Health and Social Care Bill
(13 years ago)
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16:54 - Division on Amendment 1 - Ayes: 212 / Noes: 244 - Amendment 1 disagreed.
Baroness Thornton
“Principles of the Health Service in England
(1) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England must have regard to the principles and values outlined in the NHS Constitution.
(2) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England, or providing services as part of the Health Service in England, must provide quality, equity, integration and accountability, not the market.
(3) The primacy of patient care shall not be compromised by any structural or financial re-organisation of the Health Service in England.
(4) There must be transparency and openness wherever taxpayers’ money is being spent, and all accountable individuals and bodies should abide by the Nolan principles.
(5) “The Nolan principles” means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life (Cm 2850).
(6) Schedule (Principles of the Health Service in England) has effect.”
The Lord Speaker (Baroness D'Souza)
My Lords, I point out to the Committee that in line 8 of the amendment, there is a misprint. “Must provide quality” should be read as “must promote quality”.
Baroness Thornton
My Lords, I thank the Lord Speaker for making that correction and assure the Committee that the correct word is “promote”, not “provide”. In the context of the Bill, as noble Lords will be aware, the difference between promote and provide is a subject on which we will have many debates in the days to come. I apologise to the Committee for not having read my own amendment more carefully when it was published.
To noble Lords who are familiar with this kind of amendment, I apologise in advance. There may be some who are not; we have many new Peers with us today. Perhaps I may explain what we are doing here. The Liberal Democrats will be more familiar with this procedure because from time to time they placed this kind of amendment before the House, aiming to set a framework for the Bill in question or to give further definition of a Bill. Indeed, from time to time, they succeeded in persuading the House to support them. I know the House appreciates a good precedent. I believe that the last time there was an amendment before Clause 1 was in the Apprenticeships, Skills, Children and Learning Bill in 2009, when the Liberal Democrats and the Conservatives both put amendments down before Clause 1. Forgive me, I am not absolutely certain if either or both of them succeeded. I have a feeling that the noble Baroness, Lady Sharp, may have succeeded on that occasion.
The aim of this amendment is to set out some principles and a framework for the Bill to follow. In doing so, we have sought the widest possible genesis for this amendment, and I will explain this to the Committee in a moment. This first amendment kicks off Committee stage and concerns the principles that ought to underpin the health service in England. The amendment stresses the rights and pledges, values and principles, as outlined in the NHS constitution produced by Labour when in government. The amendment also places protection and promotion of patient care above structural or financial reorganisation. It calls for transparency and openness in decision-making, especially those decisions on funding, to ground proper accountability at the heart of our National Health Service. It seeks to set a framework around which the debate on the rest of the Bill can follow. I tabled this amendment partly because while the Government say they agree with all of these matters, at present the Bill still fails to reassure people that it delivers them. The confusion and lack of trust will be the substantive matter in many of the almost 400 amendments that have already been put down on this Bill.
At their spring conference, the Liberal Democrats made it clear that they wished to set beyond doubt that the Bill will not establish the NHS as a utility-style market based on the now outdated model that is currently failing in energy. How right the Liberal Democrats were. I share the doubts of the noble Baroness, Lady Williams, that the changes in the Bill achieve that. The need for a defining set of principles arises out of the failure of the Government to provide any reasonable explanation of what this Bill is for and what their strategy for the NHS actually is. The Government keep telling us that it has to be a different NHS so I am seeking some definition on what we can agree about and to place those principles at the front of the Bill.
We like to think of this amendment as a perfect cross-party marriage in its crafting. We have something old, something new, something borrowed and something blue. The old is the NHS constitution; although not very old, it was devised and brought about by the Labour Government and put through the House by my noble friend Lord Darzi, and we are proud of it. This is in subsection (1) of this amendment and is reflected in Amendment 52 to the schedules that list the principles of the NHS constitution, particularly with relation to patient care. I have borrowed the words of subsection (2) from the resolution that was passed at the Liberal Democrat spring conference, with the very slight addition of “integration and accountability”, which I am sure would have been there had they thought of them. I did wonder about the last three words—“not the market”—but I think everyone knows what that means. It does not mean that the NHS should not be engaged with the market, nor that there is not a place for the planned use of private and other providers within the NHS. It is there because the first Bill included a clear commitment to use competition as the main means of reforming the NHS and I think we still need to be clear that this is not the case. These Benches and the Liberal Democrats are in some agreement about this matter—at least I hope we are—and I think we should say so at the beginning of this Bill. Subsection (3) is blue, coming as it does from the coalition agreement. We will stop top-down reorganisations that get in the way of patient care. These words echo those of the Prime Minister when he said, “no top-down reorganisation”. The new, in subsection (4), is the most recent player in this Bill: the Future Forum, which has quite rightly brought the probity of the Nolan principles into this Bill.
It seems to me that only with clarity around the principles will the Government have any chance of taking the 1 million-plus staff of the NHS with them. Given the British Medical Association survey released yesterday, and GPs’ survey a week or so ago, the words of the Royal College of Nursing and many others, the Government have some way to go in persuading the staff to wholeheartedly support these changes. So I suggest that this statement of principles will help the Government in this task. It will also help the passage of this Bill. I hope that the Minister and the Committee will feel the same.
Baroness Williams of Crosby
My Lords, may I briefly address the proposal put forward by the noble Baroness, Lady Thornton? She has made a considerable contribution to the discussion in this House about the health services; not least by organising an impressive series of seminars that were attended by many Members of this House, from all parties and also from the Cross Benches. We are extremely grateful for this.
I am moved very little by the preamble, in the sense that the central issue behind it, which I fully share—that is to say, the clear responsibility of the Secretary of State for a comprehensive health service free at time of need—is primarily, in fact, already embodied in the debate we are about to have on the first group of amendments after the amendments on education and training. The way that this has been addressed by the noble Baroness, Lady Thornton, herself but also by other members of this House, not least the noble and learned Lord, Lord Mackay of Clashfern, provides the basis for a very satisfactory, detailed and careful consideration of what the role of the Secretary of the State is.
We know that there are still fears about ambiguity. On this I agree with what the noble Baroness, Lady Thornton, has indicated. These fears have been very strongly outlined: first, by the Future Forum which said in its report that it had concerns about the accountability of the Secretary of State and, secondly, in the brilliant and concise report of the Constitution Committee, an all-party committee of this House. The committee pointed to its concerns about whether the responsibility and accountability of the Secretary of State emerged sufficiently clearly, and it gave a very impressive argument to the effect that some doubts remain about the position.
Since that time, of course, there have been concerns—rightly so—about some of the knock-on effects of removing accountability of a clear kind from the Secretary of State. All through this Bill, there are situations where the Secretary of State might be or might not be involved. I shall give two examples. The first is about the possibility of conflict between Monitor and the NHS Commissioning Board and how that is to be resolved, where one might suppose that the Secretary of State would be the ultimate decider. The second is on the question of what happens if there is a major emergency in the country of a health nature and whether the public would not, in fact, expect the Secretary of State to be the ultimate source of accountability.
My feeling is that it is better to address these issues very clearly as each one comes up, and to set out in detail, therefore, what the precise responsibilities of the Secretary of State are. Certainly, if one wants simply to assert—which many of us obviously fully understand—a concern and a liking for the NHS, the Secretary of State’s responsibility was reiterated and reaffirmed some time ago after intervention by my right honourable friend in another place, Mr Nicholas Clegg, and others.
This is not an issue for which we should hold up the whole of the Committee proceedings but, in assessing once again the commitment of many of this House to the NHS, it is certainly not objectionable. For the reasons I have given, however, it is perhaps not wise to detain ourselves on this issue at the moment.
I would add two other problems. The wording of the preamble before Clause 1 is mostly fine, but frankly I am a bit worried about subsection (3). One thing we must not do is, as it were, encompass the NHS in a form of unchangeability when all of us know that major changes have to be made within its structure. Therefore, subsection (3) could be a rigidification of the situation. Having said that, however, I believe that we should now move on from this issue to look at the most clear, legally expressed considerations of what should be the clear and accountable responsibilities of the Secretary of State.
Lord Hennessy of Nympsfield
My Lords, having suggested during the Second Reading debate that your Lordships might consider the value of a preamble to the Bill which captures the ethos and purpose of the National Health Service, I was grateful to the noble Earl, Lord Howe, in his letter of 20 October to noble Lords, for describing it as “an interesting idea”. The Minister went on to say that,
“preambles have fallen out of use in modern-day legislation, partly because there is a risk that they could lead to unintended consequences, and also because it is considered bad legislative practice to include words in a Bill that have no clear legislative purpose or effect”.
I note and accept that preambles have fallen into disuse, but I continue to see the value of capturing the NHS ethos and purposes firmly right at the top of the legislation, which is why I welcome the proposed amendment in the name of the noble Baroness, Lady Thornton, as a surrogate for a preamble.
I am especially pleased by the NHS constitution occupying a prime position in the amendment’s attempt to capture the principles of the health service in England. The first two principles expressed in the NHS constitution must continue to suffuse the whole enterprise and its legislative underpinnings. The first principle declares:
“The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population”.
Principle 2 explains quite briefly that:
“Access to NHS services is based on clinical need, not an individual’s ability to pay. NHS services are free of charge, except in limited circumstances sanctioned by Parliament”.
Faith in those principles runs deep in our country, powerfully and, very largely I think, consensually. They deserve to be emblazoned at the top of this Bill through a clear reference to the NHS constitution. In fact, apart from the words “not the market”, the amendment before us could, I suggest, represent a common bonding for our deliberations, however fiercely contested will be many of the clauses to come, just as the sustenance of a comprehensive National Health Service free at the point of delivery is one of, or perhaps the most, tenacious common bondings of our people and our country.
Baroness Murphy
My Lords, one cannot help but be moved by the commitment of the noble Lord, Lord Hennessy. In view of the public discussion that has gone on outside this Chamber, we all welcome a recommitment to the principles of the NHS constitution. But I have a number of really serious concerns about the amendment as it stands. For a start, remembering back to the 2009 Act, the whole point about the NHS constitution is that it was not just a set of airy-fairy principles, it concerned how those principles were to be put into effect. To extract these crucial principles, which along with the noble Lord, Lord Hennessy, I wholly support, and put them separately at the beginning of the Bill is to confuse the issue and, I think, to leave us open to further legal challenges over what the NHS is about. The NHS constitution stands; that it must stand is reiterated in the Bill, and therefore we should not seek to water it down in any way.
The second part of the amendment again does not quite reflect what we have tried to do, as we discussed the development of this Bill, to ensure that the NHS is about improving quality. It is not about accepting quality, equity, integration and accountability as is; it is about continuous change leading to improvement. Again, I think that that is not reflected in subsection (2), which is very confused, and I really do not understand the phrase at the end, “not the market”. What does that mean, and how does it relate to the,
“person or body performing functions”?
The third subsection, about the primacy of patient care, is crucial. We want to see the primacy of patient care throughout the Bill. Again, however, as it stands, the amendment would rule out structural and financial reorganisations, for example to improve the formula for allocation of resources to local clinical commissioning groups. It would rule out the decisions that we want local groups of commissioners to make regarding reconfiguration. It would stultify the development of an improved health service. I really think that that is confusing.
As for the Nolan principles, I think that all of us would say that they are crucial. But they are in the Bill as it is, as they were in every NHS Act recently. Standards in public life are something that everybody who is in public service must be committed to, and they are in employees’ terms and conditions of service. These are desirable things, and I am very sympathetic to the desire to make a comprehensive statement of the commitment of all sides of this House to a universal and comprehensive NHS. However, this amendment is not it.
Baroness Jolly
My Lords, I do not intend to take an awful lot of your time with my comments. I agree with many comments made by my noble friend Lady Williams, and I share the anxieties expressed by the noble Baroness, Lady Murphy. To a certain extent I am bemused, because we have a perfectly good NHS constitution. It has been said that it is only three years old and indeed it is. It was a result of the work of the Labour Peer the noble Lord, Lord Darzi, and involved a huge cross-party effort. This is to be commended. This amendment does not match it in breadth or scope.
We are now in Committee and it is not sensible of us to prolong the debate. We have many, many days yet to go and we really need to move on and get on with the Bill. However, I want to finish by thanking the noble Baroness, Lady Thornton, for her compliments about our conference motions and the way in which our policy is made following votes by our members at conference. The second subsection of this amendment came from a motion to our conference last spring. We wanted the NHS to work for patients and not providers and as a result of this and the Future Forum deliberations, this was acknowledged. Furthermore the Monitor duties were changed to reflect this so that they now are about the promotion and protection of patient care. I really feel that we need to move on and get on with the Bill.
Baroness Donaghy
My Lords, I support this amendment for three reasons. I will be brief, bearing in mind the comments made by the noble Baroness, Lady Williams.
First, in a Question in the House today, the noble Lord, Lord Low of Dalston, asked for an inquiry into the nature and extent of commercial lobbying of Ministers. If it is considered bad now, I have a great fear that it will be an even bigger problem when we get to the commercialisation of the National Health Service. As a former member of the Committee on Standards in Public Life and a former acting chair, I regard it as a reassurance to have reference to the Nolan principles in this amendment. More importantly, I think that it will be a reassurance for the members of staff who work in the health service.
I want to draw the Committee’s attention to two of the most important parts of the principles: openness and accountability. We have already seen—certainly in my experience as a non-executive director of a foundation trust until a couple of years ago—phrases such as “commercial confidentiality” creeping into discussions about how we conduct our health service. How much more will that phrase creep in when the kind of proposals in this Bill become an Act?
Currently, research and knowledge are shared by the medical profession, both nationally and internationally. If you are involved in any way in higher education and medical research, you will see how important that is for the advancement of medicine generally. Unless we embed these principles in the amendment, I fear that they will be under threat and the efforts of our medical profession will be compromised.
Lord Rea
My Lords, I have spent most of my professional life working in the National Health Service. I have also worked in and observed other healthcare systems and have come to value the NHS all the more not only for its universality but for the high quality of its coverage. I admire it also for its economy of working. We spend considerably less on health per head of population than most other countries at a similar stage of economic development.
By and large, the NHS has conformed to the principles laid down in the amendment. Of course, it is far from perfect. Its bureaucracy, as the noble Baroness, Lady Williams, said, is sometimes inflexible. For example, the treatment of whistleblowers is often inappropriate. Internal criticism should be heard and acted upon and not suppressed, but this Bill is not necessary in order to correct that. The amendment is an important reminder to government at both national and local level of what the NHS stands for. Any action by government or individual staff should be taken with these principles firmly in mind.
Baroness Morgan of Drefelin
My Lords, there is nothing like suggesting to a House of Lords Committee that we move on to encourage one to stand up and contribute.
The noble Baroness, Lady Thornton, mentioned the debate that took place at the start of the Committee stage of the Apprenticeships, Skills, Children and Learning Bill, now an Act, in 2009. I remember sitting behind the Dispatch Box next to my then noble friend Lord Young listening to the noble Lord, Lord Hunt of Wirral, make a very convincing case for the Opposition on the need to set out a clear definition of apprenticeships and the importance of a well thought through, principled preamble. I remember listening to my noble friend take the Committee through a detailed and well argued explanation of how all those issues were carefully covered throughout the very long Bill. However, both Her Majesty's Opposition and the Liberal Democrats were united in saying that they needed to be stated clearly at the start of the Bill. They won the day and there that statement is in the apprenticeships Act.
When I saw the amendment of the noble Baroness, Lady Thornton, it made me think about all the important legislation of the past, and it led me to the Children Act 1989, which I am sure the Government are still very proud of. An important aspect of that Act is the principle of paramountcy, whereby the interests of the child are paramount in any decisions taken about their health and welfare.
Listening to debates on this Bill, I have felt genuine concern about how we resolve issues around conflict of interest. The relationship between a health professional —a doctor, nurse or physiotherapist, but principally a doctor—and their patient is based on an extremely high level of trust and is one of the cornerstones of our NHS, and I was wondering how the importance of that trust and that relationship could be incorporated in some principles. Have the Minister or the noble Baroness, Lady Thornton, thought about whether it would be appropriate to have a principle under which the needs and interests of the patient should be paramount when decisions are made about them? Obviously, there are a lot of ways of thinking about that from a legal perspective, but it is something that we need to be very concerned about. How is the conflict of interest to be carefully managed where a GP refers a patient to a service that they own and profit from? How can patients—whether as individuals or a population—be absolutely sure of the decisions being made about them, at every level throughout the system, including commissioning? It is very important that we think about the principles underpinning the health service. This is a very important debate.
The Earl of Listowel
My Lords, I am most grateful to the noble Baroness for this debate on the primacy of patient care. It is very important. All noble Lords may well agree that this is fundamental, so I hope they will forgive me if I raise one concern with the Minister, which has been raised by people who practise in the NHS. The constant changes to the National Health Service over many years, particularly in England, have undermined, to some degree, our efforts to deliver the best to our patients. It is something I am familiar with from speaking to child mental health professionals in the past. They have complained that constant change undermines their ability to make relationships with other professionals work effectively around the child. Also, they get to know a commissioner who then changes. It is a different area, but social workers have also raised with me the issue of local authority changes. I remember speaking to a local authority social worker on a Friday evening who was despairing at yet another structural change to social service provision within the local authority.
In its briefing to Members of your Lordships’ House on the Bill, the Nuffield Foundation also expressed concern at the constant changes to the NHS and the short horizons. One Secretary of State may make changes but then a new Government arrive and there is another upheaval. I recognise what the noble Baroness, Lady Williams, says: flexibility and changes are needed, but my sense from speaking to the professionals and expert think tanks is that there has been too much change over a continual period. This was reinforced in the briefing that the presidents of the royal colleges gave to Members of your Lordships’ House this week, in which the president of the Royal College of General Practitioners finished with a very powerful plea: “Please, give us some stability; please stop changing the NHS”. She particularly alluded to the experience in Scotland. If I remember correctly, she said that for about the same investment Scotland has better productivity. She lays this at the door of the fact that over several years there has been some stability within the health service there. I take this opportunity to ask the Minister whether, in future, he will keep in mind the need to allow important changes to bed down. Perhaps we could build a bit more of a consensus on what needs to be done, recruit and retain the best professionals on the ground and allow them to evolve the best practices. Then we will see better outcomes for our patients, with a similar input.
Lord Mawhinney
My Lords, the noble Lord, Lord Hennessey, started by reminding us that preambles have somewhat gone out of fashion. Personally, that does not bother me one way or the other: if there is value in a preamble, we ought to get serious about that value, whether or not it is a common occurrence. However, I want very gently to take issue with the noble Baronesses, Lady Williams and Lady Jolly. I do not think we should be rushing on; this amendment requires serious consideration, not least because it is headed:
“Principles of the Health Service in England”.
I have been in this place, at both ends, for long enough to know that if we nod this preamble through so that we can get on to the meat of the Bill, for 10 or 20 days in Committee, or whatever it takes, noble Members will keep reverting to the fact that we have already established the principles in the preamble and that will determine how we should proceed. That is not helpful, certainly not if we have nodded this through as a “God, motherhood and apple pie” type of procedure.
I was struck by the introductory comments of the noble Baroness, Lady Thornton. I liked her phrase “borrowed and blue”—that was very imaginative. Whether it was meant to detract or distract from the substance of the words we will never know, because she did not spend much time talking about the substance of the words. However, I put it to her: how can you have a principle when the person who is moving it says, “I am a bit worried about the words ‘not the market’ but, hey, we all know what it means”? The truth is that we do not know what it means and I hope that the noble Baroness, Lady Williams, will not take it amiss if I say that if this is borrowed from a motion to a Lib Dem conference, we are probably even less likely to understand what it means. We cannot have a principle when nobody knows what its words are actually saying, including the noble Baroness who moved them.
Proposed new subsection (3) talks about:
“The primacy of patient care”.
I am an extremely privileged individual: I have served in this building for 32 years, as a Health Minister for a few of those years. No matter who is in government and who is in opposition, I have never heard anybody promote a proposal on the health service that is not predicated on the words “the primacy of patient care”. It is one of those phrases that we all use to reassure everybody, particularly those who do not agree with us, that actually, deep down, we are all right when it comes to the NHS. I have done it; I see others in this Chamber who have done it in my hearing, and I say to the noble Baroness, Lady Thornton, that I do not know what it means as a principle. It has to have some meat attached to it to have any substance, which it does not.
Since I have taken issue with the noble Baroness, Lady Williams, let me now agree with her comment about the reference to structure. I can hear us nodding this through and then saying, when we get into the meat of the Bill, “Of course, we have already dealt with the principle that the structure must not be changed, so we cannot have this particular amendment and we cannot pursue this particular idea. Let us move on”. Therefore, I have serious reservations about this; not the principle of a preamble, but the substance of what it is we are being asked to accept and the lack of clarity in the amendment. My concern is that this lack of clarity will then be used, unhelpfully, to shape our detailed consideration of the Bill when we get to the principles and the meat—to which I look forward.
Baroness Finlay of Llandaff
My Lords, it has been said that if you do not know where you have come from, you do not know where you are going. It is important for us to remember what we are talking about: a nationalised healthcare provision that arose originally because there were people who could access no healthcare. We have a situation in this country that is the envy of the world: if you are seriously ill, by and large you will get treated well and, most of the time, to standards of international excellence irrespective of who you are, your financial means, your social standing or anything. That does not apply in other parts of the world.
