13:45 - Division on Lord Rea's amendment - Ayes: 220 / Noes: 354 - Division on Lord Rea's amendment disagreed.
14:22 - Division on Lord Owen's amendment. - Ayes: 262 / Noes: 330 - Amendment disagreed.
Earl Howe
I rise to conclude an excellent and constructive debate. It has been long, and the task that rests with me in summing it up in the space of 20 minutes is clearly an impossible one, if I am to do justice to every speaker. Therefore, I hope that the House will find it acceptable if I aim in my response to capture the main themes of this debate and to write to noble Lords whose specific and detailed questions I do not have time to answer. In addition, I am happy to offer any the noble Lord a meeting with me or with officials from the Department of Health to discuss any of the issues that they have raised.
To begin with what might seem an emotional and emotive point, it was said by more than one speaker, including the noble Lord, Lord Hennessy, this morning, that the NHS is the nearest thing that this country has to institutionalised altruism. That is surely right. It is equally right that the NHS is a part of our national life, of which we can be deeply proud. At its best, which is often, it delivers high-quality excellent care. The investment made by the previous Government has contributed significantly to that.
A number of noble Lords asked why, therefore, the Government’s reforms are needed at all. Part of the answer to that is about the clear imperative around the quality of care, about which the noble Lord, Lord Darzi, and my noble friend Lord Black spoke so powerfully. Indeed, we have excellent care in the NHS, but sadly this is not universal. The variations in quality and outcomes and longevity around the country are too great for us to sit back and do very little. But there is another less visible reason. In a sense, the need for reform is not about how excellent the NHS may be today; it is about our making sure that in five, 10 and 20 years’ time the NHS is still there as a sustainable public service, free at the point of use, delivering the care that we all want it to.
The financial challenge facing the NHS is acute. We have protected its budget in real terms, but that is not going to be enough to meet demand from an ageing and growing population unless we take some radical steps to simplify and streamline the NHS architecture and to free up the service from central control in a way that will drive innovation and productivity as never before. That is the purpose of these reforms and this Bill. It is not just about today; it is about safeguarding the future. If I had one criticism of some of the contributions from the Benches opposite it was of their failure to acknowledge the scale of the financial and quality challenge that now faces us. Money will no longer grow on trees in the NHS; we have to think out of the box. So we are seizing on the evidence of what works in order to drive quality—namely, empowering commissioners. We are cutting the cost of NHS administration by one third, and we are trusting the men and women of the health service—including, incidentally, our many excellent managers—to deliver what we know they can, which is an even better service for their patients. And make no mistake—there are doctors and nurses and managers out there who are keen to get to grips with this. Yes, of course, there are many who have no appetite for change, and there are many critics and doubters. But I have met so many clinicians that I cannot count them, who believe that what we are doing is right, and who are being inspired by these reforms to lead the way in the local pathfinder groups and in local authorities.
The NHS needs continual renewal. It has never stood still, and it cannot do so now. The noble Lord, Lord Darzi, put it perfectly when he said:
“To believe in the NHS is to believe in its reform”.
Many speakers, most prominently my noble friend Lady Williams and the noble Baroness, Lady Jay, have spoken about accountability in the role of the Secretary of State. For me, the debate on this topic crystallised into two issues. A number of speakers aligned themselves with the Select Committee on the Constitution in questioning why we have removed the Secretary of State’s duty to provide. There has been concern that this means that the Minister’s ultimate accountability for the NHS is in some way diluted. I can reassure the House that this is not so. A change as pointed out by several noble Lords, including the noble Lord, Lord Warner, and my noble friend Lady Bottomley, as well as the noble Baroness, Lady Murphy, is to reflect a fact which has been the case for many years; namely, that the Secretary of State does not directly provide services himself.
Under the Bill, the Secretary of State will continue to have a statutory duty to promote a comprehensive health service, and a duty to use his powers to secure the provision of the service. As has been the case for decades, it does not extend to the Secretary of State directly providing services. So rather than pretend that somehow the Secretary of State is responsible for all clinical decision making in the NHS, the Bill recognises that expertise for such decisions must sit with those health professionals closest to patients. Indeed, my noble friend Lord Marks put it well when he pointed to the means by which Secretaries of State will be able to do this; namely, the mandate to the NHS Commissioning Board, the standing rules, and the failure intervention powers. I may say that the improvements that my noble friend suggested to these powers sounded interesting to me, and I look forward to discussing these with him in greater detail at a later date.
The noble Lord, Lord Owen, asked what would happen in the event of a pandemic. If I could direct the noble Lord to Clause 44 of the Bill, he will read of the extensive powers the Secretary of State has to take control in an emergency—and this even extends to foundation trusts, which is a power not available to Ministers today.
