. Part of that was due to the fracturing of the system from the social care Act. There might be only one breast unit within an area, and quality was left to commissioners. How can commissioners measure whether a local breast unit is treating people properly or achieving the aspired-to targets?

In Scotland, 19 of the commonest cancers are audited; I was involved in developing the breast cancer standards in 2000, and they have been updated many times since. They are assessed annually with an annual peer review conference, where clinicians will openly discuss the challenges they face and therefore will share the solutions many of them have come up with. The clinical things that we know will affect the survival and outcomes of our women in the future are all set as national benchmarks. It is important that, while data would be collected locally, it is benchmarked against national standards.

The Getting It Right First Time project was restarted in England a few years ago but, to my knowledge, although the Getting It Right First Time for breast cancer report was completed at the end of 2019, I have not seen it published. That appeared to be due to the election in December 2019; perhaps the Minister can clarify whether the breast cancer GIRFT report has now been published, when it might be published and what other GIRFT reports have come out.

The problem is that, even if that report were published now, two years after its completion, it would largely be based on data from 2018, and therefore clinicians would shrug their shoulders and say, “Out of date.” It is important that data is used in a timeous manner to audit as quickly as possible, so that the audit loop can be closed and services improved. Having led on this process in Scotland, I saw the change in standards between 2001, when we began the first assessment, and 2005, and it is an incredibly satisfying, not frightening, thing for clinicians to see year on year the quality of care delivered by their unit driven up. There must be national standards, but local audit.

--- Later in debate ---

As a result of the above, I do not believe that adding an additional duty to ICBs would be necessary, as the work is already under way.

[Alex Norris]

This is not something that we will be able to resolve with top-down prescription, but I have made the point that I hope we will do everything we can at a national level to model best practice, to demonstrate best practice and to give our local systems access to best-practice systems, because that will be very important. On that basis, I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 56

Domestic violence training for GPs

“(1) The National Health Service Act 2006 is amended as follows.

(2) After section 83B (inserted by paragraph 3 of Schedule 3 of this Act) insert—

“83C  Duty concerning domestic violence and abuse

(none) Integrated care boards must ensure that specialist domestic violence and abuse training, support and referral programmes are universally available to all general practitioners.””—(Alex Norris.)

This new clause adds a requirement for specialist domestic violence and abuse programmes to be available universally throughout general practice.

Brought up, and read the First time.

[Alex Norris]

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

Domestic abuse is an issue of significant interest across this place. We know that two women a week are killed by a current or former partner in England and Wales alone. As we mentioned the other day, a quarter of women will experience domestic abuse in the course of their lifetime, which has devastating effects. It impacts on both the physical and mental health of survivors and their children, and it has a terrible cost in general to everybody, including a financial cost.

New clause 56 would impose a duty at a local level to ensure that GPs have access to specialist domestic violence and abuse training. It is something that would be very welcome, and we are proposing a duty for integrated care boards to provide that. GPs are a credible point of contact for people in violent relationships. Some 80% of women in a violent relationship seek help from health services first. In some cases, that is their only contact. Training for GPs is vital to ensure that such contact is of the best possible quality. A study of women in violent relationships in the Netherlands found that 50% of women who did not speak to their GP about the matter would have done so if the GP had been in a position to approach it. Moreover, 50% of the women who did talk to their GP did so because they hoped to be referred on, so they wanted to have a high-quality conversation with someone who knew the system.

From my time prior to this place and my experience in Nottingham, I have a lot of enthusiasm for the IRIS programme—the identification and referral to improve safety programme. A trial carried out by Bristol University found that the training programme led to up to six times more women receiving the help they needed, and that it boosted the number of referrals to specialist domestic violence agencies. After IRIS training, GPs reported being better able to assess domestic violence risks and a greater awareness of services, while 99% of service users felt listened to and 87% felt safer.

The evidence is that such training works. This is of course not the way in which we should write a new clause, but I am saying that IRIS should be universal or something like it. I would leave the “something like it” to the provider market and to commissioners but, in general, the principle is that all GPs should have training so that they can understand and act on domestic abuse and have the right resources to provide support and make skilful onward referrals, so that the system can wrap its arms around an individual who is trying to get out of an abusive situation. That would be exceptionally important for such women, and I hope the Minister will have some thoughts about how we can get to a universal, IRIS-like level of engagement with our GPs.

[Edward Argar]

The new clause would require ICBs to provide specialist domestic violence and abuse training, support and referral programmes to all GPs, with the aim of strengthening the health response to domestic abuse and improving links between the NHS and voluntary sector support for victims. We have concerns about the new clause, which is why we cannot accept it, but I hope that I can set out to the shadow Minister my reasoning.

Domestic abuse, as we discussed yesterday when considering another proposed new clause, is a terrible crime, and it can have a devastating impact on victims and survivors. It is also important that we remember that children are often just as much victims as the victims themselves, through the experiences that they have of domestic abuse and domestic violence. The Government are clear that there is absolutely no excuse for abuse. Tackling domestic abuse and supporting victims, survivors and their children is a key priority for Government, now more than ever.

The Domestic Abuse Act 2021 and the forthcoming domestic abuse strategy will help to provide a whole-system approach to protect and support victims and their children. The measures in the 2021 Act seek to promote awareness by introducing a statutory definition of domestic abuse, and to recognise children, as I alluded to, as victims in their own right, in order to protect and support both, tackle perpetrators, transform the justice response, and drive consistency and better performance in the response to domestic abuse.

The 2021 Act also sets out the convening of local domestic abuse partnership boards, with healthcare representation. We recognise the key role that healthcare services play within a whole-system approach to tackling domestic violence. Healthcare services must identify signs of risk and harm, enable victims and survivors to come forward, and provide timely integrated care and support. We know how important it is that statutory agencies and professionals properly understand and react to domestic abuse. However, I hope that I can reassure the Committee that placing in the Bill a formal duty on ICBs to ensure that specialist domestic violence and abuse training, support and referral programmes are universally available to all GPs is not necessary.

General practice is delivered by multidisciplinary teams, rather than just GPs, and existing Care Quality Commission registration requirements include a review of practices’ safeguarding processes. In addition, NHSEI’s ICS people guidance sets an expectation that ICBs will foster learning and continuing professional development. Going further, the Bill, in proposed new section 14Z41 of the National Health Service Act 2006, imposes a duty that each ICB

“must, in exercising its functions, have regard to the need to promote education and training for the persons mentioned in section 1F(1)”

of the 2006 Act.

[Edward Argar]

I am grateful to the hon. Lady. In part, the reason is because this is sadly not a well drafted new clause. It is very narrowly drafted to GPs, not recognising the multidisciplinary nature of how healthcare is delivered in GP practices. I suspect that we all have correspondence from constituents—whether happy or unhappy—going to doctor associates, practice nurses and others. That is one of my key concerns, but let me articulate a little more what is already being done. I see where she is coming from. As I mentioned yesterday, I was the Minister with responsibility for victims of domestic violence, and of crime in general, when I was in the Ministry of Justice, so it is something that I am very familiar with. It is about raising awareness not just with GPs, but within the police and a range of agencies. My challenge, just before she intervened, was partly about the way the new clause is drawn, but let me articulate a little further our views on it. I am keen to do so before the business possibly collapses early in the House, and we have to adjourn in order that I can respond to the Adjournment debate.

Section 1F of the 2006 Act defines a wide group of people, covering persons who are employed, or who are considering becoming employed, in an activity that involves or is connected with the provision of services as part of the health service in England. That duty on ICBs would already cover general practitioners, but it goes wider. I appreciate that the new clause goes beyond training, so I will also discuss the support and referral elements that the hon. Member for Nottingham North talked about.

The NHS provides care and support to victims of domestic abuse through a range of healthcare services. This response is centred around ensuring that healthcare professionals are trained to spot the signs of domestic abuse and those at risk; to make safe and sensitive enquiry of the issue; to know where to refer people to get further support, and to know when and how to share information appropriately with colleagues and other organisations.

All NHS staff must undertake annual mandatory safeguarding training, which includes focus on domestic abuse. NHS England, NHS Improvement and Health Education England are reviewing mandatory safeguarding training for all health professionals to ensure that they are fully equipped with the key skills, knowledge and principles to protect all citizens. The Government published an online domestic abuse resource for health professionals and have developed a number of training modules with the Institute of Health Professionals, the Royal College of Nursing and the Royal College of General Practitioners.