Those of us who have spent any time in the US will have seen what happens to some people who are not covered. I will never forget a young black man I saw with a terrible cardiac condition. All the money had run out and he was dying in a hospital because there was no further treatment. I was a medical student then and it made me resolve never to practise privately, which I never have, and to do all I could to further the principles of the NHS.
I suggest that there is much merit in considering a preamble, as the noble Lord, Lord Mawhinney, has just outlined. This brief debate has shown that the wording of this preamble is not right—I am sure that the noble Baroness, Lady Thornton, will not be moving it today—but that there would be merit in taking it away and coming back to it at a later stage. Perhaps I am wrong and she intends to move it; I did not have that discussion with her beforehand. However, I suggest that there is much here to commend.
We have a country that is very worried about its NHS, which is much beloved because it is the universal insurance policy that everyone needs if things go terribly wrong and they lose their health. The NHS Constitution was universally welcomed because it set out simple principles. There is much merit in enshrining that at the front of the Bill partly because, as it is written now, it concurs with the NHS and the direction of travel, accepting lots of change, that we want to see. There is anxiety that this could be amended in future.
We have had scandals about bad patient care. We have heard about bad staff attitudes, things not being done properly and personal interest overriding the interests of the patient population. There is much to be said for looking at putting in the Bill the vocational role of patient care and the duty to the health of the nation for those who are well to prevent ill health where we can, maximise the potential of those who are ill and restore them as much as possible to quality living. In the delivery of that, everyone, wherever they are coming from, whether they are a state sector employee or a private commercial venture, should adhere to the Nolan principles. That very essence of how we care for each other in our society sets the moral tone for the whole of our society. The Nolan principles are, if you like, the minimum that we should require across the board.
There is the question of transparency and openness. Questions have already been raised during this debate about potential conflicts of interest for those commissioning who may also be providing. There is a need for transparency about financial transactions and other personal career interests that might be there—about family members working in different parts of the service, about where people’s thinking might be biased and distorted, and about where there may be a wish to cover up one thing or another for different motives but where transparency would serve the greater good better. Linked to that, of course, is openness.
There is much merit in stating up-front on the Bill where we want to go. Where the NHS has come from, starting before its foundation and then as it evolved, has served us better than the alternatives. We want to drive up care and we want to change. Much can be changed and made more efficient. Nobody is advocating fossilising the services we have, but the principles about what we are trying to do need to be in the Bill.
Lord Mackay of Clashfern
My Lords, in 1946, the then Government promoted the National Health Service. They did so in the National Health Service Act 1946. Section 1 of that Act states:
“It shall be the duty of the Minister of Health (hereafter in this Act referred to as ‘the Minister’) to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act”.
Section 1(2) states:
“The services so provided shall be free of charge, except where any provision of this Act expressly provides for the making and recovery of charges”.
These are plain, clear, concise words which completely incorporate the fundamental principles of the National Health Service, as they have done since 1946. What is more, these provisions are enforceable at law, as the decision quoted by the Constitution Committee shows. They are enforceable in law, clearly, easily, without difficulty.
The previous Labour Administration had many skilled Ministers in the Department of Health to my certain knowledge and I pay my warmest tribute to them. One of them was the noble Lord, Lord Darzi, and during his watch in this House the National Health Service constitution was promoted. As some of my noble friends have said, that was agreed by all parties. The noble Lord, on behalf of the Government, declined to put that in a statute. I questioned that, because if we are dealing with the constitution of the service, one would think that it should go into the statute that is the fundamental part of setting up the service.
The Act of Parliament incorporated a duty such as referred to in the first part of this amendment, to have regard to the constitution. Everyone in the health service had to have regard to the constitution. The Government declined to put that into legislation. When I asked the noble Lord, Lord Darzi, why that was, he explained that he did not wish the constitution of the NHS to become a plaything for lawyers.
Noble Lords will understand that that reason was not particularly attractive to me. On the other hand, the sense of what he was saying certainly was, and I accept that it was wise and is still wise. The obligation to have regard to the constitution is fundamental and remains. However, I do not believe that it is possible for us to provide a simpler, clearer and more effective preamble to the National Health Service Act at any time than that which was thought of by the founding fathers of the National Health Service in 1946.
I should point out that this is not strictly a preamble at all; it is a first clause in the Bill. However appropriate some of these sentiments may have been for a resolution at a party conference, they are not suitable for an Act of Parliament, in my respectful submission, because the provisions in an Act of Parliament should be enforceable. When we have such a clear constitution of the NHS and such a fine example in what was provided by the founding fathers, which is enforceable, I respectfully suggest that it is unwise to muddy the waters now. I embrace all the sentiments expressed in this draft amendment and hope that we will have them in mind as we go through our later deliberations. All the sentiments are very acceptable, with the exception of the one about the market, which I find a little difficult. However, I will not elaborate on that now.
I am extremely grateful to the noble Baroness, Lady Thornton, and the noble Lords, Lord Hennessy and Lord Owen, for discussing this matter with me yesterday. I greatly profited from that discussion. It took me back to the beginning of 1946 when I was a second-year student at university. I remember that one of the difficulties envisaged in the founding of the health service was the fact that family doctors—GPs—did not wish to be employed by the Government. Therefore, the constitution provided that the Secretary of State had to provide the service—he did that from time to time at the beginning in hospitals and so on—or secure the provision of the service. “Secure the provision” was, of course, the one operative for GPs. That has served us well. As far as I am concerned, the proposed constitution, however one appreciates the principles that it expresses, is neither as clear or precise nor as readily enforceable as what we have. I respectfully suggest to the noble Baroness that she might wish to consider that aspect.
Lord Peston
My Lords, I, too, support my noble friend Lady Thornton. I suffer from the disadvantage that it seems to me the amendments are totally clear and it is perfectly obvious what they are saying. I totally agree with them for one specific reason which noble Lords opposite will find extremely disagreeable; namely, that I believe that this Bill paves the way for the end of the National Health Service as it was founded and as we know it and have experienced it. The whole purpose of our deliberations in Committee is to try to save the National Health Service. I am not optimistic that we can do it, because the Government do not seem to be in listening mode on this Bill.
The noble Lord, Lord Hennessy, puts his finger on the main question here, which is the ethos of the National Health Service. If someone does not understand the difference between a market ethos and, if you like, a public service ethos, they ought not to be taking part in these debates, as the two are completely different. The purpose of a market ethos is to make money and perhaps then do good as a result. I refer to the famous Adam Smith quotation regarding the baker and the butcher and why they provide their services. However, that is not the nature of the health service. Noble Lords opposite cannot wriggle out of that.
Noble Lords may also find it disagreeable that the only reason I am alive today and addressing them is because I have had marvellous service from the NHS over the past few years in my time of need. That service was as good as any that one could pay for. I, of course, paid for it though my taxes, but you cannot buy a better service. That is the fundamental point, and noble Lords opposite cannot wriggle out. If they support the Bill and do not like these amendments, they are paving the way for the end of the service as we know it.
Lord Ribeiro
My Lords, I am grateful to my noble friend Lord Mawhinney for referring to the words, “motherhood and apple pie”, because when I first saw this amendment, that is the way it looked. When one reads proposed subsections (1), (2)—or parts of it— (4), (5) and (6), they seem pretty innocuous. However, in proposed subsection (2), we are talking about high principles, which none of us would disagree with—principles which crop up time and again throughout the Bill. Quality—something that the noble Lord, Lord Darzi, referred to in a speech a few weeks ago —equity, integration, accountability are all points that we will address in the coming weeks, and are fundamental aspects of this Bill. However, the phrase “not the market” is not a principle—it is a mechanism for delivering what one wants.
The noble Lord, Lord Peston, said that any form of market would turn the NHS into a privatised industry. May I remind him that during the time of the previous Administration, we had independent sector treatment centres? What were they if not an example of a market-driven industry? They were introduced—
Lord Peston
I was not a Minister in that Government, so I do not have to defend them.
Lord Ribeiro
At least the noble Lord recognises that it was something that happened, and that it was a market. It was deliberately introduced by the previous Government. Were it not for the fact that NHS consultants were excluded from working in that area, it achieved the objective it was designed to do, which was to reduce waiting list numbers. However, it was a market, so if we were to accept proposed subsection (2), we would effectively say that we must call an end to all forms of privatised healthcare provision that currently exist in the NHS. I think that noble Lords would agree that this would not be acceptable.
Proposed subsection (3) talks about restructuring and reorganisation. The noble Baroness, Lady Williams, addressed this very effectively when she said that we do not want to encapsulate the NHS in aspic, creating rigidity rather than flexibility. The previous time the House debated the health service, I made reference to the decision that had been made on Chase Farm. It had taken 17 years for it to be made. If we were to accept proposed new subsection (3), effectively every constituent of Chase Farm would have a very good legal reason to challenge why that reorganisation had taken place. While I am fully supportive of the idea in Amendment 52 of having the NHS constitution clearly laid out—we all agree with, understand and support it—I am not in agreement that the five principles as set out in Amendment 1 should be accepted in their present form. If it came to a vote, I would certainly oppose the amendment.
Lord Bichard
I have some sympathy with the suggestion that we should set out at the beginning of the Bill the values and principles on which the service is based. My difficulty is that I fear the amendment is not appropriate or adequate in its current form. Therefore, I will be unable to support it for reasons that other noble Lords have given, and for two others in particular.
First—and others may find this provocative—the NHS is still not driven often enough by the primacy of patient care. It is not, therefore, enough to say that the primacy of patient care will not be compromised by structural or financial reorganisations. We should surely be much more positively committed to the need to redesign services around patients, and I thought that that was one of the major purposes of the Bill. It is difficult to believe that in a modern world we can be content that people should stay in accident and emergency departments for four hours and longer. That is a question not just of resources but the way in which we design the service and the primacy we give to the patient. We cannot be comfortable that that is happening enough. I agree that we should not have more structural reorganisation, but that in itself is not enough. We should positively redesign our services.
The second reason why it is difficult to agree with this particular amendment is that if we are going to have a clear statement of values and principles, they should be clearly directed at the commissioning agent itself—the service—not to contractual providers. They should be built into contracts and specifications, and the service should ensure that these are taken seriously. I am afraid that the amendment seems to be muddled in that respect, and we cannot expect people performing functions to behave in a way that the commissioning agent is not specifying and requiring. Therefore, the values should be directed primarily at the commissioning agent.
I regret that I cannot support the amendment; I would like to see a clear statement of values early in the Bill, but this is not it.
Baroness Barker
My Lords, when I looked at the amendment that the noble Lord, Lord Hunt of Kings Heath, had put his name to, I was immediately taken back to the debates on the Mental Health Bill that many Members of the House worked on. I am sorry that the noble Lord is not in his place. I mention a phrase of his in that debate. I have some form as regards proposing that there be principles at the head of a Bill, just as he has a lot of form in resisting them. He and several of his colleagues spent a considerable amount of time resisting all attempts to have principles inserted into that Bill. When we were discussing that issue in 2007, the noble Lord, Lord Hunt, in reply to my noble friend Lord Carlile, said that,
“putting the principles in the Bill is not a constitutional problem, rather we are concerned about the practical impact of those principles”.—[Official Report, 8/1/07; col. 46.]
That for me is the problem with the amendment.
Various Members of the Committee have talked about the NHS Constitution. I am afraid that the consequence of selecting some parts of it may be that the noble Baroness, Lady Thornton, is unintentionally placing other parts of the NHS Constitution at a lower legal status. I want to defend the members of my party at their conference in Sheffield. When they voted on a resolution, they were not voting for legislation. They were passing some words in the form of a resolution. This section has been taken from a far bigger resolution. They were expressing their views, which were then taken forward into the Future Forum work. I would not condemn them for doing that. But I do not think that those words are now adequate to achieve what is intended.
A number of noble Lords have talked about openness and accountability, and the importance of the Nolan principles. Those are important. As we continue through this Committee stage, I want to look in great detail at how those principles are applied to the NHS Commissioning Board, and to clinical commissioning groups, because it is how those principles work in practice that is important.
For a number of reasons I cannot support this amendment. But I would think it unfair to characterise anybody who does not support it as resiling from these or any other principles. We do support many of them. We will return to many of them during further stages of this Bill, and I hope that we will make sure that some of them are passed into the legislation, but not this amendment in this form.
Lord Owen
My Lords, I support the proposed new clause. It is not perfect, but that is not the issue. What we are really debating is whether we want, at the start of this legislation, something that talks about the principles and values of the National Health Service. It will not be easy to find the right words. The noble and learned Lord, Lord Mackay of Clashfern, drew attention to some very fine words in the original NHS Act, and they might well find their place. It is not a preamble, but it has the spirit of a preamble behind it. It is very necessary.
Let me explain one thing. People know that I was a doctor, a medical scientist, and also a Minister of Health. But it is not so well known that I was for 15 years on the board of Abbott Laboratories—one of the largest healthcare companies in the world—and there will be many occasions in Committee when I will be dealing with conflicts of loyalties because I am still a shareholder. I just wish to state that.
It is also important to realise that I am not opposed to the market. Indeed, at very early stages in 1985, I was the advocate of the internal market. I must say I am ashamed of that advocacy now. So often the work that was done on an internal market is used to justify the external market that is the basic fundamental underpinning of this Bill, which I am afraid will become an Act.
Ten years old is a very impressionable age. My father, in 1948, said to our family that this was a day of freedom for him. He had voted Labour in 1945. He had been a general practitioner through the 1930s in the Welsh valleys, and he had never got used to charging patients. This was the day when he no longer had to charge patients. But he always said with a rueful smile that there were a few exceptions. One was the Gypsy encampment, which considered that a consultation had taken place only if silver had crossed the palm.
We all know there is a market and there always has been. People have talked about the independence of general practitioners, which has been fiercely fought for. But the interesting thing about this National Health Service legislation is that it was not only a Labour Government achievement. When I was on the Labour Benches I used to proudly claim it as a Labour achievement. Then when I worked with the Liberals and the alliance, I used to claim it was Beveridge. The truth of the matter is that if there are two outstanding people who can claim paternity to the spirit and values and principles of the NHS, they are Beveridge and Bevan.
There is a great wish in this country, wherever people are situated in the political colour frame, to keep some of these values in whatever happens to this NHS. I happen to agree with the noble Lord who spoke that this is a disastrous Bill. It will unutterably change the principles of the National Health Service, and I shall reflect that argument. I have not done so to date because I have tried to see a mechanism whereby the Bill can be discussed. Others will, with perfectly genuine motives, consider it an achievement and the right direction for the NHS, but I think that we ought to be able to agree on the values. I hope that, whatever happens to this amendment in a vote, we will not lose the basic spirit of trying to find a form of words that will underpin these principles and values. They are very important.
The Earl of Listowel
Is the noble Lord aware of the report commissioned by the Government and published last year, led by Sir Philip Green, which looked at improving government efficiency? He argued very strongly for improved procurement practices and, in particular, for using the collective strength of all government departments together to improve procurement, perhaps appointing two or three very senior civil servants to procure this. Does the noble Lord recall that, and does that not support what he has been saying?
Lord Phillips of Sudbury
My Lords, I shall not detain you long. I cannot resist—given that the noble Lord, Lord Owen, was in reminiscing mood—recollecting that my Welsh father was personally appointed by Aneurin Bevan to be responsible for the inauguration of the health service in what was then the county of West Suffolk. My infancy was taken up with traipsing around hospitals and surgeries in his wake. I am as totally committed to the National Health Service as any man or woman on earth. Indeed, one of my daughters was admitted last night as an emergency patient to an NHS hospital.
Perhaps I may echo the words of the noble and learned Lord, Lord Mackay of Clashfern, because I think that he spoke from great experience and with great wisdom. I am sorry that that flies in the face of what the noble Baroness, Lady Thornton, said, in what was one of the most radical charm offensives towards these Benches in the history of charm offensives. However, as others have said, the notion of incorporating resolutions of party political conferences into legislation is a short road to legislative anarchy. I want to make two points in relation to that.
First, I absolutely concede that an upfront statement of principles makes legislation more comprehensible and more friendly to the layperson. I do not deny that for a second, and that very much draws me to such a statement. But then one comes to the hard, unaccommodating realities of construing statutes. We already have here a Bill of 445 pages, with at least that number of pages to come in secondary legislation, with—as I counted the other night—DHS documentation in support of the Bill in excess of 1,000 pages. I put it to the noble Baroness that principles, however well drafted, may give even more room for manoeuvre and obfuscation to my profession. There is room enough already in this Bill.
If noble Lords do not know what I am talking about, I offer an example. There is no reference in the amendment as drafted to an absolutely fundamental principle of this Bill, which is the subject of an amendment in the name of the noble Baroness, Lady Finlay, the noble Lord, Lord Kakkar, and myself—namely equality of clinical treatment and care for NHS patients with private patients. That is but one example of an omission in the present statement of principles. I am sure that many Lords in other parts of the House could say, “What about this?” or “What about that?”. We could argue until the cows come home. All the while, as the noble and learned Lord, Lord Mackay of Clashfern, reminded us, we have that historic, catholic and satisfactory statement in the 1946 Act of what it is all about. Therefore, I add my voice, with a degree of reluctance, to the voices of those who feel that the amendment, although good in intention, might not achieve its purpose but sow inadvertent mischief.
Lord Newton of Braintree
My Lords, I begin a very brief set of remarks by apologising to the House, and especially to my noble friend Lady Williams and to the noble Lord, Lord Hennessy, for not having been here at the beginning of the debate. The reason is perhaps apposite and might help to calm down the noble Lord, Lord Peston; I was at an NHS clinic in Braintree at lunchtime.
On the basis of this debate and looking at the amendment, I am with my noble friend Lord Mawhinney and a number of other noble Lords who have no objection to a preamble or general statement of principle. I will come back to that in a minute. However, if we need one, this amendment is not it, as the noble Lord, Lord Bichard, said. There is a case for the Government looking at a possible preamble or broad statement of principle, partly because, in my judgment at least, the views that the noble Lords, Lord Peston and Lord Owen, expressed—which would lead me, if I believed that they were true, to refuse to support the Bill—have raised fears and concerns among a significant number of members of the public. If we can reassure them by a preamble or statement of principle at a proper time, we should do it.
My noble and learned friend Lord Mackay of Clashfern did us a service by going back to the founding statement in the 1946 Act. I say to the Labour Front Bench that it may need a bit of tweaking—I have not studied it in the way that my noble and learned friend has—but going back to the statement of principles on which the NHS was founded would give people that reassurance. For me as a Conservative, and no doubt for the Liberal Democrats as well, it would do a real service by assuring people that we are not about destroying the NHS but about making it better and more fully equipped to fulfil its initial objectives. I hope that my noble friend will look at what my noble and learned friend suggested.
Lord Alderdice
My Lords, I agree considerably with the suggestion of the noble Baroness, Lady Thornton, that some of us might have a sense of déjà vu about the setting down of a list of principles pre-Clause 1. She is right that it is what opposition parties tend to do—and the response, as the noble Baroness, Lady Morgan, pointed out, is that Governments tend to resist them. Her Government were no different from how I suspect the Minister will be in this respect. However, I hope that when Liberal Democrats and Conservatives in the past put down such amendments, they were a little more careful about the wording.
As a number of noble Lords who are susceptible to the notion of a statement of principles pointed out, the statements before us are not very well put. The first states that the health service,
“must have regard to the principles and values outlined in the NHS Constitution”.
I have no doubt that if this had come forward as a government proposal rather than an opposition amendment, the Opposition’s place would have been to say, “Only having regard to the principles and values? What about all the other aspects of the NHS constitution? Will they not be set aside now that we have a subsequent piece of legislation?”. Legally, that would be a perfectly legitimate point. The second one identifies a number of principles—quality, equity, integration and accountability —and then speaks of the market, which is not a principle at all. It is a mechanism, as my noble friend Lord Ribeiro rightly said. Indeed, the noble Baroness then pointed out that actually a little care was lacking in the setting down of the original words.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Baroness for introducing these first two amendments in our Committee proceedings. I confess that I approach them with a feeling of some nostalgia: a debate about overarching principles has been a feature of our Committee proceedings on a number of health Bills over the past several years, and I therefore understand entirely why the noble Baroness and other noble Lords opposite should have approached this particular Bill with a similar thought in mind.
Amendments 1 and 52, tabled in the names of the noble Lords, Lord Hunt and Lord Beecham, and the noble Baronesses, Lady Thornton and Lady Wheeler, seek to set out the key principles of the NHS. I am grateful to the noble Baroness, Lady Thornton, for explaining them so clearly. As regards their broad intent, I am sure she will be pleased to hear that the Government support most of these principles very warmly.
However, despite having confessed to a feeling of nostalgia on the Opposition’s general approach, unfortunately I have to let them down gently by saying that the amendments as they stand will not do. I suggest to the Committee that the various principles listed can be categorised into two groups: the unimpeachable and the unworkable. Unfortunately, even the unimpeachable parts are completely superfluous in legal terms. As we are in the business of creating statute—which, the noble Lords will understand, needs to be devoid of unnecessary verbiage—that does actually matter.
Let me start with what might be termed unimpeachable but unnecessary. I hope that I do not need to say again what I have already said on a number of occasions—that the Government strongly support the NHS Constitution. All organisations, including private bodies, already have a legal duty to have regard to the constitution when performing NHS functions or providing NHS services. Included in these principles is that:
“NHS services must reflect the needs and preferences of patients, their families and their carers”.