The second issue raised with regard to the Secretary of State turns us to Clause 4, the duty of autonomy, and I am sorry that what I have said on this has been the subject of concern. My noble friends Lady Williams and Lord Marks highlighted this clause as raising the possibility that it will lead to an unacceptably hands-off approach on the part of the Secretary of State. We do not think that that is the case. However, I would like to repeat the commitment made by my honourable friend the Minister for Care Services at Report stage in the other place, about Clause 4, namely that,
“we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put it beyond doubt that the Secretary of State remains responsible and accountable for a comprehensive health service, which we all want to see.”—[Official Report, 7/9/11; col. 454.]
If there is an amendment which will improve the Bill, we will make it. This offer stands, irrespective of how the House votes on the amendment tabled by the noble Lord, Lord Owen, and I hope that this gives reassurance to those who have been concerned on this point. I also today commit to host a meeting with all interested Peers—including the noble and learned Baroness, Lady Scotland, if she wishes—to discuss any matters around accountability further so that we can all better understand each other’s positions and concerns, but also inform Committee discussions on these vital issues.
The second concern I would like to turn to is that of competition. Many speakers, such as the noble Baronesses, Lady Kennedy and Lady Billingham, fear that the Bill could lead to an American-style market free-for-all, with competition harming patients’ interests. Others, such as the noble Baroness, Lady Murphy, have claimed that we are actually doing too much to shackle the benefits of competition, and that we should look at removing some of the safeguards that we have put in place.
Let me be clear about what the Bill does and does not do. The Bill does not introduce a free market for all. It does not change competition law, or widen the scope of competition law. It does introduce a framework in which competition can be effectively managed as a means to benefit patients. That competition can work in the interests of patients is well backed up by academic research, such as the studies quoted by the noble Lord, Lord Warner, on mortality rates, and by noble friend Lady Cumberlege on inequalities. The Bill does not do anything which might or could lead to the privatisation of the NHS. What it does do is create a level playing field between different providers, putting an end to the subsidies and guarantees given to the private sector under the last Government.
The Bill will not mean that competition will trump integration. The safeguards and duties that it places on Monitor, in particular its core duty towards the interests of patients, will ensure that Monitor supports integration. The balance that we have struck in this Bill, once more returns to the North Star—that graphic metaphor from the noble Lord, Lord Kakkar—namely, patients. We believe that competition has a place, but only as a means to an end, the end being to improve quality and efficiency.
The noble Lord, Lord Darzi, made the case, as usual, very strongly, by talking of competition as a means to spark creativity and light innovation. However, it does require safeguards to ensure that other factors such as integration, service continuity and the prevention of cherry-picking are given due weight—and those safeguards are there.
I turn next to concerns raised that the Bill creates too much complexity, meaning that care will be fragmented, and decision-making harder to achieve, and we heard that concern expressed this morning by the noble Baroness, Lady Pitkeathley. Let me first be clear about the different organisations abolished and created by this Bill. The Bill abolishes the 151 primary care trusts, half of the national arm’s-length bodies, and the 10 strategic health authorities. It establishes clinical commissioning groups which are currently growing out of existing practice-based commissioning groups. Likewise, local HealthWatch will build on existing local involvement networks, and HealthWatch England will be situated within the Care Quality Commission. I can reassure the noble Lords that the Bill contains a number of mechanisms to ensure independence of HealthWatch both locally and nationally. Monitor will be expanded to become a provider regulator, and the NHS Commissioning Board, led by Sir David Nicholson, will be a new body, but it will draw on the best aspects of a range of departing organisations. We envisage that it will host the existing clinical networks and the new advisory clinical senates.
Concerns were raised that the board could have too much power over commissioning groups. I genuinely agree that the Bill contains sufficient safeguards against this, but I do of course look forward to discussing this issue further. Overall, administration costs across the health system will be cut by one-third in real terms by 2014-15—this will save £4.5 billion by the end of the Parliament alone—all to be reinvested in front-line patient care.
A number of noble Lords have asked who takes the decisions. This Bill represents a significant step forward by directly conferring responsibilities in statute, rather than having them all delegated in an opaque way through the Secretary of State. This clarity extends to how different organisations should work together and the Bill contains significant new provisions regarding collaborative working. In her opening remarks, the noble Baroness, Lady Thornton, expressed her support for health and well-being boards, which will be hosted by local authorities. Other speakers have endorsed the plans for joint strategies to be determined and agreed by all relevant local services. Many speakers have raised service configuration, which we can happily debate. However, I believe that the Bill supports effective, clinically led reconfigurations led locally but with the NHS Commissioning Board playing an important leadership role.