From 2018 to 2020, the Department managed £2 million of funding for the domestic abuse pathfinder programme, which created a model health response for survivors of domestic violence and abuse in acute, community and mental health services. The pathfinder toolkit was published in 2020 as the result of emerging promising practice at our pilot sites, coupled with the expertise of the pathfinder consortium of specialist domestic abuse organisations, to encourage best practice across the health system. Pathfinder has given us a model for our response to domestic abuse in healthcare. It is a model for integrated, joined-up and trauma-informed care and support, with healthcare settings and the voluntary sector working together.

As the shadow Minister mentioned, the Department of Health and Social Care has also funded the IRIS programme, to which I pay tribute. IRIS is a training, referral and advocacy model to support clinicians in better supporting patients who are affected by domestic violence and abuse, and to increase the awareness of domestic violence and abuse within general practice. IRIS is recognised by the DHSC as good practice, and via the National Institute for Health Research we funded a study that demonstrated the effectiveness of the IRIS programme at scale. I am delighted to note that the study won the 2020 Royal College of General Practitioners research paper of the year award.

I am proud that the Government have championed the building of that evidence base. I believe that it would not be best or appropriate, however, for the legislation to require local health and care systems to adopt specific programmes. Indeed, such detailed requirements would reduce local health and care partners’ flexibility to meet the needs of their local populations or to engage with particular local organisations and expertise in delivering their programmes.

Beyond ICBs, I see a huge opportunity for integrated care partnerships to support improved services for victims of domestic abuse, sexual violence and other forms of harm, through better partnership working and joint planning of services. The Government have also developed a cross-Government strategy for tackling violence against women and girls, and will develop a cross-Government domestic abuse strategy.

As committed to in the tackling violence against women and girls strategy, the DHSC will continue to work closely with NHS England and NHS Improvement to promote evidence-based approaches to tackling violence and abuse through guidance and engagement with the new system.

[Alex Norris]

I am grateful to the Minister for his response. I am more than happy to wait for the domestic abuse strategy, but I really hope that such measures will feature in it, and that when the strategy goes around various Departments for their comments, the Minister will make a commitment—

[Edward Argar]

May I make the offer to the hon. Gentleman that I or the relevant Minister leading on this—whoever is more appropriate—will engage directly with him?

[Alex Norris]

That is very welcome, and in that spirit, I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 57

Cancer strategy

“Within 12 months the Secretary of State must—

(a) publish a new cancer strategy; and

(b) either designate a minister or appoint a national lead with responsibility for enacting its implementation.” —(Alex Norris.)

This new clause requires the publication of a new cancer strategy, with a minister or other person made responsible for its delivery.

Brought up, and read the First time.

[Alex Norris]

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

[The Chair]

With this it will be convenient to discuss new clause 64—Cancer treatment data reporting—

“(1) Beginning within 6 months of the passage of this Act, the Secretary of State must publish each month data on—

(a) the number of patients awaiting treatment for cancer,

(b) the number of patients with a cancer diagnosis, and

(c) what NHS’s previous estimate was of the number of patients who would have a cancer diagnosis at that point in time.

(2) Six months after the publication of the first report under subsection (1), and every six months thereafter, the Secretary of State must publish a report on the action being taken to reduce the number of patients awaiting treatment for cancer.”

[Alex Norris]

I am conscious of other business, so if I am interrupted, I will not take it as rudeness.

[Edward Argar]

We may be okay.

[Alex Norris]

New clauses 57 and 64 both relate to cancer. It is not quite possible to quantify the damage done by cancer in this country because we end up just throwing big numbers around. In the UK, there are 375,000 new cases and 166,000 cancer deaths each year. Each of those numbers represents a person with a devastated family. I lost my father to cancer in my infancy—35 years ago in January—and that loss is something that lives with a family for the rest of their lives.

We know that one in two people born after 1960 will be diagnosed with cancer. Our investment in cancer services is £5 billion a year, but the cost dwarfs that, at over £18 billion. Nearly 40% of cancers are preventable. Happily—this is something we should be proud of in this country—the developments that we are making in medical and technological areas mean that cancers are increasingly survivable, with the survival rate doubling in the last four decades. Better diagnosis and treatments mean that nearly 50% of those diagnosed with cancer in England and Wales now survive for 10 or more years, and there is no reason for that to stop increasing.

--- Later in debate ---

[Edward Argar]

I am grateful to the hon. Lady, who is distinguished in this field herself, from her previous career. She quite rightly highlights the importance of the workforce. Since 2010, in both radiology and radiography, there have been significant percentage increases in the workforce of those specialist professions. However, she is right to highlight that, while we have seen a significant percentage increase, in absolute terms we still need to do more to grow those professions. We have plans in place to do that, but that is a slow task; it can, in some cases, take up to 10 or 12 years to become an experienced specialist in that field.

On those increases since 2010, the Government would argue that we put measures in place, but it is also important to recognise that the previous Labour Government were working on this as well, hence the pull-through; those radiologists and radiographers did not magically appear immediately after 2010. There were programmes in place before and after that, so it is right that we recognise the contribution of the Opposition when they were in Government.

Finally, the new clause also seeks to place a Minister or national leader in charge of that new cancer plan. My ministerial role includes responsibility for elective recovery and recovery from the pandemic—our plan to tackle those waiting lists. As the shadow Minister knows, my hon. Friend the Member for Bury St Edmunds (Jo Churchill), the former Under-Secretary of State for Health, who briefly sat on this Committee, had responsibility for cancer services specifically, as does the new Under-Secretary. Dame Cally Palmer is the national lead as the national cancer director at NHS England and NHS Improvement. She has a distinguished career as chief executive of the Royal Marsden Hospital in parallel. We are jointly responsible for the current cancer plan. It is therefore unnecessary to include that new duty when we already have those accountabilities.

I will move on briefly to new clause 64, which we are considering with new clause 57. It seeks to legislate for an additional duty on the Secretary of State to publish data on cancer waiting lists, cancer diagnoses and action being taken to reduce the number of patients waiting for cancer treatment in England. Again, I understand the intention behind the new clause. Cancer is one of the greatest challenges to people’s health, as we set out. I would like to highlight first the fact that the Government are already delivering on the request for monthly publication of cancer performance data. Ensuring transparency of data is a priority. Each month, we publish official statistics on waiting list data, including the number of patients who began cancer treatment and waited longer than 62 days for treatment. NHS England also publishes monthly management data on the number of people currently waiting longer than 62 days for diagnosis or treatment. The new clause calls for data that is very similar to what is already published, and we therefore consider that it would be duplicative.

Secondly, on the request to publish predictions—that is not something that is currently done. Doing so would likely result in unhelpful poor-quality assumptions or modelling that could lead to expectations or an understanding that is not reflected in the reality of the data that comes through. While we look at all data sources internally, it would not be in the best interests of scrutiny and, potentially, patients to publish poor-quality predictions with a limited confidence factor.

Thirdly, there is no evidence of need. Following the success of campaigns such as Help Us, Help You, we have seen the public seek medical attention for symptoms that might be cancer, while cancer referrals from GPs have been at record levels since March. At the same time, the NHS has been delivering high-quality and innovative solutions to improve cancer care and treatment. We have announced funding for elective recovery, including cancer services, of £2 billion this year and £8 billion over the next three years, which will increase activity and deliver millions more checks, scans, procedures and treatments. We will continue to publish and review the monthly official statistics to monitor progress.

Finally, on the request for the Secretary of State to publish a report every six months on the actions taken to reduce the number of patients awaiting cancer treatment, I should state that the NHS has already undertaken extensive work to reduce the number of patients waiting for treatment and to continue progress in delivering the long-term plan ambitions for cancer. We will publish the elective recovery delivery plan later this year, which will set out how the NHS will deliver increased elective capacity and how cancer patients will be prioritised for access.

Furthermore, the NHS cancer programme already regularly reports on progress through both NHSEI and DHSC governance structures, through publication of monthly data on cancer waiting times and through regular communications products. We would therefore argue that the new clause is duplicative. While I assure the Committee that we are taking urgent action to reduce cancer waiting lists, we consider the new clause to be unnecessary.

[Alex Norris]

I am grateful for that answer, which reflects the current difference in public policy between the Government and the Opposition. At oral questions to the Health Secretary, I always ask and will continue to ask whether the Government’s position is that the current plans and status will be sufficient to meet the challenges and the backlog—we think they are not. While the system was overheated before the pandemic, it has been distressed by the last 18 months. We do not think that asking that system to meet both emergent and old problems will work. However, that is probably a point for oral questions and future debates, rather than this Public Bill Committee. On that basis, I will withdraw the clause.