This enshrines the principle that the NHS is there for patients. Under the Health Act 2009, the Government cannot change the principles in the constitution except through regulations.
We have already made provision in the Bill for the NHS Commissioning Board and clinical commissioning groups to have regard to the NHS Constitution. Commissioners, therefore, are covered by the Bill. NHS providers, including foundation trusts, are already subject to this duty under the 2009 Act. We are not changing this. I am sure that it is unwitting on the part of the noble Baroness, but this subsection set out in Amendment 1 would actually do something undesirable; which is to restrict the group of people who must have regard to the constitution. At the moment, the duty applies not only to NHS bodies, and others performing statutory functions under the Act, but also to those providing services to the NHS under contract, including private providers. The amendment would appear to have the effect of removing these people from the constitution’s sphere of application. I cannot believe that the noble Lords opposite want this; and I certainly do not.
The amendment is also restrictive—again, no doubt, unwittingly—in referring just to the principles and values contained in the NHS Constitution. My noble friend Lord Alderdice was right to point out that it fails to refer to the rights and responsibilities laid out in the constitution, which many might say should not be seen as being of lesser importance. The amendment sends out conflicting, and therefore confusing, signals about the constitution.
Subsection (4) states that:
“There must be transparency and openness wherever taxpayers’ money is being spent, and all accountable individuals and bodies should abide by the Nolan principles”.
We do, of course, agree that transparency, openness and accountability must be general principles applicable to the NHS. This is why, under the new system, every NHS organisation will have its duties transparently conferred by Parliament, with the Secretary of State retaining ultimate accountability for the NHS. It is why we are providing for the boards of foundation trusts and clinical commissioning groups to meet in public, and it is why we have said that all NHS contracts will be published. As we will discuss over the coming weeks, I genuinely believe that this Bill will provide a far greater degree of transparency than current legislation about what the Government require of the NHS, and what is delivered in return. It is, I suggest, unnecessary to augment these tangible provisions with a generalised statement of principle—and unwise as well, because expressed as an absolute duty, it does not make allowance for those things which should certainly not be open to transparency and openness, such as patient confidentiality.
While I fully welcome the due regard paid by noble Lords to the noble Lord, Lord Nolan’s fine seven principles of public life, the suggestion that these must be set out as principles of the NHS for all bodies to abide by is unnecessary because there is already an expectation that all public bodies, including those of the NHS, should abide by the Nolan principles. My noble and learned friend Lord Mackay was right to remind us of something else. To put the Nolan principles into statute would, I am afraid, represent a fast route to a lawyers’ charter, something that the previous Government wanted to avoid when they set up the NHS Constitution. We have already made specific pledges that NHS bodies must abide by the Nolan principles. The Government said in the July document, Developing the NHS Commissioning Board:
“Subject to the passage of the Bill, the Board will be required to have a Chair and at least five non-executive members. Their key purpose will be to ensure effective governance, consistent with Nolan Principles, to hold the Board’s executives to account, and to contribute to the success of the Board’s key external relationships”.
In our response to the Future Forum, we said that:
“The authorisation process for clinical commissioning groups will ensure that they have robust governance requirements consistent with Nolan principles and are accountable and transparent. This will not be a one-off test: the NHS Commissioning Board will hold commissioning groups to account for this on an ongoing basis”.
It is not necessary to enshrine the Nolan principles in statute. They already have force and will continue to do so.
Subsection (2) of the new clause says that NHS services should,
“promote quality, equity, integration and accountability”,
which roughly paraphrases some of the principles in the constitution. It also overlaps or duplicates some of the general duties we have set out in the Bill, such as those relating to quality and integration. However, it adds the words “not the market” which is not a phrase that one might describe as being of luminous clarity. “The market” is a phrase which could mean all sorts of things. I take it that the noble Baroness does not mean that the NHS should never purchase anything at all from a private body or organisation in the marketplace or benefit from improvements in quality which derive from such providers. If she means the market for healthcare provision, as I think she does, that too would bring to a complete halt the process begun in earnest by the last Government which has led to patient choice in elective services. I know that the noble Baroness is not against patient choice, so it would be a pity if an amendment were to put that policy in doubt. The Government are absolutely clear, however, that an American-type free market in health services should not and will not happen in this country. I would simply point to the amendments made in another place which put this beyond doubt. The Bill now explicitly provides that Monitor’s role is to protect the interests of patients and the public, not to promote competition as if it were an end in itself. It also contains a range of safeguards against the use of price competition or any policy that might favour a particular sector of providers.
The market has a part to play in the NHS. It can enhance choice and drive up quality. As the noble Lord, Lord Darzi, said at Second Reading:
“The right competition for the right reasons can drive us to achieve more, work harder, strive higher, and stretch our hands and reach for excellence. It can spark creativity and light the fire of innovation”.—[Official Report, 11/10/11; col. 1492.]
Subsection (3) in the amendment refers to the primacy of patient care. We can all agree with the sentiment that underlies this: patients come first. I take the point made by the noble Earl, Lord Listowel, that change has been unsettling for NHS staff in the past. However, as worded, the amendment may have the effect of creating a presumption against any reconfiguration of NHS services, for the simple reason that all reconfiguration brings with it a certain element of inconvenience for patients, however temporary. If the NHS were prevented by concerns over whether it had complied with this duty from reorganising itself financially, it would not be able to extend the scope of the tariff, for example, in response to the creation of a new integrated pathway of care. Improved outcomes for patients were at the heart of our NHS White Paper and at the heart of this Bill: greater choice and patient involvement, continuous improvements in quality, reduced inequalities, and better integration around the needs of individuals are the objectives set out in the Bill with force and clarity. We cannot have a provision that acts as a block on all future change.
Baroness Thornton
My Lords, I thank all noble Lords who have taken part in this debate. It is a very useful start to the Committee stage and consideration of this Bill. I want to say to noble Lords who began their remarks by suggesting that somehow or other this was not an appropriate amendment to put down that this is the Committee stage. It is entirely appropriate to look at a preamble and principles that should inform the rest of the Bill. I want to thank noble Lords for all their remarks—particularly the noble Lord, Lord Hennessey, my noble friend Lady Donaghy, my noble friend Lord Rea and the noble Baroness, Lady Morgan, for their very wise words.
The noble Baroness, Lady Jolly, said the constitution is a good constitution. If that is so, why should it not be in the Bill? Indeed, at 80 minutes into this discussion, the noble Baroness also said that we might be wasting the time of the House; that it was not sensible to prolong the debate. I think the debate has shown the noble Baroness, Lady Jolly, that it was a discussion worth having. I hope that when the Liberal Democrats do not feel comfortable about things we propose from these Benches they will not suggest we are prolonging the debate.
The noble Earl, Lord Listowel, made very important points about the principles of trust and the principles that should underpin this Bill. I take comfort from the questions the noble Earl raised. I thank the noble Lord, Lord Mawhinney, for his good sense until he reached his conclusion, of course. There is nothing wrong with repeating good things in a Bill. In fact this House spends a lot of its time putting things into Bills that are repetition of what has gone before.
The noble Baroness, Lady Finlay, made a very wise speech. She said our NHS is the envy of the world and that is indeed true. She also made a very good point about the importance of the statement of principles and what it might achieve. We think that this is a good statement of principles, drawing on a variety of sources, and I shall probably test the opinion of the House on it. However, if we fail on this occasion, I should be very happy to work with the noble Baroness and any other noble Lord to find another form of words which we might bring back at a later stage of the Bill—indeed, the noble and learned Lord, Lord Mackay, might have given us the drafting.
The noble Lord, Lord Ribeiro, said that it was motherhood and apple pie. There is a mixture of messages here, but I actually think that motherhood and apple pie are really rather good. The noble Lord spoke about entering the market. As I made clear in my opening remarks, the part of the amendment which refers to the market addresses the priorities and principles that should be used to underpin the future of the NHS. If those priorities and principles are applied clearly, they are not the market in those terms.
I took some comfort from the remarks of the noble Baroness, Lady Barker, because she knows that we have been round this course on many occasions. The noble Lord, Lord Owen, prayed in aid Bevan and Beveridge, and I thank him for his support. To the noble Lord, Lord Phillips of Sudbury, I say that it is clear my charm offensive is not going to work on his Benches, which I regret. However, if he wishes to raise the issue of the number of pages in this legislation and its supporting documentation, he probably needs to address those remarks to the Minister and not to me.
The noble Lord, Lord Alderdice, misunderstood the point about the constitution. I do not know which light he thinks the amendment seeks to shut off, because we think that it provides us with a broad base of principles.
The Minister provided his usual forensic interpretation of the amendment. I had a great sense of déjà-vu, because all the arguments that he used against it were exactly those that I had heard my noble friends use against having a statement of principles or preamble in a Bill when they were Ministers.
Baroness Thornton
The noble Earl set up, and then knocked down, a series of Aunt Sallies about the market, about how the amendment would halt change, and about how it was too big, too small and too detailed. It is actually rather small. I understand the Minister’s position on this. We have a long way to go on this Bill and this is just the beginning of it. We do not see why passing the amendment will inhibit further debate or discussion on the Bill in its entirety. In fact, I know this House too well not to know that nothing will inhibit noble Lords from discussing the Bill in the detail that it merits.
Earl Howe
It is, my Lords, because Amendment 52 does not repeat the NHS Constitution. Ninety per cent of the principles are missing from it and we therefore move into a new world. The previous Government laid down very clear procedures as to what to do when a Government wished to change the principles of the NHS. That involves public consultation and so on. Does the noble Baroness wish to bypass all that?
Baroness Thornton
My Lords, this is Parliament. We can take a decision. It is not about changing the NHS Constitution. We are seeking to put some of the principles of the constitution in the Bill. We think that that is a perfectly proper thing to do. I beg to test the opinion of the House.
Lord Patel
My Lords, I shall just say something while I wait for my noble friend Lord Walton. My name is to Amendment 2, and I have no doubt that when my noble friend returns—I am glad to see that he has.
Amendment 2
Lord Walton of Detchant
“(c) in the provision of education and training of the health care workforce”
Lord Walton of Detchant
My Lords, I was locked out. As the spirit of reminiscence is in the air, I greatly enjoyed listening to the many impassioned speeches on the first amendment. I look back, as a fervent supporter of the NHS, upon the days when, as a medical student in 1944 and an officer in the British Medical Students Association, I confronted the then Minister for Health, Mr Willink, lobbying against the Act because I was pressed by the BMA. Subsequently, as I said at Second Reading, I learnt as a houseman what the horrors of the pre-NHS medical process were in the UK.
Clause 1 of the Bill, which inserts new Clause 1(1) in the National Health Service Act 2006, is very similar to what we learnt in the 1946 Act, which was so closely quoted by the noble and learned Lord, Lord Mackay of Clashfern. I am tabling this amendment with my noble friend Lord Patel because the wording in the Bill at the moment says:
“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and … in the prevention, diagnosis and treatment of illness”.
Those objectives cannot be achieved without improving the provision of education and training for the healthcare workforce—hence the reason for tabling this amendment with my noble friend Lord Patel. The other amendments grouped with ours come to a similar conclusion. The wording is different and so is the emphasis, but they all have the same objective: putting a requirement for the NHS to provide education and training for its workers into the Bill.
When the NHS began, it was recognised that a partnership needed to be established with the universities and the other higher education organisations that trained doctors, dentists and other healthcare professionals. In the original contracts of doctors working in the National Health Service, it was fully recognised that academic clinicians employed by the universities would devote part of their time to teaching and research, but would give clinical services to the NHS for about half their time. In return, it was also accepted as an article of faith from the beginning of the National Health Service that consultants working in the NHS would be required to undertake teaching, for instance of medical students.
The financial responsibility for training undergraduate doctors and dentists was that of the universities, but from the inception of the NHS it was made absolutely clear that postgraduate training of its specialists, dentists and, later, nurses was the financial responsibility of the National Health Service. That has always been the case. To that end, the NHS paid for and established postgraduate deanships in every region of the country. Those postgraduate deans continue, and supervise the training of specialist surgeons, physicians, dentists and more recently, to an extent, the postgraduate and continuing education of other healthcare professionals. Our purpose in tabling this amendment is to make certain that this responsibility is acknowledged in the Bill.
It is clear that government Amendment 43 reaches much the same kind of objective, but responsibility for training and education is so crucial that it should be highlighted in Clause 1. It is absolutely essential. Having said that, there are many uncertainties about which the Bill is lamentably silent. For instance, in what sense is postgraduate training of the NHS workforce enshrined in mechanisms in partnership with the universities? What will be the future of postgraduate deans? We understand that they are to be retained, but who will employ them? The NHS will be required to fund them, but where will they be placed? If they are housed in the so-called clinical senates, how many senates will there be, where will they be located and what will their responsibilities be in the provision of postgraduate education and training? Will their responsibilities take full account of the statutory responsibilities of the regulatory authorities, such as the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and so on? Will that be enshrined in statute?
Even more crucially, if certain NHS organisations are to be taken over by any willing provider—I am not saying that this will come about—what mechanism will be introduced in the Bill to require that those NHS bodies will still provide the facilities for education and training of the workforce? That is absolutely crucial. An exactly similar requirement is needed to make certain that commissioning bodies and the national Commissioning Board have a responsibility to maintain the high quality of education and training that has been such a feature of our NHS, in collaboration with universities and other higher education bodies, ever since the NHS was established. These issues are not included in the Bill and require to be included. I beg to move.
Lord Patel
My Lords, my name is added to this amendment along with that of the noble Lord, Lord Walton of Detchant. He has alluded to the need to include this amendment in the Bill. I consider that not only do we need it but that it is not strong enough. We may have to consider making it stronger. I say this because it is important to indicate on the face of the Bill that the Secretary of State has the responsibility to promote and secure a high-level of education in the whole of the workforce that delivers healthcare. I use the example of medical education and training but that applies equally to the training of nurses and other health professionals who are also regulated.
The current system of medical education and training—a model that is copied by many other countries and is widely respected—has evolved over many years. It is not something that was planned overnight and then executed. It has delivered well trained doctors who have improved healthcare. The system is complex and its essential relationships with different organisations and responsibilities are well documented. Only about 18 months ago, legislation was introduced which further changed the regulatory mechanisms for the training of doctors and nurses by making the General Medical Council the sole regulator of doctors’ training from entry to medical school to the day they retire, including postgraduate training, continuing professional development and revalidation. If we tinker with this, we run the risk of fragmenting it and making it inconsistent.
As my noble friend has already mentioned, under the GMC we have postgraduate deans, the royal colleges, the deaneries, undergraduate deaneries and the local hospitals where doctors are trained. These work together in a complex relationship to deliver high-quality medical education and training. The Department of Health has issued a consultation document, Liberating the NHS: Developing the Healthcare Workforce. Some of its proposals have caused a great deal of concern. If those proposals are implemented we run the risk of damaging what has been built up over many years. Adopting a localised approach to education, training and workforce planning to meet the short-term needs of employers will destroy the national training for a national workforce that has been developed over a long time.
There are many other concerns; for instance, the lack of clarity over the role of Health Education England. How will it hold education providers and commissioners to account? There are serious concerns about the continuing role of postgraduate deans, a very important group of people in the delivery and quality assurance of medical education and training. Uncertainties about the role of postgraduate deans are already leading to concerns about managing the recruitment of doctors into training in 2012. There is a lack of information about what part local skills networks will play and about the risk of serious damage occurring to workforce planning, and a lack of clarity about their governance and accountability. The training of doctors also includes training in research methodologies, as the noble Lord, Lord Walton, mentioned. Development of academic doctors is crucial. We already have a problem with recruitment to academic medicine. Therefore, training in research methodologies, postgraduate research and higher degrees in research is crucial. None of these is included in the Bill. They are not included because, we are told, there will be a second Bill. It might even be called the social care and health Bill as opposed to the Health and Social Care Bill. However, we are waiting for the responses from Future Forum, which is considering this. Then we will have the Government’s response, despite the fact that they have indicated that all the proposals in Liberating the NHS: Developing the Healthcare Workforce will need to be implemented by April 2012—the time is rather short. Perhaps the Minister will indicate when we are likely to see this Bill related to education and training. If there is not a satisfactory answer, we may have to consider putting a framework for medical education and training in this Bill.
Baroness Finlay of Llandaff
My Lords, I have two amendments in this group, but noble Lords who have looked at them will have noticed that they are almost identical. One of them has inverted commas in it. At this point, I ask the Committee to discount Amendment 8B because the inverted commas do not mean a great deal. However, I would like to take a moment out to pay tribute to those in the Public Bill Office, where this drafting error occurred, and I know exactly why. They have had unending patience, have been infinitely polite to everybody who has gone up there and have provided impartial advice when under enormous pressure. So if this is the only mistake they have made with my amendments, they have done amazingly well.
I would now like to quote from the report from Future Forum by Steve Field. In it he pointed out:
“The professional development of all staff providing NHS funded services is critical to the delivery of safe, high-quality care but is not being taken seriously enough”.
I am glad to see that the Government have also decided to put down an amendment providing that we should state on the face of this Bill the importance of education and training.
Amendment 8A is almost exactly the same as Amendment 6 except that it adds the words, “a nationally co-ordinated system”. The reason is that currently, the standards are set by deaneries, the royal colleges, the universities and the regulators. At the other end from the high-profile degrees and specialist competencies from the royal colleges, there are qualifications such as the NVQs, which have been used for training healthcare assistants. There has recently been much debate about the standard of healthcare assistants, but I think there is a foundation there that could be built on to raise standards across the board. However, it needs to be nationally co-ordinated rather than have lots of odd little bits of training in one particular area, because otherwise when staff transfer, the organisation of management of another area believes that they are adequately trained, when actually there is no national benchmark for that competency. That is why I put in the words “nationally co-ordinated”.
I turn to the amendment put down by the Government. I hope that the Minister will explain how those deaneries and those national co-ordinating bodies that set standards will link in. Will the national Commissioning Board and the clinical commissioning groups have to consider education and training in everything that they do? If they do, the deaneries will have a national planning function in conjunction with the royal colleges and specialist societies which set specific competency standards. I also wonder whether this government amendment, which talks about the health service in England, takes consideration of the NHS in Wales and Northern Ireland. If it does, how would that happen and, if it does not, what arrangements have been made with the devolved Administrations?
I should also ask whether the Secretary of State has a comprehensive duty. Will the national Commissioning Board and clinical commissioning groups have a duty to include education and training when deciding contracts and making commissioning decisions? If they do not do build in education and training right across the piece, will an appeal go to the Secretary of State?
In proposed new subsection (1) of the Government’s amendment, there is mention of,
“provision of services as part of the health service”.
Given the nature of the health service as we see it developing, am I right to understand that that would include all private providers, all voluntary sector providers and all public health and health protection arrangements? Am I right that any provider which does not then provide education and training would need to prove why they were exempt from providing it, if they have a contract for a specific service?
We heard earlier about the independent treatment centres and the sense that they had milked off some healthcare services but had not undertaken training and education. We hear now about specialist trainees in some of the disciplines. Orthopaedics is a clear example whereby a lot of shoulder and knee surgery is not being done in their training environment, so the trainees are not adequately exposed to the range of operations. Indeed, an orthopaedic surgeon contacted me about how she was crowded out in theatre by trainees desperate to watch her carry out a shoulder operation simply because they had not seen that operation done—whereas previously they had broader experience.
If the clinical care of patients is contracted out to private sector or voluntary sector providers, the clinical experience associated with providing that care, if it is high quality, will provide a fantastic education and training opportunity. If we are truly developing a healthcare workforce that will be comprehensive for the needs of the nation, it does not matter who owns the building or the service where that patient is being treated. If that is really high quality, there is much to be learnt. In all the years when I have asked patients if they minded students, postgraduates or whoever being present, there have been only two occasions when patients have said that they would prefer them not to be there—and they were for very understandable reasons. Everyone understands the need to educate and train, and the majority of patients understand that if the person looking after them is also teaching they are being held to account by the group that they are teaching.
Those are some of my questions to the Minister when he comes to speak to his amendment. I ask the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath, whether they see the use of the word “comprehensive” as a duty on the national Commissioning Board and clinical commissioning groups, and whether, when they talk about delivering NHS services, they are intending that private providers and public health are included.
My final point is: whichever of these amendments is agreed—and I have a sneaking suspicion that mine will not be top of the polls; but that is the way it tumbles—the different providers, whoever they are, need to contribute to the cost of education and training. I suggest that when determining a tariff, those who do not contribute to education and training on a particular part that they are providing should not receive the full tariff because they will be ducking out of part of the ongoing responsibility to secure the nation’s health.
Lord Turnberg
In speaking to these amendments, I am conscious that we are hamstrung by the fact that we have an education and training regulation or Bill to follow. So there is much to come. However, education is so important and so much an integral part of every aspect of the NHS that we must have some recognition of that in this Bill. It is just not possible to imagine a health service run by an uneducated workforce. I am obviously in support of all these amendments, and I am delighted that the Government have got their own helpful amendment in there, but there is much that remains to be clarified. I hope that noble Lords will forgive me if I go over some of these just a little. I should state my own interests of having spent most of my working life deeply involved in undergraduate and postgraduate medical education.