A number of speakers spoke about particular service areas within the NHS and how the reforms would impact on them. Let me start by reassuring noble Lords that those working in general practice will not be commissioning in isolation. Clinical commissioning groups must obtain appropriate advice from a broad range of professionals. This would, for example, include experts in mental health, children’s health, learning disabilities or other areas as appropriate. Given this duty to obtain advice, we do not think that it is necessary to expand the membership of clinical commissioning groups’ governing bodies further than is currently set out in the Bill, which was a suggestion made by a number of speakers, including the right reverend Prelate the Bishop of Bristol. Indeed, if all the additional representatives suggested in this debate alone were to join the governing body it would quickly become unwieldy and unworkable. Clinical advice would also come through other forms, such as clinical networks, which I can confirm to my noble friend Lord Clement-Jones will continue, and new clinical senates. These mechanisms should ensure that specialist advice at all levels of the NHS is there. They are not extra layers of bureaucracy.
Many speakers have stressed the importance of public health and health inequalities and the changes proposed by this Bill. I completely agree that these are fundamental issues. Our plans seek to create a new focused approach for public health, protected by a ring-fenced budget. The noble Baroness, Lady Gould, asked a range of questions about the detail behind our arrangements and I will respond to her in writing. But in terms of inequalities, this Bill, for the first time, puts in place specific duties on key relevant bodies to act with a view to reducing health inequalities. That should surely be seen as welcome.
One or two noble Lords, including the noble Baroness, Lady Royall, raised the removal of a foundation trust private income cap and feared that it could lead to longer waiting lists for NHS patients. I am confident that it would not have this effect. My right honourable friend the Minister for Health said on Report in the other place that,
“we are proposing to explore whether and how to amend the Bill to ensure that FTs explain how their non-NHS income is benefiting NHS patients. We will also ensure that governors of FTs can hold boards to account for how they meet their purpose and use that income”.—[Official Report, Commons, 6/9/11; col. 289.]
I hope that provides some reassurance. I look forward however to further debates on that issue.
The future of both education and training, and research, were raised by a number of speakers. The noble Lord, Lord Walton, and my noble friend Lord Willis spoke passionately about the benefits of research. The noble Baroness, Lady Masham, and my noble friend Lord Ribeiro spoke equally passionately about innovation. As Minister responsible for research and innovation, I fully share this passion and I hope that I can reassure noble Lords that we are taking all necessary steps to ensure that we act quickly on taking forward the report of the Academy of Medical Royal Colleges, including future legislation.
Such legislation will also take forward the future arrangements for education and training but I can confirm to the House that we will table a new duty for the Secretary of State with regard to education and training in time for Committee. In addition, as both issues have attracted so much interest, I will ensure that new fact sheets on both topics are produced by officials in the Department of Health and made available prior to Committee. Again, my door is open to noble Lords to discuss any or all those issues.
Several noble Lords called for healthcare assistance to be given full statutory regulation. While I accept the need for action in this area, I cannot agree that statutory regulation is the best way to proceed. Our view is that employers of such workers have to take responsibility for the quality of services provided, including the use of existing systems. In addition, when tasks are delegated by qualified professionals, this has to be done with appropriate and effective supervision. I am of course more than willing to discuss this issue further as the Bill proceeds.
I turn now to the procedural concerns raised during the debate and to the Motions tabled by the noble Lords, Lord Owen and Lord Rea. First, a number of speakers questioned what they call the democratic mandate for this Bill claiming that the Bill’s proposals were not in manifestos or the coalition agreement. Both these claims are untrue, as any quick read of these documents will show.
What is true, as my noble friend Lord Rodgers pointed out, is that sheaves of documents covering every detail of policy were set out in July last year when we published the White Paper and associated consultation documents. This was followed up by a period of public engagement, a lengthy Government response, the listening exercise in the spring of this year and 40 sittings in Committee in the other place. At all stages, we have been open and transparent about our plans. This approach will of course continue and I welcome the proposal of the noble Lord, Lord Kakkar, in terms of ensuring effective post-legislative scrutiny. I can confirm today that while five years would normally elapse prior to post-legislative scrutiny of a Bill, we will bring that forward for this Bill to three years. As a result, I simply cannot accept the amendment in the name of the noble Lord, Lord Rea. I respectfully suggest to your Lordships that to vote for that amendment would run directly counter to the proper role and functions of this House.
Secondly, concerns have been raised about what has been seen as implementation of the Bill’s proposals prior to Royal Assent. I suggest that this fear is unfounded. Preparatory work is ongoing to implement the Government’s plans, such as the creation of clinical commissioning group pathfinders. This is all within the current legal framework. However, such powers can get the reform only so far; hence the need for this Bill. For example, while early implementers of health and well-being boards are emerging all over the country, until this Bill is passed they lack all the statutory powers that we think are essential for them to operate.