As we are coming to the end of the debate, I might gently say to the Minister, on his point that the Government do not make predictions because they might be unhelpful in the future, that it feels as if, every time he goes on the news, the Health Secretary puts waiting lists up by another million in an extraordinary attempt to manage expectations. Was it 13 million last time? It just goes up and up. I do not think it is quite fair to say that Ministers do not do that—the Health Secretary, at least, certainly does. Nevertheless, that is no reason not to withdraw the clause, and I therefore beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

Ordered, That further consideration be now adjourned. —(Steve Double.)

Health and Care Bill (Twenty Second sitting)

Alex Norris Excerpts

Committee stage
Tuesday 2nd November 2021 Public Bill Committees

[The Chair]

As Members have possibly worked out, I am a last-minute stand-in for Peter Bone, which has always been my ambition in life. [Laughter.] Seriously, Peter has been caught up in some kind of road traffic incident. I think he is fine; he has just been delayed, so that is the reason for the delay in proceedings.

I remind Members of all the usual things: please switch electronic devices to silent, and remember that no food or drinks are permitted. I encourage Members to wear masks, as per the House of Commons Commission rules, and to give their notes to Hansard or to send them to [e-mail].

New Clause 58

Duty on NHS England to promote evidence-based public health programmes

“(1) NHS England must promote to integrated care boards the value of evidence-based public health programmes.

(2) NHS England must publish a report each year on the state of evidence-based public health programmes within England and their impact.”—(Alex Norris.)

Brought up, and read the First time.

[Alex Norris (Nottingham North) (Lab/Co-op)]

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

I have heard about the fastest gun in the west; I think you might be the fastest-moving Chair in the west midlands, Mr McCabe. Turning to the substance of the new clause, covid-19 has shown the value of public health programmes in building this country’s resilience and improving public health outcomes, yet there is no duty in the Bill on NHS England to promote such public health programmes to integrated care boards or to evaluate their impact. New clause 58 seeks to change that.

During proceedings over the past couple of months, I have highlighted on multiple occasions the damage caused by the short-sighted health cuts we have seen over the previous 11 years, so colleagues will be relieved to hear that I am not going to repeat those points. However, we should be looking to do better now and to use this Bill as a watershed moment. As the Association of Directors of Public Health noted when the White Paper was published, there is a limited focus in the Bill on the health inequalities that have been exposed and exacerbated by covid-19 and, again, this new clause seeks to improve that situation. With the changes to Public Health England and the announcement of the new Office for Health Improvement and Disparities, it is vital that the Government make a belated recommitment to public health and prevention.

There are a number of ways in which that commitment could be manifested. Public health programmes are particularly crucial to the prevention agenda, and it is right that NHS England promotes the value of those programmes, looks at them, assesses them and reports on their impact. To draw on one example that is linked to an item we will be discussing later—dental services—community dental services and oral health public health programmes have shown that significant savings and significant improvements in individuals’ lives can be generated through effective, evidence-based public health programmes. Social enterprises such as those can bring a number of additional benefits. They exist not to make a profit but to deliver on a social mission and to reinvest any surplus in improving local services.

That is what the public health grant traditionally funded. When I first had responsibility for the public health grant in 2014, 85% of that money went into commissioned services. That funding will have been diluted by the cuts in recent years, but largely that money went to community-based, not-for-profit, evidence-based schemes. Public health programmes really improved our communities, but we have lost them, and that is a sadness. We need to recommit to them and have a real focus on getting integrated care systems to commit to them, demonstrating what works in one part of the country and promoting it across the rest of the country. That is what this new clause seeks to achieve.

[The Minister for Health (Edward Argar)]

Mr McCabe, it is a particular pleasure to see you in the Chair this morning, allowing us to get going.

I very much welcome the opportunity to debate and put on record again the Government’s commitment to improving and protecting the public’s health and to supporting evidence-based interventions. Like the shadow Minister, the hon. Member for Nottingham North, I can think of no better example than the remarkable speed of this country’s roll-out of covid vaccinations and the response to the pandemic, saving lives and supporting our economic recovery. That, of course, is testament to the hard work and dedication of our NHS and public health professionals in rising to the greatest infectious disease challenge of modern times.

Our commitment to evidence-based public health is also writ large in many of the Bill’s provisions, our wider programme of public health reform and the proposals set out in the Government’s recently published plan for health and care, “Build Back Better”. We made it clear in that document that although the Government’s immediate priorities for the NHS must be dealing with covid and recovering from the elective backlog, the long-term priority is to shift the NHS towards prevention. Prevention must be a central principle in delivering a sustainable NHS and levelling up. That means fixing the underlying causes of ill health, which is at the heart of the mission of the new Office for Health Improvement and Disparities and the new UK Health Security Agency.

As new clause 58 hints at, a focus on prevention, coupled with a strategic approach to population health more generally, will also be at the heart of integrated care systems. The new triple aim will bind NHS bodies to consider wider effects on health and wellbeing, alongside a duty to reduce inequalities in access and outcomes. Integrated care boards will be required to seek advice from persons with a broad range of professional expertise on public health and prevention, complementing the role, already set out in regulations, of local government and directors of public health to provide advice. Moreover, each integrated care partnership’s strategy will be clearly rooted in, and draw extensively on, local place-based joint strategic needs assessments so that real needs and priorities can be addressed at local level. The ICB’s plans must have regard to that strategy.

I entirely concur with the shadow Minister that evidence-based public health practice is always desirable, and a learning culture essential, but the Government do not see the need for a specific legal duty on NHS England to promote that to ICBs—as envisaged by the new clause—although it undoubtedly will have a role in exhorting and supporting them to their best efforts. The Office for Health Improvement and Disparities and the UK Health Security Agency will also have an important role in this regard, and the National Institute for Health and Care Excellence will continue to issue evidence-based guidance on public health topics referred to it.

There is already a broad obligation on NHS England and NHS Improvement to promote continuous improvement in the quality of services provided across the NHS and, in doing so, to have regard to evidence-based public health quality standards. That includes having regard to quality standards prepared by NICE.

It follows from the rejection of the first limb of the new clause that the Government cannot support the second. However, as set out in “Build Back Better” the Government will bring forward separately from the Bill a new requirement for NHS England

“to introduce a yearly prevention spend, outcome and trajectory reporting criteria, including an assessment of the 10-year spend and outcome trajectories…of the major preventable diseases such as diabetes.”

It may not, but I hope that that goes some way towards meeting the intent behind the shadow Minister’s new clause.

There is a somewhat different matter where public health programmes are commissioned directly by the NHS itself, in exercise of the Secretary of State’s public health functions. That is the case with, for example, national screening or immunisation programmes. These programmes are currently commissioned by NHS England but are rooted in expert advice from the UK National Screening Committee and the Joint Committee on Vaccinations and Immunisations respectively. NHS England is already prepared to report to the Secretary of State on its performance against these functions.

Were any of these functions to be delegated to ICBs to deliver in future, we would expect NHS England to clearly convey the requisite standards and performance expectations for those evidence-based programmes, and overall information about performance and effectiveness will be provided to the public.

In summary, there is a good deal of unity of aim and objective, but I fear there is a difference as regards methods. On that basis, I encourage the shadow Minister not to press the new clause to a Division.

[Alex Norris]

I share with the Minister the desire for a shift to prevention. My anxiety, from the Government action we have seen over the last decade, is that that is a rhetorical shift rather than a substantial shift in policy, and definitely not a substantial shift in resourcing. Nevertheless, the Minister’s answer on the documentation that NHS England will be asked to publish is a suitable substitute for a provision being on the face of the Bill. On that basis, I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 63

Young carers’ needs assessments following hospitalisation

“In the Children Act 1989, after section 17ZC, insert—

‘17ZCA Young carers’ needs assessments following hospitalisation

(1) An NHS trust or NHS foundation trust must ascertain during hospitalisation whether a patient when discharged will be cared for primarily by a young carer.

(2) Where an NHS trust or NHS foundation trust ascertains that a patient when discharged will be cared for primarily by a young carer then the NHS trust or NHS foundation trust must give the local authority where the patient lives notice that a young carer will require a needs assessment.