It is vitally important for the Secretary of State to take on responsibility for education and training in the NHS. It is how that responsibility is fulfilled that I want to focus on, by examining where the potential risks lie in this Bill to the system that we currently have in place and, indeed, where we might take advantage of the Bill to look for improvements in the way that we operate now. I will concentrate on medical education as the system I know best.
At the moment, GPs and hospital specialists are trained using a range of curriculums designed and delivered by the medical royal colleges. The colleges assess the trainees and set their exams, and all of this has to be approved by the General Medical Council. The GMC is the competent body set up under EU law that has to ensure that the training programmes reach the minimum standards set by the EU. It has to be said that in the UK we are way above those minimum standards. All of that is relatively straight-forward. But most of the actual delivery of all this training has to take place locally, at GP practices and hospitals. It is here that we have to be very careful as the NHS moves into its new mode of working.
At this level, the royal colleges have oversight of training through their own regional adviser network, while the postgraduate deans and their teams make sure that the conditions for training are right and that the trainees go through the programmes supervised by local programme directors. They are available in every major discipline and speciality. So there is a complex network for direct oversight of postgraduate education which currently works reasonably well.
However, it is the deans who carry the heavy responsibility of the budget for salaries for all of the trainees. They pay their salaries and they can, theoretically, withdraw funding for trainees if trusts fail to provide the right conditions for training. So the postgraduate deans are absolutely critical and yet their role is threatened as the strategic health authorities which now employ them seem to be disappearing. The deans have enormous power, and budgetary responsibility, but where will they go, and who will appoint and employ them now? I believe that it makes a lot of sense to think about them being employed somehow by the proposed new Health Education England when that is set up, but meanwhile it will be critically important not to lose them. Uncertainty about their future is not a good recipe for them to function effectively. They need some certainty now.
Leaving the deans aside for the moment, it is clear that the current system is dependent on close-working collaboration between them and the royal colleges, the GMC and, at the local level, the consultants and GPs doing the training. All this is going on in an NHS busily providing services for patients at the same time. This is the second threat to education, because it is increasingly evident that the service pressures on consultants and GPs are limiting their capacity to provide the teaching. They are increasingly feeling that the time available to teach is being eroded as service pressures build up. This is not a new phenomenon, but one that is more obvious now. The fear is that this will get worse unless—this is the key—we place a duty on the commissioners of the service for them to fund the extra sessions that consultants need to teach their trainees. One alternative might be for the postgraduate deans to have a budget for these sessions, but I suspect that this would not meet with much favour. I personally am not moved by it. It is a responsibility that we have to place on the commissioners.
Finally, I want to mention the public health doctors and their training in the brave new world. They are in some disarray, as I understand it from the public health doctors themselves. The directors of public health are to be transferred to the employment of local authorities. That makes some sense, at least on the face of it. But there may well be difficulties. They may find that the local authority terms and conditions are significantly different from the NHS terms. That may affect recruitment and retention. I have a fear of a return to the days of the medical officer of health, who was in the local authority, rather a rather sad figure remote from the medical community at large. However, rather more important is the training and education of public health doctors. It is quite unclear where the local authorities sit in relation to meeting the needs of those trainees in what is a vital medical discipline. It may be that all of this has been thought through. If so, it would be helpful to hear about it. The public health community certainly needs to know.
Meanwhile, I think that a better solution all round would be for the public health doctors to be employed by Public Health England and for them to be seconded to the local authorities. That might be more satisfactory all round, and it would give some security to the education and training of this key professional group.
I have not spoken about nursing education, not because it is not important—it clearly is—but because we are coming to it later in the Bill, and at least some aspects of nurse training and education will come in later clauses. I am sure that we will return to that. For the moment, I want to support this group of amendments, including that of the Government. But it seems entirely possible, I fear, that there will be further amendments at a later stage to try to tease out some of the issues I have been discussing.
Lord Ribeiro
My Lords, I thank the noble Lords, Lord Walton of Detchant and Lord Patel, for introducing this amendment. It highlights not only the importance of education and training in advance of the report that we will receive later in the autumn from the Future Forum group, but the fact that the Government have responded with an amendment of their own. That identifies the importance of bringing it on to the face of the Bill, so much so that it is right at the very beginning of Part 1. It is one of six duties that the Secretary of State now has to perform. That is very important.
It is quite understandable in a Chamber such as this one, full of doctors, that we tend to overemphasise the importance of medical education. As the noble Lord, Lord Turnberg, rightly said, nursing will be discussed later. However, it is not just about nursing. My wife is a physiotherapist—there are physiotherapists, radiographers and other healthcare workers as well. That is why the Government’s amendment talks about education and training without qualifying exactly which areas we are discussing. It is important that we bear that in mind.
The noble Baroness, Lady Finlay, I think, referred earlier to the independent sector treatment centres and the lack of training in that area. I must declare an interest as a past president of the Royal College of Surgeons. I had countless negotiations with the Department of Health to put into place a requirement for independent sector treatment centres to be able to train. The big issue was that all the surgeons and the ISTCs were overseas doctors. No UK doctors were allowed to train. We asked for a way in which we could introduce NHS consultants into what was effectively spare elective capacity. I fundamentally believe that we must separate emergency and elective surgery to produce the best-quality care for patients.
As a consultant, I would regularly do an out-patients’ clinic at Basildon hospital on Mondays. If I was also on call, as I sometimes was, I could be told that there was a patient in the emergency department who needed urgent treatment. That would ruin my out-patients’ clinic because I would have to go to theatre and sort out that patient. Our last assessment showed that 64 per cent of the general surgeons in Great Britain and Ireland have a responsibility to be on call while they are doing elective work. If you have that degree of commitment to doing two things, you cannot provide the best possible care for your patients. If NHS consultants could structure their work so that it was possible to work in a centre which was perhaps in the hospital—there are a few hospitals, including one in Nottingham, with elective centres within the hospital—or perhaps outside, they would be able to take their registrar and SHO to the independent sector and they would be able learn how to carry out the surgery.
Baroness Finlay of Llandaff
Perhaps I may ask for clarification from the noble Lord. I am not sure whether he is advocating that the duty in the government amendment should or should not be on every provider, whichever sector it is in. I tried to make it clear that I felt that the duty to provide education should be on everyone who provides patient services. I was hoping that the Minister would clarify that that was what was in the Government’s mind, so that history—what had happened before—could not be replicated.
Lord Ribeiro
I accept that point, although it might be difficult to implement when you consider the third sector and the voluntary sector, which may not be in a position to undertake education and training. That is a point to bear in mind.
Baroness Finlay of Llandaff
Forgive me but, as someone who works hugely in the voluntary sector and is a patron of many of the healthcare providers, perhaps I may point out that they carry out a great deal of education. An example is Marie Curie running NVQ courses for care assistants across the whole country. They are trying to drive up the standard of care given by people who are absolutely not at the medical end but whose care is critical to the quality of service that patients receive.
Lord Ribeiro
The noble Baroness makes her case but there is a wide spectrum of medical provision, and the question is whether this could be applied to every single provider. I am not clear about that but perhaps the Minister will be able to address it.
Returning to the question of training, I believe that through the Bill there is an opportunity, perhaps when the contracts for some of the independent sector treatment centres are up for renewal, to give some serious thought to whether these centres could provide the extra capacity that the NHS desperately needs if it is to go forward with the functional separation of emergency and elective care. I am of course talking about surgery and I recognise that that is a special case. None the less, we come from a history of one type of surgical provision to the situation in this Bill. If we are talking about quality as the indicator of the outcomes that we are looking for, it may well be possible to achieve this by utilising the ISTCs for NHS consultants. I shall give way if the noble Lord wishes to speak.
Lord Winston
I had no intention of interrupting the noble Lord. I merely thought that he was concluding his remarks and I was going to follow.
Lord Ribeiro
I take the distinct hint that it is time to conclude my remarks. I merely wish to say that we have an amendment in the Government’s name. It may well have been prompted by noble Lords introducing their own amendment, but the fact is that it is now there in the Bill.
Lord Winston
My Lords, I was interested to hear that the noble Lord, Lord Ribeiro, thought that the Chamber was full of doctors. I suspect that if we were discussing a legal matter, it would be full of lawyers, or if it was a matter relating to the City, it would be full of industrialists and so on. It depends on the nature of the Bill. It is very good that the Chamber is currently full of doctors because, like the noble Lord, Lord Ribeiro, we can give special credibility to the discussions and amendments that we are trying to tease out. It is a pity that there are not more members of the nursing profession in the Chamber, as well as others who are involved with healthcare and its wider applications.
Lord Winston
Perhaps I may be permitted to tell a very minor story. In the 1960s, I was in an NHS teaching hospital out in the sticks of Essex. It was certainly not a university hospital. I was a junior registrar in training and I had been supervised pretty carefully by a remarkable surgical colleague in his sixties, Mr Sandy Crawford, who was my consultant. One night, I rang him up at about two o’clock in the morning. It was a very cold night and it was snowing. I said, “I think this woman needs an emergency caesarean section”. At the other end of the phone came the reply, “Eh, Robert, do you think you’d like to do it?”. I said, “Well, I’ve not done a caesarean section without supervision before”. He said, “Why don’t I just come in and sit in the surgeon’s changing room while you’re doing the operation. You carry on and I’ll drive in”. That is what he did. When we had done the operation, which went perfectly smoothly, and delivered the baby, at about four in the morning he poked his head round the door of the theatre and asked, “Robert, is everything all right?”. I said that it was and he said, “Do you think I could go home now?”.I told him that he could. The following morning I told him that I thought it was very good of him to have come in to supervise me in that way. He said, “Training, which I think is important, is part of my responsibility as a member of the National Health Service”.
I think that here we are talking about the ethos of the Bill, as was the case with the previous amendment. I had some problems with that amendment because I felt that the Minister had demolished some of the arguments very well. However, here the issue is different. The noble Lords, Lord Walton and Lord Patel, have made very powerful points about absolutely embedding training in the Bill. That is of increasing concern, as the health service may become more fragmented and any willing provider may end up doing surgical procedures such as the ones on which I learnt. I am sure that the noble Lord, Lord Ribeiro, will agree. Doing a routine hernia, for example, within an academic environment was of great advantage to me, as I was able to learn how to operate and handle tissues in a general way for other procedures. One problem is that, because it is more efficient, willing providers may end up streamlining those sorts of procedures outside an academic environment, and that training experience will be lost.
I have worked in America, Belgium, Australia and one or two other countries. I spent a year in Belgium. I can tell your Lordships that the training, and commitment to training, in some of those other countries is quite different. We recognise that we have something rather special and unique in the academic environment in this country. In fact, it is not just two jobs that we do as consultants; in my view, it is four jobs. They include delivering the best possible clinical care that we can, but there is also the question of doing research in the academic environment, which is quite different. I know that the Minister agrees that we need more clinical research to improve the translational element which is so critical in our National Health Service, but there are two other areas which are different in many ways. One is teaching, which is different from training. Training is the ability, for example, to take a surgeon through a procedure and learn not to interfere when he or she might be making a minor error which will not damage the patient in any way or jeopardise the patient’s care. In my view, that requires a different kind of judgment compared with training someone in the scientific basis of a procedure or the physiology of the patient undergoing the pathological condition.
At the heart of this is an issue which was briefly touched on by my noble friend Lord Turnberg. One concern is clearly how we appoint people to the health service—particularly nurses and doctors. If we have that ethos, which is stated clearly on the front of the Bill and very solidly within the Bill, we must have in mind that in appointing new people to the health service we must consider not merely their ability to do the job well but how they communicate skills. It is widely felt by the public that sometimes many of those aspects of communication are not well served, both in teaching and in communicating with patients. I hope that the Minister will agree that there is a very strong case for considering the points that have been raised by those in whose names these amendments stand.
Lord Mawhinney
My Lords, it is hard to think of any group of people in this country who have had the opportunity to listen to six such distinguished medics talking about what is in the best interests of patients and the common good. It has been a privilege to listen to them all. I am conscious that I am not remotely on the same level as they are, although in a previous life I spent three years teaching medical students at the University of Iowa, 19 years teaching medical students at the Royal Free Hospital School of Medicine, and did a bit of radiography student teaching on the side. So I have some sense of the importance of the issue that we are discussing. I have a personal sense of its importance because, since I stopped teaching, at least two of those who I taught have subsequently offered me healthcare.
I am pleased that the Government have recognised the importance of education and training, and have tabled their own amendment. If there was any doubt about it, the six speeches that we have had thus far would have removed it. We spent some time in the debate on the previous amendment talking about the primacy of patient care. It does not make a lot of sense to talk about the primacy of patient care unless you have an education and training system that gives substance across the many activities that constitute our health service. Education and training are the sustainers of the importance of the primary care ethos.
My noble friend is in a slightly difficult position. If I understand the circumstances correctly, there will be more difficulties coming on education and training. The Government set out to produce an almost comprehensive re-evaluation of the health service. That was always a big ask. Here we are on day 1, and we have already discovered that that big ask is probably not going to be delivered in quite the way to which the Government aspired. I hope that my noble friend will not take the view that we will agree his amendment unadorned and wait for the next Bill that might come along. It is important that there should be some more substance to the Government’s amendment than that which presently exists; welcome though that is.
My noble friend has the privilege of having not only the Department of Health to advise him, but, as we have heard, international experts in this House, who I am sure will also be willing to give their expertise and experience to him to help draft what might also be helpful in a government amendment.
I finish with two very practical points. First, I absolutely agree with the noble Lord, Lord Winston, about the importance of communication. It is great that the medical profession know what to do to the best of their ability, but if they cannot convey that to the patient, that in itself constitutes a problem. I hope that my noble friend will think about that. The second point is something that I have raised in this House previously. I cannot be the only one who is concerned at the number of newspapers stories about patients going to see their GPs, to be told “You’ve got the flu”, or “You’ve got indigestion”, and within days they are dead because they had cancer, and nobody even identified it. That is a very good example of why training and education is so crucial. I give the Government high marks for their amendment, but I hope that my noble friend will be able to assure us that he can go a bit further.
Lord Davies of Stamford
My Lords, I think I am the first person to speak in this section of our proceedings this afternoon who is not either a doctor or a specialist in some branch of science very close to medicine—in the case of the noble Lord, Lord Mawhinney, biochemistry. An enormous strength of this House is that we can bring to bear such expertise and personal knowledge in our proceedings on a Bill such as this, and it greatly adds to our credibility in the nation as a whole. Equally, I am not a Platonist in any sense. It would be a disaster for democracy if the only people who took part in debating and determining legislation were those with a professional background or current professional involvement in the field concerned, so I make no apology for speaking.
It has been something of a tradition so far this afternoon to say a few words about one’s personal or family backgrounds in the field of the NHS. I will briefly follow that tradition. I am the third or fourth person to say this this afternoon, but my father also was a GP in the NHS, for 40 years, and an enormous believer in the NHS—he actually qualified a year or two after the NHS Act came into effect. I think that he believed that the NHS was a sacred institution, and I probably inherited some of that sentiment. His great political hero was Nye Bevan. Although he came to believe that something of a mixed economy, both on the supply and demand side, was necessary in the NHS—because otherwise great resources which were available to it would no longer be available to it—he avoided taking on private patients during his whole career. This was on the grounds that if he did not give them a better deal than his NHS patients he would be cheating the private patients; and that if he gave them a better deal than his NHS patients, he would be cheating his NHS patients. He was not prepared to put himself in that position, although of course he did treat his partners’ private patients when they were on leave. That says enough about my family background in this area.
The matter of education and training is fundamental to the NHS—and has been, as the noble Lord, Lord Walton, and others, have pointed out. It has been a symbiotic relationship since 1947. It has been absolutely understood that medical teaching and education were inextricably linked with the delivery of NHS medical care; not just the formal requirement on consultants in teaching hospitals to teach—obviously part of the quid pro quo for their prestigious appointments—but right through the system, including in non-teaching hospitals. This includes the obligation to take on junior doctors and train them properly—the anecdote of the noble Lord, Lord Winston, went to the heart of that tradition; the very fine ethos of the medical profession to take on trainees right through the primary and secondary systems.
That has been the case for all that time since 1947. It is so enormously important that it should continue. Quite clearly, education and training are an existential requirement of the NHS. What has also been in place since 1947 and which has been accepted by successive Governments—I am not sure to what extent it is practiced at the present time—is a willingness to plan forward, to look and see if one has to make assumptions —one is never going to be exact about this. To look and see, taking account of doctors coming from abroad, of British-trained medical students who then want to emigrate; what kind of numbers we are going to have in the future, what kind of numbers we might need, and to modulate the supply against that anticipated level of demand. That is called planning, a word which I know is a very negative word for the present Government. I do not know whether that itself has had some influence on the point I am coming to.
The astonishing point I now come to is that education and training were not originally considered by the Government to be an absolute primordial, elemental responsibility of the Secretary of State and of the NHS, going forward. We had obligations in the Bill as it was originally presented to us from another place, for the Secretary of State to ensure that there was proper consideration given to removing inequalities, to maintaining common autonomy, to encouraging the promotion of research, which is obviously very important, and I commend the Government for that; and to promote public health—again enormously important, and I again commend the Government for that. There is nothing at all about education and training. It was an afterthought.
Baroness Tonge
I do not have an answer for the noble Lord, but I am as horrified as he is that education and training were not in the Bill from the beginning. I had not noticed that the words were not there and I was incredulous when I saw the amendment. I could not believe it. Would he agree that it would be better, in case there are other huge omissions that at this late stage we have still not spotted, if the Bill were withdrawn immediately and rethought?
Lord Davies of Stamford
I certainly agree with the noble Baroness on that. If I have to speculate again, the only hypothesis that I can credibly come up with is that the education and training requirement was not initially in the Bill because the whole thing is a hurried, makeshift, politically driven, ill thought through and frankly almost frivolous exercise—an appalling way to treat a great national institution of which we are all so proud.
I return to the publication of the White Paper in 1944, to which the noble Lord, Lord Walton, referred. He even lobbied the Minister at the time, Mr Willink. It was before I was born and it is wonderful to see the noble Lord in such great form all these years later, defending the NHS. It was an all-party achievement. I am afraid that the Conservative Party in its modern form no longer has the deep commitment to what many of us feel is a matter of national consensus that we hope will continue.
I repeat that this is in no way a personal attack on the Minister: far from it. He did everything that he could to remedy the situation. However, the Government right through the election campaign were against any kind of top-down reorganisation of the health service. They come out with a half-baked Bill, are immediately attacked from many sides and make concessions. People continually run to David Nicholson and say, “You’d better redraft this or that, we haven't thought about this, we have a problem here, what do we do about this?”. David Nicholson dashes off something on a piece of paper and we get another amendment. It is not the way to legislate on any serious matter. It is certainly a lamentable way to legislate on our great National Health Service.
Lord Kakkar
My Lords, I strongly support the amendment in the names of the noble Lords, Lord Walton of Detchant and Lord Patel. I remind your Lordships of own interest as professor of surgery at University College, London. I point out that of all the Members of your Lordships' House who have a background in medicine, I completed my training most recently, some 12 years ago, and am acutely sensitive to the fact that training is vital if we are going to deliver high-quality care. I still remember vividly, and benefit from, the instruction that I was given in my training as a general surgeon.
The purpose of the Bill is to ensure that we provide the highest quality healthcare, achieving the very best outcomes and always putting the interests of the patients of our country at the centre of everything that we do. For this purpose, we need to achieve two fundamental objectives. We need high-quality education of undergraduates to prepare them properly for a life in any of the healthcare professions and to inspire them to be excellent doctors and other healthcare professionals. We must also ensure in postgraduate training that we train future doctors and other healthcare professionals to develop the skills that they require to deliver the best for our patients, and the judgment to apply their skills in an appropriate fashion.
Our system of training is so good and respected throughout the world because it is clinically based. Throughout, those who are fortunate enough to be taken on for training in positions in the National Health Service are exposed to, and have the great privilege to be involved in, the care of the patients of our country. However, the delivery of education and training is a hugely complex issue. Not only must we have the matter in the Bill; it must be dealt with in detail. Notwithstanding the fact that Her Majesty's Government propose to introduce a further Bill to deal with education and training in healthcare, which will be hugely welcome, in the intervening period we must recognise that the delivery of healthcare is integral to the delivery of education and training.
I give an example from training in surgery. Consultants who wish to take on training responsibility have to be trained to do so. They must make time available to have the training to become a trainer. They need to organise the delivery of their clinical practice in the care environment in which they work in a thoughtful fashion, to provide training opportunities for their trainees. Frequently that will mean that the utilisation of NHS resources is less efficient than if the facilities and sessions were delivered purely by a consultant. Training takes time; trainees work at a slower rate; they interrupt what they are doing to seek guidance; and they must be provided with the confidence to become good practitioners.
Beyond that, we need to release those working in our healthcare systems to support medical royal colleges and other professional bodies to set and then supervise the standards of training that must be applied across the National Health Service. That takes them away from clinical practice and again makes the utilisation of the resource potentially less efficient. For trainees, we have to provide an environment that supports training. This is complex, because it requires not only release from service commitments—again, this has an impact on resource utilisation in healthcare systems—but time within the delivery of clinical practice to learn to develop judgment in a fashion that is less efficient than it would be if the clinicians had been fully trained as medical or other healthcare practitioners.