Finally, I turn to the Motion in the name of the noble Lord, Lord Owen. I do not feel that a further Select Committee would add significant value to our normal processes. A Committee of the Whole House with all interested Peers, including constitutional experts in attendance, would in my view be the best forum to ensure effective and thorough scrutiny. Perhaps I may say that this Second Reading debate has amply proved that. My noble friend Lord Rodgers put it well in saying:
“The House is now able to make fully informed decisions … we should not duck … them further”.—[Official Report, 11/10/11; col. 1543.]
Furthermore, I agree with my noble and learned friend Lord Mackay of Clashfern that the early clauses of this Bill, which cover the Secretary of State’s duties and powers overarch the rest of the Bill. It is right for a Committee of the Whole House to consider them at the outset of the deliberations.
I engaged in discussions with the noble Lords, Lord Owen and Lord Hennessy, to see if there was a way to accommodate their proposals for a special Select Committee. The only way, I feel, that such a novel procedure could work would be to put a clear end point on both the Select Committee and the Committee of the Whole House. It is not sufficient to put a time limit solely on the Select Committee. This Session, all pre-legislative scrutiny committees set up in this House have required time extensions.
While the noble Lord, Lord Owen, says in perfectly good faith that the committee will report before Christmas, there is no way in which this House can make that truly binding without an end date on both committees. The key point is that if the Select Committee needed more time or if it recommended amendments affecting parts of the Bill—
Lord Peston
Is the Minister certain that there is no way that the amendment to which he refers can be made to work so that the job gets done in time? That bears no resemblance to my knowledge of how this House works. The House can end things at any time it wants to.
Lord Hunt of Kings Heath
My Lords, in my experience, if this House wants something to happen it finds a way for it to happen. Even at this late stage, I ask the noble Earl to give careful consideration to this. I have already said from this Bench that we are happy to meet through the usual channels to agree a date by which the Committee stage will be finished on the Floor of the House. I am sure that the noble Lord, Lord Owen, as far as he is able, will wish to say that he is happy for the special committee to finish by a certain date. I do not believe that it is impossible for agreement to be reached on this.
Earl Howe
My Lords, I very much welcome that offer, which has come rather late in the day. My understanding is that discussions over the timetabling of the Bill have taken place over the past week. However, we are faced with the amendment that is on the Order Paper and must vote on it as it stands.
Baroness Royall of Blaisdon
I beg your Lordships’ pardon but I have to say that we are and have been entirely open to this suggestion. I was not aware of it until yesterday. I give the House my pledge that the Bill will come out of Committee by mid-January, which is, I think, when the noble Earl was thinking of. We should be delighted to give our firm assurance that the Bill will come out in mid-January.
Earl Howe
My Lords, that is an extremely welcome offer, which we accept. I am grateful to the noble Baroness.
It is right for me to conclude, with your Lordships’ agreement. I bring this extended debate to an end by returning to the point of the Bill, which is to improve the quality of care for patients. For all the generosity of the noble Baroness’s offer, the amendment of the noble Lord, Lord Owen, would not help patients. It would insert additional uncertainty into the parliamentary passage of the Bill. As my noble friend Lord Fowler rightly emphasised, the amendment of the noble Lord, Lord Rea, would leave the NHS in far greater uncertainty. It would also leave it unprotected from both the present and future challenges that it faces.
Baroness Royall of Blaisdon
My Lords, I crave the indulgence of the House to confirm one point that was clarified by the noble Lord. I do not advocate any timetabling Motion: that would not be appropriate for the House. I give the assurance that, were the noble Lord’s amendment to be agreed, my Benches would wish the Bill to be out of Committee by mid-January. However, if the amendment is not accepted, it will be right and proper for the usual channels to discuss the appropriate number of days needed in the light of this excellent Second Reading debate. I cite the excellent speeches made by many noble Lords, including the wise words of the noble Lord, Lord Walton of Detchant, who spoke before me last night and who said that enough time must be given. He is absolutely right. I have no intention of delaying the Bill. My intention is to ensure that there is proper agreement between the usual channels on the appropriate amount of time that the Bill needs in Committee.
Earl Howe
My Lords, I will make three very brief points. The provisions that the noble Lord, Lord Owen, asks us to send to a special Select Committee affect the entire Bill. The twin-track approach that he advocates carries a major risk: the potential disconnect between the special Select Committee and the Committee of the whole House. The Select Committee might recommend amendments to parts of the Bill that have already been debated by the Committee of the whole House. The result could be that, notwithstanding the offer made in good faith by the noble Baroness, Lady Royall, we could see a slippage of the timetable of the Bill that would be most unwelcome.
I repeat my assurance that I am entirely open to considering the concerns that have been raised about the issue and to make any necessary amendment to put it beyond doubt that the Secretary of State will remain responsible and accountable for a comprehensive health service.