(3) The local authority receiving notice under subsection (2) must carry out a needs assessment, and in doing so must—

(a) ascertain whether it is appropriate for the young carer to provide care, and

(b) identify what support or services need to be in place for safe discharge of the patient.

(4) The needs assessment required by subsection (3) must be conducted before the patient is discharged.’”—(Karin Smyth.)

This new clause would ensure that the needs of young carers are assessed before a patient who they care for can be discharged.

Brought up, and read the First time.

[Karin Smyth (Bristol South) (Lab)]

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

It is a pleasure to see you in the Chair, Mr McCabe. I will not delay the Committee too long on this new clause, but it is an important one to consider. We had a good discussion last week on the needs of carers, although I am not sure we resolved it satisfactorily. Carers do a huge amount of work on behalf of their families. As my hon. Friend the Member for City of Durham so eloquently said, they want to do that work, but many of them essentially keep our services going. Without them, the demands on our services would be so much greater.

[Mr Peter Bone in the Chair]

All of us who have met or who know young carers recognise the particular stresses and strains on them from caring for their relatives. They do astonishing work. Again, as my hon. Friend said, many feel that they are doing it because these are their loved ones; they do not feel like they are carers in many cases, but they are. Often people then do not come forward, if they are not known to the authorities, to make that clear. That is often because of fear of what that might mean for the family set-up they find themselves in.

The new clause draws attention to the needs of young carers, particularly following hospitalisation. It would require trusts and local authorities to be cognisant of who is caring for a person when they are discharged, particularly where young carers are involved. When the issue was first drawn to my attention—particularly the need to highlight the different needs of young carers—I must confess that I thought that these things were routine in good care settings. Obviously, the situation into which someone is being discharged should be fully known and recognised, and their needs met. We had a good discussion about that and we know that that does not happen, but the pressure on young carers is particularly acute. As part of that discussion last week, I almost intervened on the Minister to ask that when we are considering carers more generally, we highlight young carers separately. A hospital needs to know and understand that the person going back home will be in the charge of a young carer, and the local authority needs to make sure that a needs assessment is conducted.

The new clause suggests that should happen before the patient is discharged. Clearly, the Bill is instigating a new process, which will look at post-discharge. We had a good debate about that. As my hon. Friend the Member for Nottingham North said from the Front Bench, doing that assessment differently may be better in the long run—we do not know. In particular, when it comes to young carers taking up that role, it is even more acute that it is recognised in the new arrangements.

I will not move the new clause to a vote, but I would like the Minister to be cognisant of young carers and assure us that these needs will be highlighted to hospital trusts and local authorities in the discharge planning process.

--- Later in debate ---

[Dr Whitford]

I accept the Minister’s reassurance that they will finally look at correcting this anomaly; I hope that he will take that forward. It is something that we will be looking for. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 66

Support provided by the NHS to populations at risk of malnutrition

“(1) Each integrated care board must—

(a) assess, or make arrangements for the assessment of, the need for support for patients and/or populations at risk of malnutrition, including social and clinical/disease related malnutrition, using their services;

(b) prepare and publish a strategy for the provision of such support in its area;

(c) monitor and evaluate the effectiveness of the strategy; and

(d) designate a malnutrition lead.

(2) An integrated care board that publishes a strategy under this section must, in carrying out its functions, give effect to the strategy.

(3) Before publishing a strategy under this section, an integrated care board must consult—

(a) any local authority for an area within the relevant Integrated care board’s area; and

(b) such other persons as the relevant local authority considers appropriate.

(4) For the purposes of subsection (3), ‘local authority’ means—

(a) a county council or district council in England; or

(b) a London borough council.

(5) An integrated care board that publishes a strategy under this section—

(a) must keep the strategy under review;

(b) may alter or replace the strategy; and

(c) must publish any altered or replacement strategy.

(6) The Secretary of State may by regulations make provision about the preparation and publication of strategies under this section.

(7) The power to make regulations under subsection (6) may, in particular, be exercised to make provision about—

(a) the procedure to be followed by an integrated care board in preparing a strategy;

(b) matters to which an integrated care board must have regard in preparing a strategy;

(c) how an integrated care board must publish a strategy;

(d) the date by which an integrated care board must first publish a strategy; and

(e) the frequency with which an integrated care board must review its strategy or any effect of the strategy on the provision of other provision in its area.

(8) Before making regulations under this section, the Secretary of State must consult—

(a) all integrated care boards; and

(b) such other persons as the Secretary of State considers appropriate.” —(Alex Norris.)

This new clause would require integrated care boards to publish a strategy for the provision of support for patients and/or populations at particular risk of malnutrition using their services, and designate a malnutrition lead.

Brought up, and read the First time.

[Alex Norris]

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

This new clause would put responsibility on integrated care boards to take the lead on tackling malnutrition in their community. We spoke about malnutrition in the context of hospital food standards, and we were not able to move the Minister to extend those hospital food standards to other care settings. I thought that was a shame, and I hope the Government will continue to look at the issue. I want to broaden the conversation on malnutrition to try, via another way, to improve the standing of our communities.

Malnutrition is a serious condition that occurs when a person does not get the energy or vitamins that their body requires to function properly. It affects at least 3 million people every year, and it costs the health and social care system £23.5 billion each year. The condition is particularly common amongst certain groups. Those groups are: older people; hospital patients; people in mental health units and care homes; people living in sheltered housing; and those living with chronic diseases, such as cancer. Malnutrition can seriously threaten patients’ health. Hospitalised malnourished patients are three times more at risk of infection than the well-nourished, while hospital patients at high risk of malnutrition are 12 times more likely to die early than those at no risk. It is a very significant issue. Unfortunately, the figures are not moving in the right direction. The number of adults being admitted to hospital with malnutrition has more than doubled in the last decade—that is the bill for austerity. The evidence is clear that malnutrition impacts a wide range of people in different health settings; again, those are hospitals, mental health units, care homes and sheltered housing. It has a knock-on effect on other conditions.

Earlier this year, the media reported the death of a young disabled woman after a routine operation. Her death was partially caused by malnutrition, and the coroner said there had been a gross failure of care in managing her nutrition. A July 2021 report on malnutrition called it a widespread yet historically overlooked and undertreated issue in the NHS and social care, and attributed that to two factors that block progress—a lack of understanding, and a lack of systematic leadership. The new clause seeks to address that at a local level, which is why we think it is a good one.

The tragic case that I have mentioned shows how important it is to have a clear strategy to tackle malnutrition, to have designated leads and to have targets and co-ordinated policy. The Government say that integrated care boards are about ensuring proper integration between health staff and community services, and this is a really good example of a way in which that could be done. I am keen to hear the Minister’s assessment of the new clause, which should be included in the Bill. We have a significant issue that we are not addressing and that is getting worse, so what are we going to do differently?

[Edward Argar]

We recognise and know that malnutrition can be a significant problem that can be both a cause and a consequence of ill health. We remain committed to improving the NHS and public health systems, which is helping to improve health and secure early diagnosis of major diseases, tackling some of the root causes of malnutrition. That is backed by the development of the outcomes frameworks covering public health, the NHS and social care, and the development of specific disease outcome strategies.

Individuals, carers and professionals all have a role to play in tackling malnutrition, and there are tools and guidance in place through a range of organisations to help health and social care professionals identify and treat the problem of malnutrition, and to access appropriate training. I note that e-learning modules are currently in place through the Royal College of General Practitioners and the managing adult malnutrition in the community pathway, which was set up by a multidisciplinary group and is widely endorsed by professional bodies aimed at healthcare professionals.

I hope I speak for the whole Committee when I say that we all agree that the NHS can play a vital role in protecting vulnerable people. As part of that, it should have strategies and processes in place for supporting patients and vulnerable people in the community who are at risk of malnutrition. I hope I can reassure the Committee that placing in the Bill a formal duty on ICBs to develop a separate strategy is not strictly necessary, as there is a range of ongoing activity across health and care.

As we have previously discussed, there are already significant existing duties, and duties proposed in the Bill, to prepare plans, including joint local health and wellbeing strategies made at a local authority level by health and wellbeing boards, the integrated care strategy that is to be developed by the integrated care partnership, and the forward plan that is to be developed by the integrated care board. All those plans should be informed by local joint strategic needs assessments, or JSNAs. All the strategies can, where appropriate, consider malnutrition and populations at risk of malnutrition. We have previously debated the range of guidance available to inform thinking on both JSNAs and strategic plans, and we will of course work with NHS England to consider whether it is necessary to include specific references to malnutrition in the guidance.