For this reason, I strongly support the amendment that education and training must appear in the Bill as a commitment, an obligation on the Secretary of State for Health. We must also spend more time dealing with the issues that might present problems between the enactment of the Bill and the subsequent appearance of a future health Bill that deals specifically with education and training.
Lord Warner
My Lords, I support Amendments 2, 6 and 44 in particular in this group. However, I am sympathetic to and support the other amendments. The debate is going downhill. Following the eminent doctors, noble Lords will now get the perspective of a jobbing ex-Minister who was responsible for workforce matters in his time. What is particularly attractive about this set of amendments is not just that they put education and training of staff in the Bill, but that they bring a proper national perspective to this set of issues. I want to talk more about that national perspective because it is often lost sight of as people get very concerned about the responsibilities of employers at the local level. Of course, employers at the local level have a lot of responsibilities. They have the responsibility to ensure that the people they appoint to particular jobs have the skills, expertise and character, and can actually do those jobs. However, the sphere of operation of many of these local trusts, or even GP practices, is quite small geographically and they simply do not have the perspective to do the kind of planning that is required.
My noble friend Lord Davies said that planning is a dirty word. I am a child of the 1960s and was brought up to think that planning was rather a good idea, and I still think it is rather a good idea. Trying to work out what you want to do in the future seems quite a sensible way to run a National Health Service. We need to accept that there is a national role for the Secretary of State and the Department of Health in workforce planning and development. If you do not believe me, it would be worth going back to some of the Health Select Committee reports on this issue under the previous Government, which are very condemnatory of historical approaches by the Department of Health to doing good workforce planning across the NHS.
The issues that arise in this area for a Minister sitting in Richmond House are not ones that you can leave to employers at the local level to deal with. These issues are of long-standing provenance, such as the relationship between doctors from other parts of the world coming to work in the NHS, immigration law and the European working time directive, which has had a massive influence on the way doctors work. We cannot expect local employers to sort these issues out. We also have other big issues to consider; for example, revalidation of health professionals to ensure that they can and do keep up to date.
Another area where the previous Government have a lot to be proud of is the development of a range of sub-medical professionals who could take on jobs to relieve doctors to do more significant work. A good example of this was emergency care practitioners in the ambulance service, where totally new groups of people were brought in, who turned the ambulance service, if I may put it this way, from being just a taxi service to a hospital into a service that had people who could keep patients alive until they got to the hospital. We have a good tradition of developing those areas but in many cases, after a lot of good pilot schemes were introduced by particular local employers, the NHS was reluctant to go to scale. Nurse prescribing is a very good example where we trained lots of nurses but local employers did not always use them to do the job they had been employed for. You need some national perspective to tackle some of these areas.
I now want to say a few words about the much-maligned strategic health authorities. It has become fashionable to say that they were just bureaucratic empires that did not do anything terribly worthwhile. I am still proud that I set up 10 SHAs. They did a good job. The Government will find that they will need an intermediate tier between Richmond House and clinical commissioning groups and local trusts. No one has run the NHS since 1948 without an intermediate tier. The strategic health authorities were the hosts; they worked with the deans and helped to do some of the workforce planning and development in this area. They were the people you could rely on if you needed to ensure that there were enough training places at the local level for the next generation of doctors to secure their specialist training. If you do not have some capacity at that level, you will end up with the really rather difficult problem of how to find the training posts for the next generation of doctors to undertake their specialist training.
Lord Ribeiro
I should just like to acknowledge that the references that I made earlier were to wave 1. I fully recognise and appreciate the work done by the noble Lord, Lord Warner, in trying to get a training contract with the private sector. However, there was a determination on the part of the Government when ISTCs were first introduced to keep the NHS consultants and trainees out of those centres.
Lord Warner
I ought to make clear that I was not launching an attack on the noble Lord, Lord Ribeiro, with whom I had an excellent relationship as a Minister when he was president of the Royal College of Surgeons.
I finish by saying that although we are making progress on this Bill by having amendments of this kind early on, it is important to realise their limitations. A number of noble Lords, particularly my noble friend Lord Turnberg, have raised a whole raft of issues which still need to be grappled with. This may be the first of a number of debates we have on the issue of education and training as we try to strengthen the Bill in this area.
Baroness Emerton
My Lords, I rise as the one nurse here. The debate so far is music to my ears but it would be even more so to the professions. When the Bill was published there was great concern and great disappointment that we had to wait for education and training to come as a further step in the White Paper and after this Bill. They see, as I think every professional here sees, that education and training is a fundamental basis for ensuring the primacy of patients.
This Bill gives an opportunity to look at the future of health and social care and to bring in integration and holistic care, as was pointed out at Second Reading. To do that, we have to look at the education and training of all healthcare professionals, and the holistic approach from primary to secondary and tertiary, back to primary and community care, and to work alongside social care.
One of the things that we particularly need to address is the commissioning of the workforce in the future. The noble Lord, Lord Warner, has mentioned the strategic health authorities. I am sure that we all have comments against the strategic health authorities, but one of their functions was to engage in workforce planning. At the moment, it does not seem at all clear how the commissioning will be for the future workforce of healthcare professionals. This will be a great issue that needs to be addressed urgently because we all know that education and training is a three or four-year process—longer for doctors. It will need to be addressed immediately.
I want to support the amendment tabled by my noble friends Lord Walton and Lord Patel, proposing an overarching responsibility for the Secretary of State. I am sure that we will have certain other amendments, which have been already mentioned, and future debate. I would just say how urgent it is that we get something in the Bill to reassure the professions that education and training are essential for the primacy of patients.
Baroness Jolly
My Lords, it seems that we are now getting an outbreak of agreement that there should be a duty on the Secretary of State regarding education and training in the Bill. This is to be welcomed.
The noble Lords, Lord Mawhinney and Lord Kakkar, put it really well, and I will slightly paraphrase what they said. The delivery of high-quality patient care is absolutely predicated on quality training. It is also critical, however, that standards are set, maintained and monitored, not only for doctors and nurses—we have heard a lot today from very eminent doctors—but for allied health professionals.
There will, however, be a plethora of local healthcare providers: some within the NHS and some outside. We are anxious to ensure that the local responses to the delivery of training will meet these standards. We hope that proper checks and balances will be put in place to give some sort of national oversight on this. The noble Baroness, Lady Finlay, alluded to this in her remarks. I was going to carry on by giving a couple of examples about the need for co-ordination across providers and talking about these independent treatment centres. I will refer only to phase 1 and not to phase 2; we will have got it right by then.
There were complaints, certainly in my local district general hospital, that doctors were seeing only quite complicated operations and not standard ones. It was to do with hips there, and we have already heard about elbows or shoulders elsewhere. Similarly, the noble Lord, Lord Winston, cited hernias and I have a hernia example, which I shall not share with the House.
With this Bill, there is a wholesale need for a total change of culture within the NHS about the way we work. If we put patients at the centre it will create a huge need for training. It will be one-off training in the first instance but it will also need to be ongoing. This is something that I had hoped the Future Forum might be considering as part of its deliberation.
We are assured that the Government are keeping deaneries in place at present, but we share the anxiety of some of the royal colleges about their future. I have to repeat what others have said—and I heard it only this morning: there really is anxiety about this second Bill. The first assurance was that it would come in the next Session but now organisations are worried that the delay might be even longer. Therefore, we need something from the Minister that will help to focus people’s attention and give them confidence that things are in place.
I have spoken to universities and other providers of training. They need reassurance and certainty, too. They need to plan their staffing and, in this, they form part of the health economy. It is in no one’s interest to destabilise them. Can the Minister offer such reassurance on this?
We welcome the duty for Monitor to have regard to the need for high standards in the education and training of healthcare professionals. How will this interact with the potential for insufficient caseloads, in some circumstances, to train new healthcare professionals properly? How will national oversight of education and training be carried out to ensure higher quality? All these areas need to be teased out further, and we will come back to them on Report.
We all acknowledge the critical need for training and for standard setting. Can my noble friend give the House some reassurance that he will look at these issues again and, where possible and appropriate, consider regulation as a way of moving some of them forward in advance of the Bill?
Lord Alderdice
My Lords, I do not wish to repeat what other noble Lords have said very eloquently, but there are one or two issues which have not been referred to, to which I wish to draw attention. First, I pay my own tribute to the noble Lords, Lord Walton of Detchant and Lord Patel, and indeed other noble Lords who have kept fighting the good fight on education and training.
It is important, however, that we see this in as broad a fashion as possible. I am a doctor but I intend to speak mostly on non-medical education within the health service, since it has not, perhaps, received as much attention as it might. Like everyone else, I will undoubtedly speak from my own experience, which is, perhaps, a little different because it is in psychiatry and the psychological services. That is not just about treating patients; it is often also about training doctors in communication skills and the capacity to understand the psychological aspects of disease.
The noble Lord, Lord Hunt of Kings Heath, knows that I am not a recent convert to this question of trying to get regulation of psychotherapists and counsellors so that they can properly become part of an overall healthcare system.
Lord Hunt of Kings Heath
My Lords, I think it was in 1999 that I was converted, alas.
Lord Alderdice
Sadly, just a little late, but there we are. The point is that when we think of medicine and nursing, we largely think about people who are educated at public expense—partly within the healthcare system and partly within the higher academic institutions—and employed largely in the health services but, in some cases, outside. In the area in which I work, I am afraid the truth is that the health service has not tended to provide the training for these people. In many cases, psychotherapists, counsellors, and HPC-approved people such as art therapists and music therapists, have had to train at their own expense because the health service has not provided the training. Some of them have worked in alcohol and drug addiction services, which the health service uses; or they have been used in suicide and self-harm services, which the health service uses; or they have been employed in general practice or in psychiatry and psychological services, which the health service uses. The health service, however, has not paid for the training of these people.
When I see amendments that refer to the maintenance of education and training, I see an ambition that is too small. I see a sense of self-satisfaction—of, “We’ve got to maintain what we’ve got because it’s the envy of the world”, rather than, “Some parts of the world have been moving substantially ahead of us, and we have to do some work to catch up with them”. Therefore, I welcome the fact that there are amendments on this front, but also that the Minister has gone a little further. He is not just talking about the health service; he is talking, in the words of this amendment, about anyone who may be,
“providing services as part of the Health Service”.
He is also saying that the Secretary of State will need a greater area of responsibility to ensure a wider provision of training.
Even within those services, which have been provided for the training of doctors and others, I have noticed in recent years that it has become more and more difficult for doctors to continue to provide for their own continuing professional development—which is an aspect of education and training—and to be free to provide supervision and training for others. The pressure is on them to provide the direct clinical service, and not to be free to commit themselves to education and training. I welcome these amendments, particularly that of my noble friend the Minister, which say, “No, the Secretary of State will have to undertake this”.
I come to one final matter because I know the clock is going along. The noble Baroness, Lady Finlay, raised concerns about those who are outside direct healthcare provision having to demonstrate that they are providing training. I understand that entirely, and there is a lot to be said for it. However, one needs to be a little careful. In my service, for example, it was clear that the NHS was not going to provide care and treatment services, and it was not going to employ more people. So the question for me was this: how did I find a way, by using a small number of experienced and highly trained people, of creating a multiplier effect out in the community? The only way I could do it was by taking on and supervising some people who were working in the voluntary, community and other sectors so that they then had the capacity to train themselves or anyone else. I reduced the amount of clinical service I was providing directly by taking them on and supervising them. Then, effectively, I could treat a whole raft of people whom the health service was not prepared to provide the money for.
If we make it a rule that those often small NGOs and charitable groups have to account for the training of all sorts of other people, one simply makes it impossible for them to make their provision. So I understand entirely what the noble Baroness has said and I have a great deal of sympathy for the sentiment here, which of course is what is important, but I would simply caution against making such a strict rule that it becomes impossible for smaller providers who are not able to provide training—and could not pay the extra to do it. That would prevent some of us within the health service using them to provide the range of services which, until now, the health service has not provided. The Minister has been given some credit for this and I commend him and other noble Lords who have brought forward this proposal for the Bill, but let us build on it and try to be ambitious about what we can say in this Bill, never mind the one that might be coming down the road a little later.
Baroness Finlay of Llandaff
My Lords, perhaps I may briefly intervene to try better to clarify my concerns. I am not asking that small providers should have to account for all the education they provide. Let me give a specific example. If you have a hospice home care team, it is very appropriate that they should take nurses under training on placement. They can go out with the specialist nurses and learn about provision in the community. It will not cost the hospice anything, but the hospice management might feel that having students around is difficult because of regulatory functions and so on. All I am saying is this: if the management says that it will not take on students to learn about its excellent clinical service, it must justify why it is closing that educational door.
Similarly, if a group of physiotherapy providers dealing with back pain has an NHS contract, it would seem appropriate that it should take on physiotherapy students in order that they can observe and learn ways of managing back pain, which is what the group is primarily dealing with. Those students will get very good training. If the group says, “We do not want to take students”, then I suggest that it would be appropriate to point out in the contractual process that it needs to justify why it is refusing to provide education. Also, perhaps that group should not receive the full tariff because other providers will want to share their expertise for the greater good.
Lord Alderdice
My Lords, as I say, I understand the sentiments that the noble Baroness is trying to convey, but one has to be careful about generalising from one’s own experience, which might not necessarily fit everywhere. For example, a noble Lord said earlier that in a lifetime of clinical work, only a couple of patients had ever said that they did not want a trainee sitting in. I am afraid that psychiatry and the psychological services are a wholly different ball game. Whenever we were setting up for trainees, we had to warn them in advance that one in every three patients would not allow them to sit in on an assessment because of its personal nature. When you are living in a smallish community, as mine is, where people know people who know people, these things are much more of an issue.
It you make demands of some of the NGOs and smaller community services—demands that may be completely appropriate in a larger setting such as hospice care—that is quite a different thing. I accept absolutely what the noble Baroness is saying, but please let us not make a rule for everybody which may detract from some provision that is entirely appropriate.
The Earl of Listowel
My Lords, I am reminded by this debate of my experience 10 years ago when visiting a hostel for young drug abusers in Kings Cross and speaking with the mental health nurse there. She said, “I was placed here nine months ago with three other mental health nurses. We were given no support and I am the last mental health nurse working with these very needy young men”. She was doing an immensely important and demanding job. I do not know if she was not getting her line supervision from the NHS, although I imagine she should have been. I know that there is a concern that when health professionals are placed away from the mainstream of the NHS, they do not necessarily get the support they need. One issue that I would like some clarification on, perhaps in a letter, is that of continuing professional development and the supervision of professionals even when they are working in outreach services. When they are away from the mainstream health service, they should still be getting the proper supervision and support they need.
I said at Second Reading that one cannot legislate for the NHS to care for patients, but what one can do is nurture the people who work in the health service—the doctors, nurses and physiotherapists. One can give them the best training and the best ongoing support so that they are capable of caring and being considerate. What was happening with the mental health nurse I mentioned was that she was caring in the most adverse circumstances. She had everything stacked against her. She said, “We just did not get the support. It was not thought that we needed support to do this important work”.
Concerns have been raised about future pressures on the training and development of healthcare professionals. There is also the Nicholson challenge: a lot of money has to be shaved in a short time. There is concern about fragmentation. As my noble friend Lord Kakkar said, training is an expensive process and costs professionals’ time. It might be helpful to consider for a moment what has happened in the social work arena over the past 20 years or so. One has seen a lowering of the thresholds of entry into the social work profession and a diminution in quality. Many good people are working extremely hard, but it is widely recognised that there has been a diminution in quality. I am thinking particularly of child and family social workers. They have to assess a family and decide whether a child stays in the family or is removed, a decision that will quite probably have consequences for the rest of that child’s life. But the thresholds have been lowered so far that, until recently, one could get on to a social work course with two Ds at A-level. Current social workers talk about “old school social workers” who knew the law and were methodical in their approach, and how they regret their passing.
I am grateful that this amendment has been tabled and it is right that it has been given such priority. There must be no diminution. Indeed, we must strive to improve training and support for the development of our care professionals. A particular area of concern has been that of psychiatry. We have had difficulty recruiting sufficient psychiatrists, and I understand that nowadays most psychiatrists do not have English as their first language, which is a matter of concern. I would cite the area of child mental health professionals as well. I know that the Royal College of Psychiatrists has been working hard on this, but I wanted to light this up as an area of concern.
Finally, I recently visited midwives working in a hospital in central London. I was advised that they received only one supervision session per annum. That seems an extremely poor amount of supervision. Normally in the health service it is provided every one to two months. Supervision sessions provide an opportunity to discuss, among other things, the continuing professional development needs of practitioners. I may have misunderstood the position and there may be some other context for midwives, but I would be grateful if the Minister could write to me with a bit more information about how midwives are given the continuing professional development they need.
I look forward to the Minister’s response. This is a tremendously important debate that is key to ensuring that, in the future, patients in the NHS get the quality of care they deserve.
Lord Cotter
My Lords, like others, I should declare an interest. My father was a GP and my wife an occupational therapist. I have taken an interest in the NHS for the past 12 years in Parliament, but I feel more intimidated than the noble Lord, Lord Mawhinney, for good reason. However, I see great merit in Amendment 2 and the other amendments in the group. As many colleagues have said in their speeches, there is a big issue here that needs to be addressed in a specific way. To be specific, at Second Reading I raised the issue of healthcare assistants. A concern has been expressed to me by others—and I read in the newspapers—that a voluntary code for healthcare assistants may just not be enough.
This morning I was speaking to a nurse and she made a very clear point. She said: “We are directing healthcare assistants in nursing and we give them the jobs to do but I do have a concern that if they do not have sufficient training they may carry out the job I have given them not particularly well and that is a responsibility which goes back upon my shoulders.”. To quote from the papers,
“It is amazing that healthcare assistants, caring for patients in uniforms indistinguishable from nurses, are completely unregistered”—
That may not be quite correct, I do not know—
“and can start work with as little as an hour’s training”.
I have highlighted this issue for later in the Bill. I hope the Minister will consider this and have time to look at it at a later stage.
Earl Howe
My noble friend will be aware that we have had two Oral Questions recently that have covered this point. I want to correct one point he made—our proposals are for a voluntary register, not a voluntary code. He was talking about a voluntary code. If under our proposals a healthcare assistant were to register under the voluntary system there would be a set of standards that went with that registration. The code would not be voluntary in that sense. I look forward to the later stages of our Committee debates to discuss these very important issues. We will have that opportunity.
Lord Cotter
I thank the Minister very much. As usual he was addressing the issues. I hope that by highlighting them again we will ensure that training is going to be really adequate for them to meet the requirements.
Lord Mackay of Clashfern
My Lords, I support the view that this is an extremely important issue. It is also extremely difficult and there is a lot to be done to get this right. I am an honorary fellow of two Scottish medical colleges. The contribution of Scotland to the training of doctors and nurses has to be kept in mind, and many other parts of the world also contribute to our NHS training, particularly at the graduate stage. It makes it extremely difficult to know how to cater for all the possibilities and I wish my noble friend every success in coping with this problem.
Lord Hunt of Kings Heath
My Lords, as this is the first day of a new stage of the Bill, I am required to start by declaring my interests. I am chair of the Heart of England NHS Foundation Trust, president of the Royal Society of Public Health, the Fluoridation Society and the Health Care Supply Association, consultant trainer with Cumberlege Connections and member of the advisory council of Easy Care.
The noble Lord, Lord Cotter, put his finger on it when he spoke of concerns about the quality of nursing care in some parts of the NHS. This has led in the past few months to considerable debate about the quality of education and training of nurses and indeed healthcare assistants. We will, of course, be coming back to that issue later in Committee. However, it has served to illustrate the critical importance of education and training of the healthcare workforce, be they doctors, nurses, AHPs or indeed even psychotherapists.
My Amendments 6 and 44 seek to ensure that the Secretary of State exercises leadership and responsibility in this area. This is very important in the context of the Government’s intention to create a much more diverse and disparate healthcare system in the future. It is essential that we protect the integrity of a national approach to professional education and training.
Earl Howe
My Lords, I thank the noble Lord, Lord Walton, for introducing his amendment, which began this debate, and other noble Lords for their excellent and powerful contributions.
The Government recognise that we have some of the best health professionals in the world and we believe that they should be supported by a world-class education and training system. I am heartened by Amendments 2, 6, 8A, 8B and 44, because they indicate that many noble Lords here today share the Government’s view on this matter. That has been amply confirmed by the speeches that we have heard.
Amendment 6, tabled by the noble Lord, Lord Hunt, and the noble Baronesses, Lady Thornton and Lady Finlay, and Amendment 2, tabled by the noble Lords, Lord Walton and Lord Patel, would both insert in Clause 1 a duty on the Secretary of State to maintain a system of education and training in the health service.
Amendment 44, tabled by the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt, would insert after Clause 5 a new clause that would give the Secretary of State a new duty to maintain a comprehensive, multi-professional education and training system for health professionals, as well as to ensure the continued professional development of all staff delivering NHS services.
Amendments 8A and 8B, tabled by the noble Baroness, Lady Finlay, would both insert in Clause 1 a duty on the Secretary of State to maintain a “nationally co-ordinated” system for professional education and training as part of the comprehensive health service.
In its report earlier this year, the Future Forum emphasised the critical role that education and training will play in the continued improvement of healthcare services. In our response to its report, we not only made it clear that we agreed with this point but also, in recognition of this fact, committed to introduce an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service.