Should the Bill pass into statute, we expect clinical commissioning groups and ICBs to consider the needs of patients and vulnerable people in their communities, including people who may be at risk of malnutrition. That includes working across health and social care partners to undertake needs assessments on malnutrition, and developing and implementing a work plan to maintain high standards of nutrition through integrated pathways of care. NHSEI’s enhanced health in care homes implementation framework sets out best practice guidance for primary care networks and others in relation to hydration and nutritional support for care home residents. The framework supports the implementation of minimum standards in relation to enhanced health in care homes in the Network Contract Directed Enhanced Service for 2020-21.

The malnutrition task force has also published a series of guides offering expert advice on the prevention of and early intervention in malnutrition in later life, which will support health and care bodies. Alongside that, we have published an independent review of hospital food, which made recommendations for addressing malnutrition in hospitals, and a review of what works in supporting older people in the community to maintain a healthy diet. This “what works” review included a range of examples of good practice at local authority level that others can learn from, and we have provided in the Bill for powers to impose requirements on hospital food standards.

We are helping to raise awareness of malnutrition among individuals and carers through the nhs.uk website, and through the NICE quality standard on malnutrition, which gives a clear and authoritative statement of a quality service. There are ongoing inspection requirements, including for unannounced inspections of health and care settings by the Care Quality Commission, which will continue to ensure expected standards are met.

The new clause would place a requirement on ICBs to have a malnutrition lead. The Bill intentionally allows for flexibility in the make-up of ICBs above the minimum membership requirements that we have previously debated in Committee. They could, if they wished, include condition-specific officers, but we do not want to bind their hands by specifying that they must. That once again returns to the permissive versus prescriptive thread that has run through many of our debates.

However, I do see a huge opportunity for ICPs to consider how best to improve services for people at risk of malnutrition through better partnership and joint working and planning of services, given the complementary services that the NHS and local authorities offer in this context. The new Office for Health Improvement and Disparities is committed to improving the diet of the population and supporting people to maintain a healthy weight.

I hope I have given the Committee some reassurance that we are taking this issue extremely seriously and are committed to enabling the NHS and the wider health and care system to effectively tackle malnutrition.

[Alex Norris]

I was a little surprised to hear the Minister defend the status quo. The state of play in this country is not good enough and is getting worse, so I dare say that more of the same will beget more of the same. The Minister said that the new clause was not necessary because of the range of ongoing activity, but I reiterate that what is happening is not sufficient and is not addressing this really important issue.

The two areas for development that were offered were local prioritisation through integrated care strategies and the Office for Health Improvement and Disparities. They are obviously relatively new actors in this space, so it is probably right that we give them time to see whether, as the Minister says, they will prioritise this, choose to make it a top-rated issue and do something about it. I am very sceptical of that, and I suspect that we will be back at this sooner rather than later. However, in the meantime, I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 67

Review of the capacity of the dental laboratory sector

“The Secretary of State must within six months of the passage of this Act publish a report assessing the capacity of the dental laboratory sector in the UK to meet the needs of patients.”—(Alex Norris.)

This new clause would require the Secretary of State to review the capacity of the UK’s dental laboratory sector.

Brought up, and read the First time.

[Alex Norris]

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

[The Chair]

With this it will be convenient to discuss new clause 68—Access to NHS dentistry—

“The Secretary of State must within one year of the passage of this Act publish a statement setting out what measures the Government is taking to ensure universal access to NHS dentistry.”

This new clause would require the Secretary of State to publish a statement of what measures it is taking to ensure universal access to NHS dentistry.

[Alex Norris]

The two new clauses refer to two linked but distinct sectors of the heath service—dental laboratories and dentistry. In each case, we are seeking for the Secretary of State to publish a report about the health of these important sectors.

On new clause 67, the dental laboratory industry manufactures dental appliances to assist in the provision of oral care, such as crowns, bridges and dentures. The British dental laboratory industry plays an important part in the wider oral health landscape, and it is vital for patients, dentists and other registered dental care professionals. This is an unheralded industry, but it touches all our constituencies, and enables our constituents to live without pain. It also provides skilled work in an economy that has too little of it. It is based in communities all over the country, not concentrated in big cities or in London and the south-east. In many ways, it is a towns industry in a country that desperately needs more towns industries.

However, the industry is struggling. It was struggling prior to the pandemic, but it has particularly struggled during it. In the early stages and indeed even today, dentists have rightly—we supported this—been paid full contract for reduced output to reflect the challenging circumstances in which they are operating, but there has never been an obligation to pay this forward to their suppliers. Whereas we might normally expect dental labs to account for 6% to 7% of a dentist’s outgoing, as output has fallen so has that outgoing, so the sector has suffered, but dental labs have needed to stay open to meet need, so they have not been able to completely avail themselves of support.

The messaging around dentistry at a local and national level has also had knock-on impacts for dental laboratories trying to make insurance claims for business disruption, because there has been a misunderstanding, shall we say, about whether they are operating, and how they are operating or not operating.

--- Later in debate ---

[Justin Madders]

As my fellow shadow Minister quite rightly points out, this is a huge issue for most constituency MPs. I am not surprised to hear what he said about this being the No.1 complaint to Healthwatch, because behind GP access, dental access is now a huge issue. Before the pandemic, dental services in the Cheshire area were contracted to attend to 55% of the local population’s dental health needs. Clearly, that is insufficient, but the challenges of the pandemic have only made matters worse. I encourage my hon. Friend to continue to raise this very important issue.

[Alex Norris]

I am grateful for that intervention. It is sobering to hear that 55% was what we started with; we know that it will be less than that now. That rather picks away at the idea of a universal healthcare service.

To finish where I was going with my previous point, if I am wrong about where recovery funding for the NHS is going, and there is to be investment in dentistry, I hope that the Minister will correct me. I would be delighted if that was the case, because the BDA is warning—again, this is something that we will have picked up on in our constituencies—that morale among NHS dentists is at an all-time low. Almost 1,000 dentists in England have stopped providing NHS services in the last financial year. There was the failed contract—I know there is enthusiasm for contract reform in the Department and we will support the Department on that, but we are running out of time to have anything ready for April. In fact, we are probably already too late in that regard. The shambles of the negotiations before Christmas last year that led to the breakdown and the imposition of targets really whittled away at good will and caused a lot of upset.

Almost half of NHS dentists are saying that, unless things change, they intend to hand back their contracts or reduce their NHS commitment. This exodus of dentists from the NHS will have a disastrous and lasting impact on our ability to access NHS dentistry. If 55% is the summit of our ambition, goodness me, where will we go from there? The British Dental Association talks about the last-chance saloon; it is not hyperbole to say that we will not have NHS dentistry in the medium term if we do not have a course change.

More and more people are being pushed into the private sector. That creates market forces that mean that it is almost a self-fulfilling prophecy that dentists—both new ones entering the profession and those who have come to the end of their tether with their NHS contract—go into the private sector. We are seeing significant growth in that space as people living in pain seek drastic action. We will see more pushed on to dental insurance if people do not want to be worried about their finances. That is what privatisation looks like. We will not have NHS dentistry in the medium term unless we do something about this issue—that is the wrong way forward.

New clause 68 makes a very modest ask; it asks the Secretary of State to do what any Secretary of State should want to do: commit to universal access to NHS dentistry and say how it will practically be achieved. At the moment, we have a yawning gap. In that lack of leadership, we will see the drip, drip, drip of the loss of NHS dentistry, until we no longer have it.

[Dr Whitford]

I rise to support new clause 68, which is linked to new clause 67. We are aware of the impact of the pandemic, particularly on dentistry. Using a drill on someone’s teeth generates aerosols in their mouth, and that would vastly increase the risk of spreading covid to the dental staff, or to any patient who entered the space soon afterwards. Despite that impact, there has not been significant funding from the UK Government for the dental industry in England to fund the establishment of ventilation and air purification systems. The Scottish Government have committed £5 million specifically for this. As the hon. Member for Nottingham North highlighted, the pandemic impact comes on top of an underlying issue, the core of which is the 2006 dental contract in England and Wales, which breaks provision down into units of dental activity. It does not reward preventive dentistry. It does not reward any practice for taking on someone who already has dental issues, because it will not be properly funded for that.

Out of that comes the failure to focus on child dental health and making sure that this generation of young children grow up with good dental health. Scotland set up Childsmile in 2007, and Wales set up Designed to Smile in 2011. There is plenty of data from both of these programmes to show that providing free dental treatment to children—along with supported tooth brushing at school, fluoride coating and so on—can decrease caries found in children in primary school and at the beginning of secondary school.

Poor dental health has a big impact on general health and self-confidence, yet we hear repeated reports of families and children struggling to access an NHS practice. In the last five years, NHS practice numbers in England have dropped by over 1,250. BDA surveys suggest that almost half of remaining NHS practices are planning to reduce their NHS commitment over the next 12 to 24 months. There was a promise that the contract would be changed by next April, and 100 practices have been trialling a new method of contract. According to the BDA, it has been warned of a return to using units of dental activity from next April. This would be an enormous missed opportunity to improve NHS dental access for everyone, and particularly to take the further step of ensuring that every child in England does not just have access to a dental practice, but is involved, as they grow up, in a programme promoting good dental health.

--- Later in debate ---

[Edward Argar]

I am very touched by her medical concern for my welfare.

In light of the reduction in activity within dentistry due to the pandemic, dental practices have been asked to deliver as much care as possible, with their first priorities being urgent care, care for vulnerable groups and for children, and then delayed planned care. I put on the record my gratitude to the profession for its hard work and efforts during this time, and I am pleased to note that the levels of urgent care being delivered have now returned to pre-pandemic levels, because of the over 700 urgent care centres established in practices to improve access for people during the pandemic. Throughout the pandemic, we have worked closely with NHS England and NHS Improvement to consider the level of NHS dentistry that can be delivered safely. Activity thresholds for full renumeration are based on data showing what is achievable while maintaining compliance with infection prevention and control measures.

The pandemic has reinforced the fact that transformation in NHS dentistry is essential. As has been alluded to, NHSEI is leading ongoing work on reforming the current dental system, working with a wide range of stakeholders and system partners. We acknowledge that, even before the pandemic and the imposition of limitations that it necessitated, access to NHS dentistry was sometimes a challenge in some areas and for some people. Putting that right will require action to both reform contractual arrangements and ensure that there are trained and qualified dental teams providing NHS services throughout the country.

Since the announcement in March that NHSEI is leading on the next stage of dental system reform, it has continued to work closely with system partners and stakeholders, including the British Dental Association in particular. The NHSEI dental system reform will deliver against a number of fundamental aims, including delivering improved health outcomes, an increased focus on preventive dental work, affordability for patients, and recognising that changes need to be supported by the profession. Making the NHS dental contract more attractive to the profession is a key part of helping with vital recruitment and retention. I know that will be particularly welcome to hon. Members from rural and coastal areas, as it has been highlighted that there is a particular challenge in some of those communities.

A key objective of this work is to improve patient access to NHS care, with a specific focus on addressing inequalities. We will set out our proposals in that area next year, in addition to the provisions in this Bill that will allow the Secretary of State to expand water fluoridation schemes. In addition, Health Education England’s “Advancing Dental Care” programme will, over the next four years, deliver its blueprint for change to reform education and training, develop skills, enable modernised flexible working, and widen access and participation among the workforce.

Together, we believe these measures will address the key challenges that impede the delivery of NHS dentistry, and improve patient access to NHS care. The Government will carry on with this essential work, and will continue co-operating with HEE and external stakeholders on this important issue. For that reason, I ask—possibly in vain—that the hon. Member for Nottingham North considers withdrawing the new clause.

[Alex Norris]

I am grateful to colleagues for their contributions. I am particularly glad that the hon. Member for Central Ayrshire brought up units of dental activity, which are a Treasury way of understanding activity, not a public health way of understanding oral health. Although they are effective for setting balanced budgets on an annual basis, they are really bad for saving money—in fact, they have cost money. There is broad consensus that UDAs are long out of date, and that after 15 years, it is time to move away from them.

Dealing with new clause 68 first, I was glad to hear the Minister at least suggest that this is an active process, because it was the first sign I have seen that the move away was not just a conceptual one. On that basis, I will not press the new clause to a Division, because we will not prejudge that process. However, I gently say that we really need to get on with this, because lots of dentists are waiting on the outcome of that process before making their judgment as to whether or not NHS dentistry is in their future. I was also glad to hear the Minister acknowledge that the system was not good enough before the pandemic. In response, I would say that removing a third of the real-terms funding was perhaps a significant reason why it was not very good anymore, and in future the answer may lie in tackling that point.

Turning to new clause 67, I was of course glad to hear the Minister say that this issue is being taken seriously. However, I was not clear on what “taken seriously” means beyond the existing support there is for businesses generally, not least because dentists have operated in this half space of still being open but not having the fullest demand on their order books, which has often meant that they have fallen between stools. However, I think the offer of that meeting is better than the new clause and, on that basis, I will pursue the route of that kind offer. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 69

National lead for policy related to allergies

“Within 6 months of the passage of this Act the Secretary of State must direct NHS England to designate a national lead for policy related to allergies.”—(Alex Norris.)

This new clause brings in a requirement for the Secretary of State to ensure the appointment of a NHS England allergy lead.

Brought up, and read the First time.

[Alex Norris]

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

New clause 69 is very important indeed. It requires the Secretary of State to direct NHS England to appoint a tsar to lead on policy related to allergies.

In 2016, 15-year-old Natasha Ednan-Laperouse tragically lost her life after suffering an allergic reaction to a Pret A Manger baguette. Since then, her parents have campaigned tirelessly to ensure that her death was not in vain and to stop other parents and loved ones having to suffer as they are suffering. They set up the Natasha Allergy Research Foundation and their campaigning has already successfully led to Natasha’s law, which was implemented just last month and requires food retailers to display full ingredient and allergen labelling on foods made on premises and prepacked for direct sale. That is a tremendous achievement, and it will make a significant difference to lots of people. I have met the Ednan-Laperouse family, with their MP, my hon. Friend the Member for Hammersmith (Andy Slaughter); they are inspiring people and tremendous campaigners. The new clause is very much in the spirit of their latest campaign—I certainly would not bet against them.

The World Health Organisation has described allergic disease as a “modern epidemic”, while Allergy UK estimates that up to 21 million people in the UK are affected by allergies. Allergic disorders can have a detrimental impact on patients’ quality of life, as they not only have the obvious health effects, but can mean that social interactions that others take for granted—such as eating out, or even going to work—are a major health risk. Allergies can be complex: patients can suffer from several disorders at the same time, each triggered by different allergies.

In the 20 years to 2012, hospital admissions for anaphylaxis rose by 615%. Despite that, allergies are not particularly high up the political agenda for conversation and there is a perception of poor management across the NHS due to a lack of training and expertise. At the root of that is the fact that we have a very small number of consultants in adult or paediatric allergy and the fact that GPs receive basically no training in allergy.

Following the inquest into the death of Shanté Turay-Thomas—another tragic teenage death—the coroner highlighted the lack of a national allergy lead in her prevention of future death report, which was sent to the Department of Health and Social Care. I think today is a chance to make good on that, and I would be very interested to hear what the Minister has to say on those suggestions. Natasha’s foundation, with the support of Shanté’s mother, subsequently made the call for an allergy tsar.

Two weeks ago, the all-party parliamentary group on allergy, in conjunction with the National Allergy Strategy Group, launched its report, “Meeting the challenges of the National Allergy Crisis”. The report

“calls for an influential lead for allergy to be appointed who can implement a new national strategy to help the millions of people”

suffering. There is a real coming together across our communities of people in this space calling for this measure, and this the moment to do it.

Otherwise, as I have suggested, NHS allergy services will continue to get little attention, little prominence and little investment. Care is patchy and we know that people deserve much better support. An allergy tsar would act as a public champion for those with allergies, helping to deliver a national plan to join up GP and hospital services so that patients have a consistent and coherent NHS care pathway, and helping to promote the training of more specialist allergy doctors, consultants and GPs. It would make a difference to millions of people. I hope that the Minister will look upon the new clause favourably and give the answer that millions of people are waiting for.

[Edward Argar]

As the shadow Minister set out, the new clause would place a statutory responsibility on the Secretary of State, requiring him or her to direct NHS England to appoint an allergy lead. The shadow Minister rightly highlighted that tragic case that demonstrated to the country the issues and challenges in this space. I entirely sympathise with the intent of the hon. Gentleman, but I hope I can provide him with some reassurance that the amendment is not necessary, because NHSE is already able to appoint an allergy lead, or allergy tsar—call it what you will.