Government Amendment 43 fulfils the commitment that we made in June in response to the Future Forum’s report. Indeed, it goes further than our original commitment. First, the Secretary of State’s duty goes beyond just health professionals—I say to my noble friend Lord Cotter that healthcare assistants would be included, as well as other health professionals. Secondly, the Secretary of State will be under a duty to maintain an “effective system” of education and training rather than just a “system”. I was not quite clear, listening to the noble Lord, Lord Walton, whether the Government’s amendment has found favour with him. It has been very carefully drafted and I hope that he will support it. I say to the noble Lord, Lord Hunt, that the amendment is not restrictive of the Secretary of State’s accountability. I hope that he can see from the wording that the duty is clear. Subsection (2) is drafted so as to cover all potentially relevant powers. These are not necessarily powers in the 2006 Act. We are satisfied that he has sufficient powers.
I take this opportunity to reassure the noble Baroness, Lady Finlay, and the noble Lords, Lord Warner and Lord Hunt, that our amendment provides for co-ordination of education and training at a national level. We agree that that is essential; it has never been in question. The Secretary of State will be under a duty to secure “an effective system” of education and training. No system of education and training could be considered effective were it not co-ordinated at a national level. The noble Lord, Lord Warner, was right to mention some of the wider issues that need to be factored into that process. In addition, a new body, Health Education England, will be set up to provide oversight and national leadership for education and training. In its leadership role, HEE’s task will be to bring together all the relevant parties to oversee and shape the development of the healthcare workforce, including the royal colleges and the professional regulators. Finally, the department will own the strategic design of the new education and training system and develop an education and training outcomes framework to set out the outcomes against which the system, and HEE, will be held to account. That is a first.
We believe that the amendment that we have tabled most accurately reflects our policy intention and the Secretary of State’s legal functions in relation to education and training in the new system. Indeed, we have already seen a positive response from the BMA to our amendment.
Lord Maclennan of Rogart
My noble friend was a little cursory in dealing with Amendment 44 and the criticisms made by the noble Lord, Lord Hunt. Why he has not simply accepted the amendment of the noble Lords, Lord Walton of Detchant and Lord Patel, which seems to be all-embracing and to cover the entire spectrum of healthcare issues, in the light of the requirement, which is in the Bill, that the Secretary of State must continue the promotion in England of a comprehensive service designed to secure improvement? My noble friend spoke not of improvement, but of supporting existing services. That does not go far enough in the present circumstances.
Earl Howe
My Lords, I cannot speak for Amendment 44, which is not the government amendment; but I can speak for Amendment 43, which is. My advice is that the amendment delivers everything that my noble friend has just said. I have not given a critique of the amendment of the noble Lord, Lord Walton, but as I have been invited to do so, I will now offer one. It does not cover non-clinical staff or trainees; it covers the healthcare workforce. So, in actual fact, I think it is deficient; and I urge the Committee to accept the government amendment on that basis.
Lord Warner
I am sorry to interrupt the Minister’s flow, but he has been interrupted, so I thought I would ask my question now. The Minister has given us quite a lot of assurances about what the government amendment would cover, but I put to him a particular issue that came up—not that long ago, in 2006—when there was a major national row about the number of specialist training places. A large number of doctors and would-be doctors marched on London to complain about that system. It was absolutely clear that the only person who could deal with that issue in any satisfactory way, for both the professions and the public, was the Secretary of State. Is the Minister absolutely confident that the government amendment would enable the Secretary of State to act in such circumstances?
Earl Howe
The Secretary of State could act if Health Education England was failing in its functions. Our vision is that we will be giving functions to Health Education England to oversee a national system. If it does its job properly, then the situation the noble Lord describes would, one hopes, be handled in a satisfactory way. If it fails in its functions, then, yes, of course it would be the duty of the Secretary of State to step in and oversee the process.
Lord Owen
This is a crucial question. The word failure is extreme. A lot of us worry that waiting for failure would be too late. We want to see an intervention capacity when the Secretary of State has anxieties or doubts about what it is doing and that he has a position to represent this Parliament—or any Parliament —on the issue.
Earl Howe
I know that is the noble Lord’s concern and of course I understand it. However, it is the policy of the Government to confer functions where they best sit. If the Secretary of State were to intervene at any whiff of trouble, it would run counter to that vision. I believe that there will be ample scope in the next set of amendments to talk about this very subject; but it is very important to understand that we have quite deliberately taken the view that functions, duties and responsibilities should sit with individual bodies and that the Secretary of State should be there to ensure, to the public and Parliament, that those bodies fulfil their duties and functions correctly.
I suggest that we defer the particular issue raised by the noble Lord, Lord Owen—about the degree of system failure that has to occur before the Secretary of State intervenes—to the next set of amendments. The amendment we are dealing with now has to do with the ultimate accountability of the Secretary of State for the education and training system—which I am saying to the Committee is there in our amendment.
Lord Mawhinney
I understand why the Minister wants to take this issue in the next set of amendments. A number of us will contribute to that debate, because it is crucial. A moment ago, he said that the Secretary of State would have national co-ordination responsibilities for education and training, which I think was broadly welcomed. My question is simple: is my noble friend willing to put that phrase or convey that aspect in the Bill by amending government Amendment 43?
Earl Howe
The trouble with that is that we are straying into the mechanics and the detail of the education and training system, and we are still consulting on how it will work. That is the difficulty I have in answering some of the detailed questions that are being put to me. I can answer many of them, but once we move into particular questions on how the system for education and training will all fit together, it would be imprudent of me to put anything on to the record at this stage.
Lord Patel
I go back to the question that the noble Lord, Lord Warner, asked. In the event that the example he gave should happen, ipso facto, it would mean that Health Education England had failed.
Earl Howe
It might or it might not. All I can say is that the Department of Health will have designed and co-ordinated the new system and will develop the outcomes framework. Health Education England will be providing oversight and national leadership for education and training. The department and Health Education England, together, would no doubt have a role in sorting out the kind of situation that the noble Lord, Lord Warner, has adumbrated. However, it is a little difficult to discuss this in hypothetical terms. I have tried to set out, broadly, how the system should operate—
Earl Howe
It did happen, but it did not happen with the system that I have outlined in place. As I have just said, NHS Future Forum is talking to a great many people about where exactly responsibilities should sit for what, and how the system should work, which is why—I confess freely—I am in difficulties. While I would love to be able to answer detailed questions about the system, we have quite consciously deferred these matters to a second Bill.
Lord Winston
Perhaps I could ask the Minister a general question. The noble Lord has been specific in picking up some of the details of the amendments. The beauty of the amendment proposed by the noble Lords, Lord Patel and Lord Walton, is its simplicity and ethos. Government Amendment 43, proposed by the Minister, refers to the,
“delivery of education and training to persons who are employed, or who are considering becoming employed”,
in the health service. Considering becoming employed can mean a whole range of things. A lot of people who are considering becoming employed in the health service may not actually apply for a job. How is that possibly enforceable within the context of this amendment?
Earl Howe
I am surprised by that criticism because that is designed to capture trainees, who may not have a guaranteed job at the end of the day. If you simply refer to people who are already employed, you surely cut that cohort out of the equation. That is the purpose of those words, and I think they are entirely appropriate.
Lord Hunt of Kings Heath
I return to my noble friend Lord Warner’s intervention. In the case that he mentioned, it was I who was summoned before the Health Select Committee to explain what we were going to do about the problem. We intervened and told the SHAs that they jolly well had to sort this out. I do not see, under the arrangement that he is proposing, who on earth is going to be able to intervene.
As the noble Lord, Lord Owen, suggested, I suspect that an intervention against Health Education England will be very rare indeed, in terms of being able to be comprehensively assured that HEE had failed in its duty. Indeed, there is surely a risk that if you have a narrow quango, such as HEE, solely concerned with education and training, it will not be concerned about resource issues or about the duty of the Secretary of State to promote or assure a comprehensive health service; only the Secretary of State himself can come to conclusions about the overall direction of the health service; only the Secretary of State can balance the conflicting demands of education, service provision and resources. There is a great danger of seeking to push all these responsibilities offshore, because when trouble comes—and trouble will come—it will be the Secretary of State whom the public and Parliament will expect to intervene. At the moment, I cannot see how, under this system, if things go wrong, they are to be put right.
The Earl of Listowel
I take the noble Lord’s point, but I also think of the case of the Youth Justice Board, which has been a very successful non-departmental body and has improved outcomes for young people in the criminal justice system significantly. There has been concern from the Secretary of State responsible for criminal justice about the accountability of the Youth Justice Board, which is shortly to be wound up—well, depending on the views of your Lordships. The virtue of the Youth Justice Board is that it is a great centre of expertise in the area of youth justice. Its chair and board have great experience: one member of the board is a judge in the youth court, another is the chief executive of a children’s charity. The point is that there is great virtue in distancing the Secretary of State to some degree—for instance, the education, perhaps, of health professionals—and giving it, if the board is chosen well, to people of the right calibre.
The other side of that is that sometimes the Secretary of State will intervene too often and detrimentally to the education of health professionals. In fact, vesting authority in a board which is well chosen and has the full support of health professionals and keeping the intervention of the Secretary of State to the minimum may ensure better continuity in the education and training of the workforce and better outcomes.
Lord Hunt of Kings Heath
My Lords, surely there is a very great difference between the Youth Justice Board, the abolition of which is greatly to be regretted, and Health Education England. The Youth Justice Board has to embrace the whole of the responsibility for youth justice. What the noble Earl, Lord Howe, is suggesting with Health Education England is establishing a quango which will have a very narrow focus on education and training. The Youth Justice Board is concerned with that, but is also concerned with the provision of custodial places within our prison system. That is very different.
The Earl of Listowel
I thank the noble Lord. I can see the difference and I thank him for that helpful correction.
Baroness Finlay of Llandaff
Before the Minister resumes his speech—I am sorry to do this, but I would like clarification. From what he has said, I understood that under this amendment the Secretary of State will not have a comprehensive duty, so that if Health Education England finds that the National Commissioning Board and the clinical commissioning groups are not making provision for education within the commissioning process that they set in place, the appeal would not go to the Secretary of State. I am not sure who the educational providers would appeal to if Health Education England found that it could not function because the commissioning process was not allowing for education.
Earl Howe
Perhaps I may just clarify some of this. The wording of the government amendment could not be clearer:
“The Secretary of State must exercise the functions … so as to secure that there is an effective system for the planning and delivery of education and training”.
That means that he is ultimately accountable. Of course, he will be answering questions in front of the Select Committee or Parliament: that is a given in relation to education and training, as it is for anything else. The role of Ministers in Parliament will not change. Ministers will still answer letters, Written Questions and so on. Whatever system we put in place, the government amendment makes the Secretary of State’s ultimate accountability and responsibility for ensuring an effective system absolutely clear. However, many of the questions that have been asked—I was very grateful to the noble Earl, Lord Listowel, for what he said—are about how the system will work, and that is a matter on which we are still listening to stakeholders.
Lord Mawhinney
I want to go back to what my noble friend said about the Government committing themselves to a national co-ordinating role for education and training. He specified that it was something that the noble Lords, Lord Walton and Lord Patel, and the noble Baroness, Lady Finlay, would welcome, because they had been asking for it. He said that and we are all pleased that he said it. When I asked him if he would put that in Amendment 43, he said that he could not do it because they were still consulting and thinking and that that was a commitment that he did not feel able to make at the moment. But he has already made the commitment. It is on record that the Government will have a national co-ordinating role. I am not trying to put words in my noble friend’s mouth; those are the words that came out of his mouth. My question was simply, what is there to stop the Government putting those words, that commitment, in Amendment 43?
Earl Howe
I am grateful to my noble friend and, naturally, I will give full consideration to his suggestion. The government amendment represents the fulfilment of our undertaking, made in another place and more publicly, to put clearly in the Bill the Secretary of State’s accountability for an education and training system. That is what we have done. It may be that we can go further in the Bill; I will certainly consider that. Our intentions, as I have enunciated them, are clear, but I come back to saying that we do not want to pre-empt the findings of the Future Forum and the wider consultation that we are engaged in.
Lord Winston
I am sorry to interrupt the Minister again, but I find it incredible that we are now in Committee in the second Chamber on this large Bill and the Government are still apparently in the middle of their listening exercise. Does this not argue that the Bill is extraordinarily badly prepared and that these things should have been thrashed out well in advance? Is that not what the noble Baroness, Lady Tonge, was talking about? It is something that will shock people who are listening to this debate.
Earl Howe
No, my Lords, that is not the case. I completely reject not only that remark but also the remark of the noble Lord, Lord Davies of Stamford. Our plans for education and training have been moving forward ever since the election. The White Paper in July 2010 set out the broad principles underpinning education and training reforms. A consultation paper was then published in December last year, with the consultation finishing in March of this year. The Future Forum then listened to further views. It recommended the new duty which we are discussing today in the form of Amendment 43, and we accepted that recommendation. Meanwhile, the Future Forum continues to listen to the views of the wide range of stakeholders and its report will feed into future legislation on this topic. We have consciously deferred the meat of this issue to a future Bill, because we have to get it right. We have committed to publishing further proposals on education and training once the Future Forum has concluded its report and there will be a chance for noble Lords and others to feed in at that point if they so wish.
Lord Davies of Stamford
I am afraid that I must stress this point a little further. This debate has revealed a fundamental contradiction in the Government’s position. The Minister argues that Amendment 43 adequately defines the responsibilities that the Secretary of State will have for ensuring that there is an adequate system of medical training and education in this country. It may or may not be the case that the formulation in Amendment 43 is adequate, and we must decide on that matter today.
At the same time, though, the Minister is confessing that the powers that will be given to the Secretary of State in order to fulfil those responsibilities have not yet been defined. We do not know what they are. They have not been decided yet. Surely it is a fatal mistake in life to give anyone responsibility without being clear that they have the powers to undertake it. That is precisely the position in which the Government are placing the Secretary of State.
Lord Walton of Detchant
My Lords, before the debate on these amendments concludes, it had not been the intention of my noble friend Lord Patel and me, on coming to the Committee today, to divide on our Amendment 2. However, our view has been changed a little in the sense that the support that that amendment has had from all sides of the House has been very powerful. I shall read again what the actual Bill says. Under the heading,
“Secretary of State’s duty to promote comprehensive health service”,
it says:
“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and … in the prevention, diagnosis and treatment of illness”.
All that we have suggested in Amendment 2 is the addition of a paragraph (c) to secure improvement,
“in the provision of education and training of the health care workforce”.
I find it difficult to suggest that any Government could refuse that amendment. It could be complementary to government Amendment 43. Will the Minister, who everyone in this House feels great respect for, take the amendment away, talk to the Government about it and see whether they might accept it as a government amendment on Report?
Earl Howe
I will happily consider that between now and Report, as indeed I will consider all the points that have been powerfully made in this debate. I have quite a lot more to say in answer to various questions that have been raised, and I hope that I will be given the opportunity to do so.
The Government’s amendment, quite consciously, does not confer any new powers on the Secretary of State. It requires him to exercise his existing powers to provide an existing system. The duty means that he would have to intervene if the system was failing and ineffective. He has a range of powers, including the powers to provide or commission training under Section 63 of the 1968 Act, as referred to in subsection (2) of the Government’s amendment. However, the point is that future legislation may add further powers to those that the Secretary of State already has, and that is what I cannot pre-empt in my reply today.
Lord Willis of Knaresborough
My Lords, I am sorry to interrupt. I have listened carefully to the whole debate today and it seems that we are hampered by the fact that we do not know what is going to go into this new Bill or indeed when it is going to appear. The Minister has been consulting on this issue for nearly 18 months. Will he give the House a clear understanding that in the next Queen’s Speech there will be two Bills, one of which will deal with education and training while the other deals with research? Could he give the House that assurance so that we know what the timetable is for the delivery of these elements?
Earl Howe
I would like nothing more than to give that assurance but unfortunately I cannot, as I am not in a position to know what the Government’s programme in the next Session is going to be. I know that it is the hope and wish of many noble Lords that we will have a social care and health Bill.
Lord Willis of Knaresborough
This is important. I understand what the Minister is saying but at least he could have given us guidance that such Bills would have been in the next Queen’s Speech. If we are talking about another period of two years or more, we are looking at total confusion for that period of time in terms of the delivery of education, training and, later on, research. That cannot be what the Government want; it certainly cannot be what the Minister wants.
Earl Howe
My noble friend knows—very well, I hope—how important research is to Ministers in my department, how important education and training are and how important it is that we have a system for the provision of social care that commands the support of all parties. A Bill of that kind is something that we dearly wish to see coming to Parliament as soon as possible. However, he will understand that I am not in a position to give any undertaking about the next Session, much as I would love to be able to wave a wand and do so.
Perhaps I could be allowed to answer some of the questions that have been asked of me.
Earl Howe
The noble Lords, Lord Walton and Lord Turnberg, asked me about postgraduate deaneries. Postgraduate deans carry out a crucial function of quality assurance and oversight of medical education, and we value those functions. The Government were clear in our response to the NHS Future Forum that we intend to retain the deans. In future they will become part of the new provider-led bodies that will be responsible for education and training locally. We have extended the timetable for the abolition of the strategic health authorities to April 2013 to allow for greater time to manage a smooth transition. We propose that Health Education England will be established next year as a special health authority in order to support the transition.
The noble Lord, Lord Turnberg, made the telling point that the time available for teaching is steadily being shaved away so that clinical commissioning groups, as he put it, should have the budget to fund teaching sessions. Funding for clinical placements and the associated costs already comes via the multiprofessional education and training budget, which at the moment is £4.9 billion, a not insignificant figure. This budget will be allocated by Health Education England in future to healthcare and education providers.
The noble Lord also asked me about the training of public health doctors and whether such doctors employed by Public Health England and seconded to local authorities would be caught by this. Health Education England will work with Public Health England to oversee education and training for public health staff. I suggest that there will be ample time on later clauses to discuss the role of public health doctors more generally; that is perhaps where we can come back to this, and I look forward to that.
The noble Lord, Lord Patel, asked how Health Education England would hold providers to account and how local skills networks will be governed. HEE will have contracts with healthcare providers for education and training, and this will be underpinned by an education outcomes framework. We envisage that skills networks will need to have an independent chair and meet rigorous authorisation criteria set by HEE to demonstrate that they have appropriate capability, financial controls and the necessary partnerships with the education sector.
I was also asked by the noble Lord, Lord Walton, and the noble Baroness, Lady Finlay, how we will ensure that the policy of “any qualified provider” does not harm education and training and, indeed, how private providers will be contributing to education. The noble Lord, Lord Hunt, asked me a similar question. By giving healthcare providers more responsibility for workforce development, we will place a greater emphasis on their working in a co-operative way to ensure a workforce supply of health professionals. This will be reinforced by duties on healthcare providers—I apologise to him for the phrase, but it is an all-embracing one —to consult on workforce plans and co-operate on the planning and commissioning of education. Proposals are being considered for a levy on all healthcare providers to contribute to the costs of education. However, this is a very complex matter and it needs more detailed consideration before being looked at for future legislation.
With regard to the responsibilities of the board and clinical commissioning groups, an issue raised by the noble Lord, Lord Walton, paragraph 130 of Schedule 4 to the Bill amends Section 258 of the NHS Act 2006 so that the Secretary of State, the NHS Commissioning Board and clinical commissioning groups must all exercise their functions to secure that facilities are made available for university clinical teaching.
Baroness Masham of Ilton
My Lords, could I ask the Minister about something that I do not understand? Why in my noble friend’s amendment does it not include the training of healthcare assistants?
Baroness Masham of Ilton
That is the Government’s amendment. The Minister said that my noble friend’s amendment did not include them.
Lord Walton of Detchant
My Lords, this has been a lengthy debate on an extremely complex and difficult matter in a complex and detailed Bill. Medical education and training of the entire NHS workforce is absolutely crucial and it is vital that it appears in this Bill. That is why I very much hope that the Minister will take away Amendment 2 and think about trying to persuade the Government to adopt it. Other issues that have been raised will not go away. For instance, my medical colleague, the noble Lord, Lord Alderdice, talked about psychotherapists. There was also talk about the crucial problem of the future of healthcare assistants.
I would remind your Lordships that 15 years ago I steered through this House the Bills to regulate chiropractors, followed by regulation of osteopaths, so that they are now regulated by statute. I also chaired the House of Lords Select Committee on complementary and alternative medicine, which held a detailed inquiry. In that field, too, it is good to know that herbal medicine practitioners are close to being regulated. Therefore people who work in other aspects of healthcare will have to consider whether or not they will need and require statutory registration and regulation, though not in this Bill perhaps.
The government amendment is right as far as it goes, but it leaves a massive amount of information still up in the air. The Minister has given us a comprehensive and detailed report about the future of Health Education England. There is already a body called Health Education England, which has been in existence for some little time. I do not know what its provenance is now, but it is chaired by my close friend, Sir Christopher Edwards, who is a former vice-chancellor of the University of Newcastle upon Tyne. He has chaired a body called Health Education England for a while.
Lord Walton of Detchant
Medical Education England, I beg your pardon. Will that body disappear with the development of Health Education England? Do we know what the provenance of that body is going to be or who is going to fund it? What is its constitution going to be and what are its authorities? Will it have the authority to deal with the issues that we raised in this debate about the crucial importance of making certain that commissioning groups, trusts and even private providers offer facilities for education and training.