There is no specific national clinical director or specialty adviser for routine allergy services, but I am advised that NHS England and NHS Improvement keep their clinical leadership, including the national clinical director and national specialty adviser roles, under review to ensure alignment with the strategic priorities of the NHS and need. I am sure that NHSE will reflect carefully on the points made by the hon. Gentleman, and I will undertake to acquire a copy of the Hansard to pass on to NHS England and request that it considers the points he made in this context.

I also recognise that, more broadly, it is vital that NHS England and commissioners receive appropriate clinical advice in this area. That is currently provided by the clinical reference group for specialised immunology and allergy services. The CRG covers specialised treatment of certain immunological and allergic conditions. The allergic conditions include severe, complex and/or rare sub-groups. People with allergies continue to be supported through locally commissioned NHS services but, to support patients with more complex conditions, NHSE also directly commissions some specialist services. To support the implementation of coherent care pathways, NICE has also published guidance on a range of allergy conditions, including food allergy in under-19s, anaphylaxis and drug allergy.

We therefore do not believe that the new clause needs to be included in the Bill. Notwithstanding whether the hon. Gentleman decides to press it to a Division, I undertake to ensure that his comments and the case he makes for the role are passed on directly to NHS England. NHSE already has the power, should it wish to exercise it, to put such a person in post.

[Alex Norris]

I am grateful for that offer. I hope that when NHS England has a chance to consider what has been discussed in Committee, that will generate an offer to meet campaigners to understand what they are after and, we hope, to move positively on it. Beyond that, I am afraid that the Minister’s answer was too much in defence of a status quo that does not work for too many people for me to accept it. In the spirit of elevating the matter up the political agenda and creating that blinking light on someone’s dashboard to generate action, I will press the new clause to a vote.

Question put, That the clause be read a Second time.

Health and Care Bill

Alex Norris Excerpts

Report stage
Monday 22nd November 2021 Commons Chamber

[Greg Smith]

My right hon. Friend is absolutely right and speaks with great experience from her time as Secretary of State at DCMS. That is the fundamental point of the amendments; it is not a complex or difficult case, but purely one of fairness and treating the different platforms—the diverse media of 2021—the same, rather than pretending that the media from the old analogue age can somehow be treated differently from those of the digital age.

Let us not cut off the lifeline that funds so many good educational programmes. Let us think again about restrictions on advertisers, move forward in a way that can enable people to make the right and healthy choices about what they and their children eat without this level of restriction, and ensure that, when restriction is brought in, it is fair.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to speak for the Opposition in this first part of the debate on the Bill.

A decade ago, virtually to the day, I was a young activist taking part in marches, protests, online campaigns, letter writing campaigns, petitions and much more in opposition to what would become the Health and Social Care Act 2012. We argued that it would lead to more fragmentation, less integration, confused decision making and more privatisation and that it would not make anybody any healthier.

Despite significant opposition to the legislation, the Government pushed on. But as campaigners, we were right, weren’t we? The 2012 Act created a fragmented system that did not promote health and care integration. Performance against NHS targets, even pre-pandemic, was dismal and now it is even worse. Waiting lists have grown extraordinarily, and staff vacancies have grown to crisis proportions.

We are here today and tomorrow to consign that legislation to history—perhaps less the end of an era and more the end of an error. But the same Government who broke the system now offer a new package of reforms, and that should really scare us. These are the wrong reforms at the wrong time. There are no answers in them to the waiting times crisis, no answers to the capacity issues in accident and emergency or our ambulance services, no answers to access issues for our GPs or dentists, and no answers to the environmental factors that make a country with so many assets so unhealthy.

[Mike Amesbury (Weaver Vale) (Lab)]

Does the shadow Minister agree that the Bill gives the green light to private profit making companies sitting on integrated care organisations?

[Alex Norris]

Yes. That was a strong theme in Committee that we on the Opposition Benches are very much against; it is likely to be a prominent theme during our discussion of upcoming amendments. Through what we are discussing now, we at least have the chance to put something in the Bill that might improve the public’s health.

[Barry Gardiner]

My hon. Friend talked about waiting lists. Would he confirm that at the moment approximately 5.6 million people are on the waiting list and that the Government’s own projections are that that figure could rise to 13 million? What in the Bill does my hon. Friend believe can address that extraordinary situation?

[Alex Norris]

My hon. Friend makes an important point. This Secretary of State must be the first in the history of the NHS who came into that important role saying that he was expecting waiting times to grow to the extent that they are. That is of course pandemic-related, but it also has a reality far beyond this extraordinary last 18 months. There are more than 125 clauses in the Bill and the Government have proposed more new clauses in Committee and on Report, but not one of them will have a meaningful impact on waiting times, so people should be really disquieted.

[Alun Cairns]

I have listened carefully to the hon. Member’s comments about waiting times in England and the measures that are to be introduced here. He urged disquiet; can I assume that his disquiet is even louder when he considers my constituents in Wales who have much longer waiting times?

[Alex Norris]

There is a danger that the right hon. Gentleman has missed the point. The reality is that for a decade there has been historically low investment in our health service, which of course has Barnett consequentials for Wales. That is the reality and why the system is as distressed as it is. I do not think he can put that at the door of the Welsh Government.

Let me come back to public health. Over the past five years we have removed £1 billion in public health funding, which means that the challenges in respect of childhood obesity, smoking, sexual health and access to drug and alcohol services are all developing and growing. The sad thing is that such cuts make an immediate local government saving for the Treasury but create greater costs for the public purse later, never mind the impact on people’s lives. They are the falsest of false economies. For all the talk of the end of austerity, last month’s Budget did nothing to tackle that reality. Indeed, local authorities are under greater pressure and the cycle will continue.

Being smoke-free by 2030 is a major national prize, and with that I turn to new clauses 2 to 11, tabled by my hon. Friend the Member for City of Durham (Mary Kelly Foy). She made an excellent case and has shown tremendous leadership on this issue, in concert with the hon. Member for Harrow East (Bob Blackman), through the all-party parliamentary group on smoking and health. They have given the Government a number of really good ways to improve our nation’s efforts and I hope we will hear from the Minister that they will be taken on.

Tackling smoking is a crucial part of not only improving the nation’s health but addressing health inequalities. A child born where I live, Nottingham, can expect to live seven years fewer than a child born here in Westminster. When it comes to healthy life expectancy, we can expect that difference to double. Tackling that inequality should be a core part of the business of this place. Nearly half that inequality is attributable to smoking—that is how pivotal this issue is.

Successive Governments have shown over the past 25 years that we can make inroads with public policy on smoking, but the benefits have been unevenly felt: the smoking rate among those in professional occupations is now down to just one in 10, so is well on track to meet the 2030 target, but incidence rates among those in manual or routine occupations remain a stubborn one in four, so we must now renew our efforts with that group of people who are, of course, disproportionately likely to use stop smoking services—the very services we have lost over the past decade. Of course, as my hon. Friend the Member for City of Durham said, the pandemic has posed new challenges, with a new group of people who have started smoking but would not otherwise have done so.

We have been promised a new tobacco control plan by the end of this year, but that promise looks a little less secure by the day—I hope the Minister will tell me I am wrong. We could get on with impactful interventions right away. The labelling and information interventions set out in new clauses 2 to 4 have very strong evidence bases from other countries, as my hon. Friend the Member for City of Durham said, and would be quick, easy to implement and impactful.

On new clause 4 in particular, we know that e-cigarettes and vaping are important quit aids, but we would not want them to be a gateway for children to smart smoking. We should be concerned about the 2021 YouGov research for ASH—Action on Smoking and Health—that suggests that more than 200,000 11 to 17-year-olds who had never smoked previously had tried vaping this year. As my hon. Friend the Member for City of Durham said, we must make sure that that age group does not take smoking through that route and that products are not targeted at it.

New clause 5 would tackle the bizarre loophole, which colleagues sometimes struggle to believe is true, that would allow the egregious practice whereby e-cigarettes or similar kit could be given free to someone under 18, although they cannot be sold. That is an extraordinary part of the law and I know that the Minister agrees it is daft—he said that in Committee, but also that he did not feel there was quite the evidence that it was a risk. Well, risk or not, I think the loophole should be closed, because I suspect that eventually someone will happen on it as a bright idea.