I shall not go on. I am happy now to withdraw the amendment in my name, but I believe that these issues are so important that they should not await the tabling of another government Bill on education. The Government should introduce something into this Bill to make the future of health education and training clear. I beg leave to withdraw Amendment 2.
Baroness Northover
My Lords, given that there is no dinner hour business tonight, we have agreed that instead of breaking now, we will sit without a break until 9 pm and therefore have a slightly earlier night.
Lord Bassam of Brighton
Does that mean that we will finish at nine o’clock or when the debate on an amendment finishes? There is a practice whereby we can carry the debate over; we do not have to complete it by that time. Will the noble Baroness clarify that point?
Baroness Northover
My understanding is that we will stop at nine. If that means that we are part way through the next group of amendments, so be it.
Amendment 3
“(2) The Secretary of State must for that purpose provide or secure the provision of services according to this Act.”
Baroness Williams of Crosby
My Lords, this amendment is tabled in my name and those of the noble Baronesses, Lady Jay and Lady Thornton, and the noble Lord, Lord Patel. It is an absolutely central and crucial amendment. I say right away that I am consumed with envy by the success of the noble Lords, Lord Walton of Detchant and Lord Patel, in getting the Government to table an amendment restoring the duties of the Secretary of State in the area about which they were concerned. I only wish that the same thing might happen as regards my amendment.
It is interesting that even in the course of a long debate about education and training we kept coming back to a consistent ambiguity about exactly what the powers and duties of the Secretary of State are, particularly with regard to the possibility of failure. I am afraid that this set of amendments covers some of the same ground. I will do my very best not to repeat what has already been said. The whole point of Amendment 3 is to restore the wording that occurred in the original 2006 Act to indicate clearly what are the duties and accountability of the Secretary of State. There are two reasons for that. First, many of us wish to ensure that what was beautifully described by the noble Lord, Lord Hennessy, as institutionalised altruism—his description of the National Health Service—should survive and continue. In order to retain the trust of the public who care so much about it we have to make absolutely clear that the Secretary of State’s ultimate responsibility is not impaired. There is another reason for that, not just the fact that so many members of the public believe in the NHS; that is, we need to retain their trust while the huge changes that are envisaged to make the National Health Service successful for the future are carried out. We need to do that by indicating that there is no reduction in the ultimate powers of the Secretary of State.
There is also a key constitutional issue. I am sure that the noble Baroness, Lady Jay, will speak to this so there is no point in my going into detail now, but the constitutional issue concerns—to put it in a sentence—exactly who is accountable and responsible for £120 billion of taxpayers’ money which is spent on the National Health Service and on health more generally. The remarkable thing about the NHS, which has been mentioned by many Peers, is that it is taxpayer funded, and because it is taxpayer funded it is in many ways much more efficient and effective than many of its competitors in other parts of the world. Therefore, it is incumbent on Members of both Chambers of Parliament to retain accountability to the people of England for this huge sum of money through Parliament and the Cabinet. That means we have to make it clear that that channel passes through the Secretary of State.
The brilliant and concise report of the Constitution Committee chaired by the noble Baroness, Lady Jay, traced its concerns about ambiguities and uncertainties with regard to the duties and powers of the Secretary of State. The noble Baroness will express this matter better than I can, but I simply want to draw the House’s attention to the concluding remarks not of the Constitution Committee but of the Government themselves in responding to the Future Forum’s concerns about accountability. The Government state:
“As the Future Forum’s report highlights, some people are concerned that the Bill could weaken the Government’s accountability for the health service”.
They go on to say:
“There have even been some fears that the core principles of the NHS could be weakened”.
Then, encouragingly, the Government went on to say that,
“the Forum is right to point out that the current drafting of the Bill is not clear enough, and we will amend it”.
I am responding to that promise by the Government in the hope that we can as a Committee ensure that that amendment takes place in ways that we regard as satisfactory.
Lord Davies of Stamford
My Lords, I congratulate the noble Baroness, Lady Williams, as she could not possibly have come forward with an amendment that is more pertinent, necessary and urgent in the light of the discussion that we have had already this afternoon on medical training and education. It was clear from that discussion that some extraordinary things are happening as a result of this Bill. One extraordinary thing is that duties are being placed on the Secretary of State without any consideration having been given, or certainly no decision having been made, as to what powers he will need in order to carry out those responsibilities. That is a very serious matter and I will come back to it in a moment.
The second serious matter is becoming clearer and clearer. One of the agendas of this very curious Bill—and one asks oneself what its real meaning and hidden agenda are—is obviously to decouple the Secretary of State steadily from political responsibility for the management of the NHS by creating an insulating barrier and a series of quangos. The Minister said this afternoon, in answer to the case put to him by the noble Lord, Lord Warner, about a repetition of the crisis in jobs for junior doctors that occurred a few years ago, that the Secretary of State would not be able to intervene, or to do anything at all, until he had determined that there was a failure by Health Education England. That means that, if he had Questions in the House, he would simply say, “It’s not my fault, Guv. Go and talk to the quango. I don’t know anything about it. I haven’t yet determined that there is a crisis”. That is an extremely unsatisfactory situation.
Earl Howe
My Lords, the noble Lord is caricaturing the position. The Secretary of State, in the case of education and training, would continuously hold Health Education England to account against a set of pre-agreed outcome measures. That is not standing at a distance from what Health Education England does. It is being intimately concerned with what it is doing. I do not want the noble Lord to caricature the Government’s position. I understand that he is not happy with the separation of functions, but that is a matter of policy; his policy differs from that of the Government. I do not want him to go away thinking that this is a totally hands-off affair. The Secretary of State will have legal responsibility and accountability for what Health Education England does and that will be manifested through the outcomes framework.
Lord Davies of Stamford
I am very grateful to the Minister. I will just respond to him before giving way to the noble and learned Lord, Lord Mackay. Indeed, I must not caricature the Government’s position; believe it or not, I do not want to do so. I want to reveal the Government’s position. I am trying to draw out the Government. We succeeded in doing that this afternoon; perhaps the latest intervention from the Minister is part of that. It was extremely useful, but I think it is clear that the Bill imposes certain duties on the Secretary of State and we have often heard, when it comes to the powers that he has, that it is not quite clear what the position is.
What I am particularly concerned about in the area of health education and training, but also in other areas, is, first, that the Secretary of State will be in a position to answer parliamentary Questions about anything to do, in this case, with health education and training. It might be on planning for numbers, public health or whatever, but there should be no sense in which he will simply say, “That is the responsibility of somebody else. I cannot answer that”.
Secondly, I am concerned about the actual powers that the Secretary of State will have to intervene—the ability he will have simply to give directions to one of these quangos, to override it in certain circumstances. The circumstances in which he would be able to override it need to be clearly defined. They should, of course, be defined already so we can look at them at the same time as we look at the new duties. However, they are not defined and we need to know that they will be. I will give way to the noble and learned Lord, Lord Mackay.
Lord Mackay of Clashfern
I did not intend to intervene; I was hoping that the noble Lord might have finished.
Lord Davies of Stamford
That is a very tactful way of putting it. I do not intend to speak for very much longer, but I want to complete my remarks. I simply want to say that any self-respecting person—and I am sure that the Secretary of State is one—would not accept being given duties and responsibilities without being clear about the powers that he or she had to fulfil them. I would not do so. This is a very anomalous position, where we are told that future consideration will be given to what exactly the powers will be, that future Bills will define them. I do not think that is a satisfactory situation at all, if that is the position.
Earl Howe
I made that point in connection with education and training where, as I have said repeatedly, we are still in consultation. As regards the Secretary of State’s powers and duties in this Bill, they are very clear; there is no ambiguity about them. We are going to be debating an amendment in the name of my noble and learned friend Lord Mackay, and I do not want to pre-empt that, but that amendment seems to set out very satisfactorily what the Secretary of State’s powers are. It draws them together very well.
Lord Davies of Stamford
It seems to me that the text of the amendment put forward by the noble Baroness, Lady Williams, differs from the Government’s position in the Bill in that it makes it absolutely clear that the Secretary of State has the duty to intervene. That is stronger wording, and I just wonder why the Government cannot accept it.
Lord Mackay of Clashfern
My Lords, your Lordships’ Constitution Committee, under the distinguished chairmanship of the noble Baroness, Lady Jay, has raised in a very succinct and clear manner a doubt that has arisen in relation to the constitutional position of the Secretary of State. The word “provide”, that was in the original duty as an alternative to “securing the provision of”, has been deleted by the provisions of this Bill. The reason for that is that the Secretary of State has never had an obligation to provide services: he has had an obligation to provide the services or secure their provision. We mentioned earlier, for example, in the very early days of the Secretary of State’s initiation of the health service, the position of general practitioners who, on the whole, did not wish to be employed by the Secretary of State, but were willing to provide services. The arrangement was that the Secretary of State, under the statute, had an option.
At times during the existence of the health service, the Secretary of State exercised that option by providing, but in recent years, as I understand it, the only services have been provided by others and the Secretary of State’s operative duty has been to secure the provision of the services. I read out earlier, for those of your Lordships who were here then, the original wording in the 1946 Act. The first part of that has been completely retained in the present Bill. That is the provision that has been operated by the courts to control the activities of the Secretary of State in relation to the health service.
The reason that the word “provide” has been left out on this occasion is that the Secretary of State no longer in fact provides. I think that it is wise, if we are trying to modify the statutory structure, to do so in such a way that it conforms, to some extent anyway, with what is actually being done. Therefore, it is right to proceed on the basis that the Secretary of State will secure the provision of the services, as he has been under a duty to do as an alternative to provision from 1946 onwards.
The Constitution Committee studied this, and raised the question of whether that alteration damaged or altered the constitutional position of the Secretary of State. As your Lordships know, the noble Lords, Lord Owen and Lord Hennessy, proposed that that was a matter that should go to a Select Committee. I opposed that, as your Lordships may or may not remember, and ultimately your Lordships decided that we would go along with the ordinary method of dealing with these matters. However, having made that suggestion to your Lordships in the debate, I felt I should do my best to try to solve the problem that the Constitution Committee had raised.
I had a very full consultation with the government advisers—the policy-makers and the lawyers—and I concluded that there was a possible way of solving that ambiguity by making it clear, as it has been, that the Secretary of State’s duty is to secure the provision of services. However, the nature of the health service and what has been the position in the past in relation to the responsibility of the Secretary of State have not depended on matters being provided, but it has been understood that the Secretary of State would be answerable in Parliament. Indeed, he is responsible for providing the budget for the health service. I thought that the way to resolve this ambiguity was to make it absolutely plain in English that all of us can understand that the ultimate responsibility to Parliament would rest with the Secretary of State. This resolves the ambiguity that the Constitution Committee raised.
Lord Greaves
This is the first time that I have spoken in this Committee and I repeat my interest in this Bill as a member of a local authority. The noble and learned Lord’s Amendment 4 refers to the “ultimate responsibility” of the Secretary of State and, thereby, accountability to Parliament. At the moment, Members of Parliament and noble Lords can raised detailed issues relating to the NHS—for example, hospitals in MPs’ constituencies that might be under threat of closure or change. Would the noble and learned Lord’s amendment allow that practice to continue?
Lord Mackay of Clashfern
In my clear opinion, yes. The idea of ultimate responsibility being with the Secretary of State is that his is not the first line of action under the statute, assuming it all goes through. Indeed, such statutory bodies already exist in the health service. They have responsibilities, but the ultimate responsibility, and that which brings the Secretary of State to account to Parliament, is the one that we want to fix on. It certainly means that he and his Minister in this House must account for the provision. I use that word; although he does not have a legal responsibility to provide, he has a legal responsibility of accountability to Parliament.
Baroness Jay of Paddington
My Lords, I am grateful to the noble Baroness, Lady Williams, and the noble and learned Lord, Lord Mackay of Clashfern, who adequately and precisely précised much of the important part of the Select Committee on the Constitution’s report on this part of the Bill, to which other noble Lords have referred.
I still have some difficulty, although I realise that the amendment of the noble and learned Lord, Lord Mackay, is helpful in addressing the problem that we have all been concerned with about ultimate responsibility to Parliament—the accountability and political responsibility, particularly for the enormous budget of the health service. I take all the noble and learned Lord’s points about the fact that in real life the Secretary of State is not running clinics or bandaging people in road accidents. However, my concern remains over why, as the Constitution Committee said, the provision clause cannot simply be maintained in the Bill. Such a clause was included in the 2006 Act and in all previous legislation—as were the Secretary of State’s responsibilities. I understand that in real life the current words do not necessarily confront the true situation, but his constitutional and legal responsibility are derived through those words.
I apologise to the Committee for not being here for the debate on the previous amendment; I was unavoidably involved at another engagement in the Palace. However, the noble and learned Lord, Lord Mackay of Clashfern, spoke eloquently on Amendment 1 and repeated to the Committee the effective and powerful words in the 1946 Act. They were widely accepted all around the House as being a forceful example of how the principles behind the Act should be invoked. There was discussion on that amendment as to whether the words should be revisited if we were considering some clause of principles in the preamble to the Bill. I took note of the words that the noble and learned Lord referred to from the 1946 Act, including the words embraced by the amendment of the noble Baroness, Lady Williams, because they have been placed in every Act relating to the health service since 1946. That is why I still find it difficult to understand why the Government resist retaining these words—although the noble and learned Lord produced an eloquent argument about real life and maintaining responsibilities to Parliament.
Lord Mackay of Clashfern
Of course the words could be retained, but the question is whether it is right to retain them when, in fact, part of the option has not been in use—it was only ever an option. You should take account of what is actually happening. The passage that I was quoting as indicating what the health service is for was the general passage preceding that. These powers were given to the Secretary of State in order to implement the grand idea that was so well expressed in Section 1 of the 1946 Act. When these powers were given, they were given as options. The Secretary of State did not have to provide, he could do so by securing the provision. That option has always been there. Therefore, there has never been a legal obligation to provide, apart from such an option. When the option that has been chosen in recent years is the second one, it seems only right that the law should proceed on the basis of what actually happens. People in my profession are not unknown for continuing to use expressions from years past, which no longer have real substance to them. I do not think that it is a very good idea for Parliament to do that. However, Parliament may have understood the provision to have been the one whereby the Secretary of State was responsible. Therefore, that is the basis on which I have put forward the Secretary of State’s accountability to Parliament.
Baroness Jay of Paddington
I appreciate the noble and learned Lord’s intervention, which is very powerful. But the fact remains that as he said in relation to Amendment 1, those original words are both legally enforceable and very clear. That is in a sense our point. Although there is political capacity to put the points that he has put in his new Amendment 4, about making it ultimately responsible to Parliament, as he said himself on Amendment 1, the present wording is clear, legally enforceable and very straightforward.
Two things are legally difficult, apart from the political and constitutional relationship of the Secretary of State to Parliament and his accountability for the budget, which, again, the Constitution Committee drew attention to. This is in paragraph 9 of our report, which I may quote deliberately, because I would be very interested in the Minister and the noble and learned Lord’s reaction. Under the existing legislation, the words, which are the words in the amendment of the noble Baroness, Lady Williams, are always read together with the capacity which is in Section 3(1) of the 2006 Act, replaced in this Bill by Clause 10, which enables that provision of services. We can discuss at greater length whether they are adequate in the noble and learned Lord’s Amendment 8, and whether they are read together in the courts. Our paragraph 9 states that,
“the courts have made it clear that the Secretary of State’s duties in these sections are to be read together”.
In the leading case, which was R v North and East Devon Health Authority, colloquially known as the Coughlan case, the noble and learned Lord, Lord Woolf, when he was Master of the Rolls, appeared in the Court of Appeal. He ruled that, for example, the Secretary of State in Section 1,
“has the duty to continue to promote a comprehensive free health service and he must never, in making a decision under section 3, disregard that duty”.
The two are to be read together. You cannot dissociate the responsibility which has been in all of the Acts since 1946 from that duty to provide. In that sense, there is a question to both the Minister and the noble and learned Lord how they would resolve that problem, even if the wording in the noble and learned Lord’s Amendment 4 does cover some of the questions about responsibility to Parliament.
Lord Mackay of Clashfern
The answer to the noble Baroness’s question is this. The quotation of the noble and learned Lord, Lord Woolf, is from the first part—the duty is to promote a comprehensive health service for the reasons given. He does not—and could not, in the nature of things—refer to provision in the last part of that as a foundation for his judgment in Coughlan, because the provision was made by others. The question was whether it should be charged. So it is only the first part, not the second part. That is why I regard the first part as extremely important as the introduction to the statute—it is enforceable, and we have an example of it actually being enforced in Coughlan.
Baroness Jay of Paddington
This must not develop into a private discussion about the finer points of our report or the law, in which the noble and learned Lord would certainly be more expert than me. Surely the difference now is that, as it says in the guidance on this Bill,
“the commissioning and provision of services will no longer be delegated by the Secretary of State, but will be directly conferred on the organisations responsible”.
So the organisations responsible cannot have the legal duty that is embraced by the present Act. Therefore, the legal responsibilities of the Secretary of State are automatically fragmented. The straight line of legal enforceability and responsibility, through the bodies who have rightly—as the noble and learned Lord has said—been delegated over a number of years to other providers, has been broken. That link in the chain has gone.
Lord Davies of Stamford
Before the noble Baroness sits down, I wonder if she could just help me with—
Lord Williamson of Horton
I thought it would be nice to hear another voice, having been here since 3 pm or earlier. I should like to come back to these points and follow on directly from the intervention by the noble Baroness, Lady Jay. The word “provide” has not been used by the Secretary of State in the past; none the less it is there in the long history of this way of handling the operation of the National Health Service. We have continually heard here how in the past it has not been used, and I understand that. However, we are not legislating for the past here; we are legislating for the future. I feel that the retention of the word still has some value if we are looking ahead to the future. In this Bill we are not making special arrangements so that the Secretary of State can provide, but what will be the consequences of unexpected events which could hit us in the future when it might be sensible for the Secretary of State to provide? I do not think that that should be ruled out and, for that reason, I am attracted to the amendment of the noble Baroness, Lady Williams. It also has the advantage that in law it is highly intelligible to an ordinary person, which I always appreciate.
I now come to the amendment of the noble and learned Lord, Lord Mackay. I fully understand why he has put it forward and why he thinks that it is better to avoid putting something into the law which has not been operational, replacing it with something which is a more accurate description of what the future situation might be. However, I have one question, which I shall put to the Minister and indirectly to the noble and learned Lord, Lord Mackay.
In paragraph (b) in his amendment there is a cross-reference to Amendment 8, which lists the various intervention functions of the Secretary of State. Basically, all these interventions will be necessary because we will have been struck by some terrible problem—a failure by the Care Quality Commission or NICE. There are all sorts of terrible failures in which the Secretary of State has to intervene. However, I am still anxious about whether, under this formulation, the Secretary of State can intervene proactively—that is, without having to wait until disaster has struck in the various forms listed in Amendment 8. I make that point because I think it is of interest and importance to the people who have raised all the questions in relation to what we are now discussing and what was discussed at Second Reading and in relation to the previous amendment, which was not carried but was in fact discussed very widely in the press. Therefore, I am interested to know whether there is a possibility of proactive intervention by the Secretary of State.
Lord Warner
My Lords, I am a bit confused as to whether we are making speeches or asking questions of the noble and learned Lord, Lord Mackay, who seems to have volunteered to conduct seminars for us on many of these issues. In making some points I shall, in a way, be trying to be helpful to the noble and learned Lord. In a sense, the criticism he is receiving is unfair because his amendments bring the legislation up to date in terms of provision, which has been a fiction for many years. However, his proposal has to be read in conjunction with all the other provisions in the Bill, which continue to puzzle me. The Government have sworn that they want to be extremely hands-off, and they have their beautifully drafted Clause 4, which I think has incurred the wrath of the noble Baroness, Lady Williams, and others. Nevertheless, the Bill as a whole gives the Secretary of State quite a lot of powers to intervene, and I shall go through just a few of them.
Clause 12 confers a power to control services commissioned by the Commissioning Board or clinical commissioning groups; Clause 13, the ability to give direction on secure psychiatric services; Clause 14, the power to make arrangements for the supply of blood and human tissue; and Clause 16, regulations to require clinical commissioning groups to exercise EU health functions. Under Clause 17—even better—the Secretary of State can make regulations that impose standing rules on the Commissioning Board and clinical commissioning groups to arrange for specified treatments and a raft of other things. Clause 20 is the mandation clause, where the Secretary of State can mandate the board before the start of each financial year to specify objectives and the requirements for achieving those objections.
That set of measures looks very un-hands-offish to simple souls such as me. I think that we are getting ourselves into a bit of a state about this, because the Secretary of State seems to have very extensive powers. I admit that some of the public discourse may have been a bit confused by the explanation that the Government’s candidate for the chairmanship of the NHS Commissioning Board gave in his interview. He seemed to have a very hands-off picture of what the Secretary of State should do, and I suspect that he may not have read the Bill quite as carefully as your Lordships will have done. We have to look at the amendment of the noble and learned Lord, Lord Mackay, in the context of making the legislation honest but with the Secretary of State retaining huge powers in the Bill to intervene and direct operations.