New clauses 8 and 10 are a beautiful support to any Minister who wants to improve smoking outcomes in this country, as I know this Minister does, but is conscious about the finances. This gives the Minister a chance, through a US-style polluter pays model, to fund all these interventions, including the restoration of the lost smoking cessation services in this country. He did not close the door to that in Committee when we talked about it, so I hope that he might tell us today that it is likely to form part of the new tobacco control plan. New clause 11 promotes a consultation on raising the age of sale, as we know that the older a person gets, the less likely they are to start smoking.

Let me turn to new clauses 15 to 17 and amendments 11 to 14 in the name of my hon. Friend the Member for Liverpool, Walton (Dan Carden). Colleagues will have been profoundly moved to hear him speak of his battle with alcoholism, and I know that his bravery has connected with people across the country. I associate myself with the remarks of my hon. Friend the Member for City of Durham regarding his entirely understandable absence from the Chamber today. With him in mind, I speak in support of those new clauses and amendments.

New clause 15 seeks to improve alcohol product labelling. This is overdue and it is popular. It is about not taking alcohol products out of people’s hands, but instead making sure that they can make an informed choice.

[Christian Wakeford (Bury South) (Con)]

While an energy drink carries not only calorific information but a health warning that drinking too much can have a laxative effect, alcoholic drinks carry no calorific information and no health warning. Does the hon. Gentleman agree that that is a damning indictment of where we are in society and that a change, which the amendment could make, is needed?

[Alex Norris]

I am grateful to the hon. Gentleman for that intervention. I completely agree with him. I would be the last one to police people’s consumption habits in the night-time economy for fear of being a hypocrite, but I do think that we should all have informed choice. What we have at the moment is inconsistent and unclear. We know that that frustrates people. A recent survey has shown that: 75% of people would like to know the number of units in a product; 61% would like to know the calorie information, as he mentions; and 53% would like to know the amount of sugar. We should give people the chance to have that full information to make their own decisions.

[Geraint Davies (Swansea West) (Lab/Co-op)]

My hon. Friend will know that two thirds of people in Britain are overweight and that one in four is obese. An enormous amount of added sugar is put into processed foods that people do not know about. Men, for instance, are not supposed to have more than nine teaspoons of added sugar, and women six, which is the equivalent of a can of coke and a light yoghurt. Does he not agree that this Bill is tremendously light on the killer that sugar is, and that not only should we be labelling it, but that the Budget should tax added sugar in processed food to reduce the waiting list?

[Alex Norris]

My hon. Friend will be delighted to hear that I will be coming on to the modesty of the Government’s plans for tackling obesity, but I have to finish my remarks about new clause 16.

New clause 16 compels the Secretary of State to publish an annual statement about the spend and impact of alcohol treatment funding. After a decade of reduced commitment in this vital area, the Secretary of State should seek to embrace this opportunity. At the moment, national Government cannot say they are meeting their responsibility to tackle alcohol harm with the requisite financial commitment and in the right place, which should discomfort them greatly. New clause 17 would replicate in England the minimum unit pricing restrictions that we see in Scotland and Wales, and we are all watching with great interest as evidence gathers as to their impact.

Let me now turn to the amendments and new clauses relating to advertising. The Government have included a couple of elements of their obesity strategy in the Bill. As I have already said to the Minister—in Committee and upstairs in the delegated legislation Committee—I wish that they had put the entire obesity strategy in this legislation, because there are bits that could have been improved by amendment, by debate and by discussion, as we heard in the contribution of the hon. Member for Buckingham (Greg Smith), and as I dare say we will in that of the hon. Member for North East Bedfordshire (Richard Fuller). We should have taken that approach to the entire document, and it is sad that we did not.

On the obesity strategy itself, it is too modest and it fails to attack a major cause of obesity, which is poverty.

[Jim Shannon]

The hon. Gentleman is absolutely right in what he is saying. I am a type 2 diabetic and I am well aware of the issues. As I understand it, figures that have been gathered during the covid-19 pandemic showed that the number of diabetics rose by some 200,000. That tells me that, if we are going to address the issue of diabetes, we need to have a tax process in place, which I think is what the hon. Gentleman is referring to, rather than a regulation, because that is the only way that we can control diabetes.

[Alex Norris]

I think that a solution might be a little from column A and a little from column B, but I am grateful to the hon. Gentleman for making that point.

We have heard about the modesty of the strategy from the hon. Member for Buckingham. The reality is that any benefits from the obesity strategy will be outstripped by losses in the nation’s health caused by the impact of the cut to universal credit. We want the strategy to succeed, but it needs to be seen in that broader category.

Obesity is an important issue, with nearly two thirds of adults carrying excess weight. Childhood obesity is also a significant issue, with one in 10 children starting primary school obese, rising to one in five by the time they leave—extraordinary at such a young age.

[Catherine West]

I thank the shadow Minister, who is making an excellent argument, and colleagues across the House for all their work on this important Bill. Does he agree that we could do an enormous amount for the health of the nation by looking holistically at the role of exercise and prescribing exercise through the national health service, including swimming—the statistics on 11-year-olds who can swim 25 metres are going backwards due to all the lessons they have missed during coronavirus—and other important sports?

[Alex Norris]

Yes, I agree. I look with real sadness at the loss of exercise-on-prescription schemes that were part of the public health grant but have gone over the last decade. Similarly, on swimming, the decisions in the Budget relating to local authorities will lead to councils, which are setting their budgets as we speak, closing more leisure centres and swimming pools. We should mourn those losses, which come as a result of a weak bit of public policy.

In the Bill, the proposed watershed with regard to high fat, sugar and salt products is broadly a good thing. With that in mind, we do not oppose Government amendments 31 to 39, which are relatively modest tweaks, but we should not lose sight of the fact that we are talking about a significant proposal; I know that colleagues have interest in this. Beyond a watershed on traditional broadcast media, we will also see a complete online ban of high fat, sugar and salt advertising. This is a blunt tool in pursuit of an important goal.

New clause 14 in the name of the hon. Member for North East Bedfordshire would implement a more nuanced system, as proposed by the advertising industry itself. This is mirrored in amendments 106 to 109 in the name of the hon. Member for Buckingham. We probed this point in Committee. I was surprised then, and remain surprised, that there seems to be little interest from Ministers or the Department in even having that conversation and exploring creative alternatives. The desired benefits are non-negotiables. If there are other ways to achieve those benefits, they ought to be approached with an open mind.

[Richard Fuller (North East Bedfordshire) (Con)]

I am grateful to the hon. Gentleman for mentioning my new clause. We have a number of issues potentially to put to a vote later. Given what he has said and given that the Minister was a bit hazy about this issue in Committee, would he be minded to support my new clause if it were put to a vote and the Minister did not come forward with something more robust?

[Alex Norris]

The hon. Gentleman tempts me, but my problem is that I want to know that the conversations have taken place and that the proposal has been considered as an option. I would not say today that I think it is the best option, but I am surprised that that conversation has not taken place, which is why I have highlighted it. There is still time for the Minister to reconsider, and he should.

I was less persuaded by amendments 3 to 5 in the name of the hon. Member for North East Bedfordshire, which seek to permit brand advertising as long as it does not refer to an HFSS product. In many cases, the brand and product are so inexorably intertwined that it might undermine the goals and aims of the whole intervention. I do, however, support amendments 6 to 8, which refer to the nutrient profiling model—the model that is used to determine what is and is not considered to be a high fat, sugar and salt product. It is important that there is certainty and that it does not move around more than the science would say that it ought to.

We talked about this issue at length in Committee. If we are asking the industry to reformulate and change, companies ought to be able to base product decisions on the certainty that the Government will not arbitrarily change the criteria. Such companies may have made significant time, financial or infrastructure investments in a certain product and then could see the criteria change overnight. In Committee, we extracted a commitment from the Minister to a Government amendment on this matter. That was reiterated in a letter on 13 November, when the Minister wrote to Committee members and committed to

“introducing a Government amendment at Commons Report Stage to include a duty to consult before changing the NPM technical guidance.”

I am surprised not to see that at this point. I hope that we will get clarity from the Minister, or indeed that he is minded to accept these amendments, because this is an important development. We also want the level playing field suggested by amendments 110 to 113, so we will be listening with great interest to his reply.

This is the wrong Bill at the wrong time. It does nothing to address the real causes of ill-health in this country today. In this part of the proceedings, colleagues have given the Minister a chance to change that and I hope he is minded to take it.