Lord Newton of Braintree
My Lords, I am once again tempted, in this case by the noble Lord, Lord Warner, with whose views I almost entirely agree. Indeed, I find myself on an alarming number of occasions having quite a lot of fellow feeling with him. I will return to one or two of those points briefly. Being a singularly modest character, these debates are beginning to induce in me a feeling of considerable intellectual inadequacy—which I suspect is not the case with the noble Lord. I constantly feel that I am in the presence of angels dancing on the heads of pins. I hear the noble Baroness, Lady Jay—I hope she will not mind my saying this—saying, “We might as well retain this, because it has always been there”, even though we know it has never been the reality. At that point, we stop being angels dancing on the heads of pins, and we start dancing round a totem pole. On the whole, if we are going to dance round a totem pole, I would like a totem pole that reflects what we want to happen, not what was written into a Bill 60 years ago. The noble Baroness thinks I am being unfair.
Baroness Jay of Paddington
I certainly do not think that the noble Lord is being unfair. I suggest to the noble Lord, Lord Newton, that he reflects on what the noble and learned Lord, Lord Mackay of Clashfern, said on Amendment 1, which was precisely to invoke the Act of 60 years ago, and to pray it in aid, as reflecting what could be a useful addition to the principles of this Bill. That is precisely what I am seeking to address.
Lord Newton of Braintree
I strongly supported and continue to support that, which is very reflective in ensuring that we do rest on the original foundations. I never thought I would be a natural Bevanite, but it appears that I have become one, together with a number of others.
That was not quite the point—we were then talking about a preamble. We are now talking about a slightly different provision. I would be entirely happy to see the preamble of the 1946 Act incorporated into this, with—as I said in my speech earlier—perhaps a little tweaking. However, we are now talking about the best way of ensuring and establishing the responsibilities, in the real world, of the Secretary of State. I have another sense of unreality in all of this, born of many years in the Commons. The idea that, whatever this Bill says and however precisely it is worded, the British political system—the House of Commons in particular—would allow the Secretary of State to dispense £120 billion per year of public money without being answerable and accountable to Parliament, is inherently ludicrous. The system would not allow it to happen. I am all in favour of writing that into the Bill if we can find appropriate terms, but in reality that will be the case whatever we have in this Bill.
I agree—and not for the first time—with everything my noble friend Lady Williams said about the importance of making this clear beyond a peradventure. I am quite happy with that.
Baroness Thornton
My Lords, I hesitate to intervene, but the problem we face is that this Bill does precisely what the noble Lord is saying he does not want to happen, which is that the Secretary of State will be properly accountable for £120 billion of taxpayers’ money. The Bill puts into statute the ability for the Secretary of State to be challenged, when and if he faces those issues. That is the problem we have.
Lord Newton of Braintree
I hope that noble Lords will forgive me for not sitting down, but it may be obvious to the House that one of my more strenuous activities is moving from the sedentary position to a standing one. I prefer not to do it unnecessarily frequently.
I do not agree with that, but I have also made it clear that I have no objection to this being made a little clearer than it is thought to be in the drafting, which is what the noble Baroness, Lady Williams, is looking for. If I might just go on, I will not do so at great length. The noble Baroness was also very sensible and right to acknowledge that the way forward suggested by my noble and learned friend Lord Mackay was better. At the moment, on balance, it probably is. I am agnostic on that; I am naturally supportive of my noble and learned friend, but these are different ways of achieving an objective that we all share.
I will not say much more except for one point on the autonomy clause and issues that have more recently been raised by the noble Lord, Lord Warner. I have some sympathy with my noble friend Lady Williams on the autonomy clause, which we have yet to get to. I hope the noble Lord, Lord Davies of Stamford, was listening to what the noble Lord, Lord Warner, said: a lot of people who have commented on the apparent or alleged withdrawal of Secretary of State powers in this Bill have not actually read what is in the Bill.
I will give one example. Under the arrangements made by the previous Government for Monitor to be the controller and regulator of foundation trusts, I think I am right in saying that the Secretary of State had no power to intervene. In this Bill, he does. If Monitor fails to do the right things, the Secretary of State can intervene. That was not the case before.
One thing that I was very iffy about—I do not know how Hansard will deal with “iffy”; perhaps I should say “uncertain”—in the previous Government’s record was their setting up of foundation trusts. The rhetoric was that the Secretary of State was abandoning responsibility to foundation trusts and Monitor without any power to control what happened. That situation was introduced by the Labour Government and is corrected by the Bill. We have heard a lot of distortion about what the Bill is intended to do and what it actually does. My concern is to reassure the public about what in my view are unfounded fears. The noble Lord, Lord Warner, has materially helped us in that.
Lord Davies of Stamford
I listened with great attention to the noble Lord and took on board what he said. Of course, the position of Monitor is not entirely comparable because under the Bill it has vastly more powers.
Lord Davies of Stamford
Monitor under the Bill will have vastly more powers than it had. As a result, the situation is not entirely comparable. That is my point.
Lord Newton of Braintree
Monitor has extended responsibilities—and, importantly, a much clearer remit to be concerned with the quality of patient services—beyond what it had when its overwhelming focus was on financial matters. I regard that as an improvement. The Secretary of State under the Bill has more powers over Monitor than it had under the original proposals introduced and passed by the Labour Government. I see that the noble Lord, Lord Warner, is nodding his head.
This is a difficult and complex area. We could argue for ever about the best way to deal with it. I say to my noble friend on the Front Bench that I hope that we can find a way forward. I also hope that many noble Lords will recognise that some things said about the Bill are simply not true.
Baroness Hollins
My Lords, I seek clarification. I am very sympathetic to the amendment tabled by the noble Baroness, Lady Williams. To remove a key word without good reason causes anxiety and I am not convinced by the reason given for removing it. Perhaps I could ask the noble and learned Lord, Lord Mackay, to clarify whether his amendment would ensure that the obligations required as a result of the Coughlan case would still be protected.
Lord Mackay of Clashfern
Yes, precisely; I tried to say that when I referred to the 2006 Act. The passage in the 1946 Act on which my noble and learned friend Lord Woolf relied as Master of the Rolls in Coughlan was the first part—that is, the duty to promote a comprehensive health service, free at the point of need. That was its function. It was in the nature of a preamble: the first part of the first provision of the Act. That was what my noble and learned friend Lord Woolf regarded as enforceable. In relation to Amendment 1, I said that that section had been demonstrated to be enforceable in law, which one could not say for sure about the amendment that the noble Baroness, Lady Thornton, promoted as the first clause of this Bill. Of course, the provision referred to by my noble and learned friend Lord Woolf is maintained in the Bill.
Lord Hennessy of Nympsfield
My Lords, at Second Reading, the noble Earl, Lord Howe, indicated that he wished to put the constitutional position and accountability to Parliament of the Secretary of State beyond doubt. In his letter to your Lordships of 20 October, he repeated his commitment, writing that:
“We are willing to listen and to 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”.
Perhaps the simplest way of achieving this is to sustain the requirements of the National Health Service Act 2006, as the amendment in the name of the noble Baroness, Lady Williams of Crosby, seeks to do.
If successful, this amendment would certainly extend the legislative DNA captured in the pioneering National Health Service Act 1946. However, it can be argued—as it has been by the noble and learned Lord, Lord Mackay of Clashfern, the noble Lord, Lord Warner, and others—that the reality of the Secretary of State’s position since the late 1980s requires a reworking of the accountability of the Secretary of State that reflects the fact that successive incumbents have not been direct providers of services for over 20 years. For that reason, a differently crafted amendment, such as the one in the name of the noble and learned Lord, Lord Mackay of Clashfern, would be more fitting.
As the Minister has said, the test is the need for this Bill to be unambiguous in capturing the Secretary of State’s core constitutional position and accountabilities at the very apex of the NHS, where policy, administration and money meet. I have great sympathy with the impulses behind the amendment tabled by the noble Baroness, Lady Williams, but I also think that subsections (2)(a) and (2)(b) of the amendment tabled by the noble and learned Lord, Lord Mackay of Clashfern, make the Secretary of State’s accountabilities unambiguous. Therefore, I profoundly hope that the Minister will be able to accept the amendment tabled by the noble and learned Lord, Lord Mackay of Clashfern, as Parliament’s instrument for genuinely putting the matter beyond doubt.
Lord Harris of Haringey
My Lords, I apologise to the House because at Second Reading I inadvertently failed to declare an interest, as I have now been reminded by the Mirror, that I am an adviser to KPMG. I regret that it had slipped my mind as I have never advised it on anything to do with health or any of its global interests that include advising on health matters. I apologise to the House and I hope I have now corrected the omission.
I rise to speak to the amendment in the name of the noble Baroness, Lady Williams of Crosby, because this is an issue that requires greater clarity, and the debate and discussion that has already taken place in Committee this evening demonstrates why that is so. As my noble friend Lord Warner has reminded us, Professor Malcolm Grant, the newly appointed chair of the national NHS Commissioning Board, has made clear what appears to be the Government’s intention with regard to the role of the Secretary of State. I assume that he did so under advice, because you do not take on a role like the chair of the NHS Commissioning Board without extensive discussions with Ministers and civil servants. He must have been briefed on the matter and quite clearly the intention is to separate out the day-to-day responsibility and answerability of the Secretary of State. There has to be some clarity on this point.
The noble Lord, Lord Newton, has pointed out that the Secretary of State de facto will be held to account by Parliament because this is about the way in which a budget of £120 billion is spent and disposed of. However, the reason we need—and the public will expect—clarity is that if the Secretary of State’s role is simply to account to Parliament that a sum of money has been passed to the NHS Commissioning Board, that will not be sufficient in holding the Secretary of State to account as to whether that sum of money is the appropriate sum and what the consequences are of not making available appropriate sums of money. That is why I suspect it becomes important.
The noble Lord, Lord Hennessy, has suggested that perhaps the form of words that the noble Baroness has used needs refreshing, because they hark back to the Bill 60 years ago. He suggests that the amendment of the noble and learned Lord, Lord Mackay of Clashfern, may be better suited to the purpose. However, I have some reservations about the wording used by the noble and learned Lord, Lord Mackay, in that he talks about ultimate responsibility. We may have an inkling about what ultimate responsibility means, but I wonder where else in legislation a phrase such as this is used. I defer of course to the noble and learned Lord’s far superior knowledge of the law. However, in my limited experience in this House, I have never before come across the words “holds ultimate responsibility to Parliament”. It seems a very strange usage and I think that there needs to be greater clarity and understanding about what it means. That is why it might be better to revert to the wording chosen by the noble Baroness, Lady Williams. It is tried and tested and at least we understand it.
We also have to recognise that the noble and learned Lord’s amendments helpfully set out the intervention powers and the circumstances in which they will be part of the Secretary of State’s duties, which is all very well. However, intervention powers, by their very nature, occur after the event. Something has already gone wrong.
In our earlier debate—I hesitate to hark back to it—about the role of Health Education England, the Minister told us that the Secretary of State would continuously hold Health Education England to account. However, that is different from having responsibility. Again, we need to be clear on who is answering for that. How will that be done? The fact that the Minister had to stand up and tell us that there are intervention powers, but that of course on a day-to-day basis he would be holding Health Education England to account, suggests that the current form of words in the Bill is simply not accurate.
The final test that your Lordships need to consider is: what do the public expect? The public’s expectation is that government is responsible for what happens in our health service; and unless there are locally elected officials who are responsible for what happens at a local level, they will expect their elected Government to be responsible, and that means the Secretary of State.
Lord Owen
My Lords, this has been a fascinating debate and it has certainly taken the arguments further. I do not think that anybody expects that we will vote tonight, and I think that we will come back to this at Report.
There are merits in both of the cases put forward. In some respects—we can argue about the word “ultimate”—the idea of responsibility to Parliament has merit. It also tallies with the expression used by the noble Lord, Lord Newton. When people realise what the chairman of this largest quango thinks he will do, there will be uproar. Unfortunately, we have not yet been able to read those things—we know about them through reports, but we have not yet read them. It is very clear that the chairman-designate takes the view that he is given the money, he is given the mandate—a three-year mandate which is of course subject to change—and he then decides. It is pretty clear that some people think that that is a very good idea. I think that the noble Lord, Lord Warner, is pretty close to that position.
Lord Warner
I cannot resist responding to that. I do not accept that position. I was trying to say that what the putative chairman is saying seems to be in conflict with what is provided for in the legislation, which requires the Secretary of State to produce a mandate before the start of each financial year. That is a very clear marching orders provision in the hands of the Secretary of State.
Lord Owen
When we look at what has been said, we will have a better idea. As the Bill unfolds in all its complexity, we are all part of the education process. We saw that in the earlier debate about education. It is not satisfactory for Parliament to rest powers against the wording of the legislation; that is why we worry about words. Words matter here; we cannot get away from that. That is why I come back to the provisions in the admitted interventions—“failure”, “emergency”—which are extreme words, and are deliberately designed to be. We have to look at that.
We will not come to a view on the Secretary of State’s powers until we have finished Committee, looked at the whole Bill and have a feeling for what is to be changed by the Government. We will then come back to it. Personally, I hope that the Select Committee on the Constitution itself comes back to have a look at this. The committee has some very distinguished members. I would like to reserve judgment. The noble and learned Lord, Lord Mackay, who was one of our most distinguished Lord Chancellors, has made a very valuable contribution. Some of his explanations may even be of use in future law courts. I certainly stand by the amendment produced by the noble Baroness, Lady Williams, because it is tried and trusted, but I have made it clear that I would not object to wording put into this Bill at an appropriate stage which states that the Secretary of State is not micromanaging the National Health Service. Unfortunately, there is a public perception that comes to the Secretary of State for every damn thing under—I think I have made myself clear. We do not want that to happen and we know that it should not happen. We mouth the words of a decentralised health service without being willing to admit that there are limits to what people can be held accountable for. However, I do not think that failure and emergency are the parameters. They have to be lowered if we are going to make sense of this.
Lord Newton of Braintree
My Lords, before the noble Lord sits down, to use the classic formula, perhaps I may take the opportunity to say that in a series of debates in which he and I have not always seen eye to eye, I agree with pretty much every word he has just said. In particular, I do not think that we should return to this until we have been through the rest of the Bill and seen where we are on things such as the powers of the Secretary of State, the wording of those powers and the like. The noble Lord has made a very sensible point by saying that we can then form a better judgment about what is required in this area.
Lord Mawhinney
My Lords, I want to associate my initial remarks entirely with what my noble friend Lord Newton has just said. The noble Lord, Lord Owen, has given the Committee good advice. I have sat through the whole of today’s debate, as have most of us, and it has been interesting to note how much we have learnt about this Bill simply by talking to and listening to each other. I share the view of the noble Lord, Lord Owen, that the learning process has only just begun and is not nearly complete, so it would be foolish to rush to judgments.
I would say to my noble and learned friend Lord Mackay that he knows there is no one I hold in higher regard than him. The formulation in his amendment is extremely helpful because it encapsulates the legal realities. So if I had to judge on the basis of the legal realities, I think I would favour my noble and learned friend’s amendment.
On the other hand, I should say to the noble Baroness, Lady Williams, that the strength of her amendment lies in the fact that it has 60 to 70 years of continuity. If we are looking for the constitutionally more helpful amendment, it may be that of the noble Baroness. I say that also conscious of the fact that out there, as we keep telling each other, there is a degree of nervousness about this Bill. Some of it is well founded and some of it is scaremongering, a word I have used before. But there is a sense of unease. The continuity of 70 years of using the same language might help to address the issue. That is why I say that constitutionally I lean towards the noble Baroness, Lady Williams, while legally I lean towards my noble and learned friend, and I do not want to make a choice at the moment.
Maybe it is partially because the noble Lord, Lord Newton, and I spent so many years in the other place but, as he said, I too believe that the reality is that out there £128 billion is really rather a lot of money. The idea that when somebody threatens to close the Peterborough Hospital my former constituents are going to settle for the chairman of a quango, no matter how illustrious, experienced or wonderful he is—I do not know the gentleman but I am sure that he is all of those and a whole lot more—is just not in the real world. I tell you that as somebody who can still fairly clearly remember what it was like to be a Member of Parliament. Indeed, I can remember fairly clearly what it was like to be the Health Minister and it is still not in the real world.
The noble Lord, Lord Warner—I promise not to keep doing this—was very helpful to this Committee because he pointed out the Secretary of State’s powers. Unusually, I am not sure my noble friend Lord Newton was quite right when he used Monitor as an example. He was right in the technical sense that the previous legislation set up Monitor apparently free. As my noble friend said that I thought about all the newspaper stories I have read recently about how PFI is falling apart and the mounting debt Monitor is having to deal with because the PFI arrangements for foundation trust hospitals were simply not in the real world. The idea that the Secretary of State for Health is not finding some way to intervene with Monitor—he would have to if Monitor wants more money to offset that debt—shows that the reality of what happens on the ground is extremely important.
I say to my noble friend the Minister that there is one other aspect of this on which, as a simple Belfast boy, I am confused. The NHS Commissioning Board has legal status. As the noble Lord, Lord Warner, reminded us, the Secretary of State gives it a mandate and then it has a legal status. Does that mean that the Secretary of State’s lawyers have to relate to the NHS Commissioning Board’s lawyers if the Secretary of State wants to have some involvement during the course of the year—even if it is only in the context that the noble Lord, Lord Owen, does not like of emergency or failure? We need to have a much clearer grasp of the practical realities of the consequences of this Bill. Whatever the intellectual framework and the ideas that coherently come together to provide esoteric new arrangements, this Bill has to work in the real world. This Committee needs to be encouraged by my noble friend to believe that the Secretary of State is going to be at the heart of making this Bill work in practice.
Baroness Warwick of Undercliffe
My Lords, I had not intended to speak but I feel quite anxious that we are contemplating the prospect of not producing an amendment of the kind the Minister suggested he would be willing to accept. I understand the points made by other Peers. I am really conscious of the anxiety that has been expressed in the huge amount of representations, letters, e-mails and so on that we have had.
A point about which I felt strongly at Second Reading is that our own Constitution Committee has indicated anxieties that I think are shared by a large number of people. We need to indicate we are going to take seriously the views of that committee.
Many of the anxieties expressed may either have been caused by scaremongering or become totemic, but they none the less exist. Some of them seem not to be so ill founded. Other speakers have already referred to the fact that, as the Explanatory Notes state, the commissioning and provision of services will no longer be delegated by the Secretary of State, but will be directly conferred on the organisations responsible. As the Select Committee indicates, the Secretary of State must secure that,
“any other person exercising functions in relation to the health service or providing services for its purposes is free to exercise those functions or provide those services in the manner that it considers most appropriate”.
There seem to be at least grounds there for anxiety that the Secretary of State may be seeking to offload responsibility.
I hope that, however long it takes us during these discussions—after some of the discussion on the previous amendment, I became even more anxious about the role of the Secretary of State—we will be able to find a form of words that satisfies the anxieties expressed. I do not know whether that wording should take the form of the amendment of the noble Baroness, Lady Williams, or that of the noble and learned Lord, Lord Mackay, but we should endeavour to allay that anxiety, because it is undermining an awful lot of interest in and support for other parts of the Bill.
Baroness Cumberlege
My Lords, this is the first time that I have entered this Committee debate, so I declare an interest as the executive director of Cumberlege Connections, which is a training company.
I am very grateful to the noble Lord, Lord Owen, for mentioning micromanagement, because a lot of our debate stretches beyond just the accountability of the Secretary of State to the organisations that are going to be set up that will have devolved powers. I can understand some of the concern felt about financial probity and the money that is going to the National Health Service, £80 billion of which will go to the NHS Commissioning Board. I shall try to provide a little comfort to the noble Baroness, Lady Williams, and the noble Lord, Lord Harris, who seemed to imply that this money was going to be shelled out by the Secretary of State and he was then going to disappear, leaving no accountability. However, paragraph 14(1) of Schedule 1 states:
“The Secretary of State may require the Board to provide the Secretary of State with such information as the Secretary of State considers it necessary to have for the purposes of the functions of the Secretary of State in relation to the health service”.
Paragraph 14(2) states:
“The information must be provided in such form, and at such time or within such period, as the Secretary of State may require”.
There is clearly an opportunity here for intervention and for the Secretary of State to make sure that probity is being exercised.
Lord Harris of Haringey
But surely that simply states that there shall be a requirement to provide information. It does not then give the Secretary of State a power to intervene. All it means is that one has an informed Secretary of State, which is tremendously helpful, but not a Secretary of State who is able to say, “Well, this is clearly not in the public interest in terms of the way that these moneys have been disbursed”.
Baroness Cumberlege
That is true up to a point, but can you imagine, when the Secretary of State receives that information, that he will do nothing about it? That would be extremely unlikely.
The other thing I would like to say is about the comments of the noble Lord, Lord Hennessy, on ambiguity and clarity. It seems quite strange to put a word into this Bill that is archaic and no longer used. It no longer serves a purpose, in that what is being done at the moment does not relate to the Secretary of State providing anything. If we are going to be really clear about legislation, surely we want to make sure that the words used are relevant to today. Including the word provide, which is no longer being used—the Secretary of State has powers to provide, but he does not actually provide services—seems a pretty irrelevant and an archaic way of producing legislation. I very strongly support the noble and learned Lord, Lord Mackay of Clashfern.
Baroness Northover
My Lords, as agreed earlier, it now being nine o’clock, I beg to move that the House be now resumed.