Grand Committee
Arrangement of Business
The Deputy Chairman of Committees (Baroness Pitkeathley) (Lab)
My Lords, if there is a Division in the Chamber while we are sitting, the Committee will adjourn as soon as the Division Bells are rung and resume after 10 minutes.
National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022
(1 year, 11 months ago)
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Lord Markham
That the Grand Committee do consider the National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, I start by wishing everyone a happy new year and welcoming the noble Lord, Lord Allan of Hallam, to his position. It gives me great pleasure to speak in this debate and I welcome the opportunity to discuss these draft regulations.
The Health and Care Act 2022 marks an important step in the Government’s ambitious health and care agenda. Noble Lords will be fully aware of how wide-ranging a piece of legislation it is. I think we can all agree with its overall objectives; making it easier for health and care organisations to provide joined-up care is vital.
With the introduction of integrated care systems came the opportunity to review how the financial frameworks in the NHS worked and tailor them to make them consistent with the new integrated approach. The Health and Care Act replaces the NHS national tariff payment system with the NHS payment scheme by inserting new Sections 114A to 114F into the Health and Social Care Act 2012. As with the tariff, the NHS payment scheme will set rules around how commissioners establish the amount to pay providers for healthcare for the NHS. It does not set the amount of money available but intends to make sure that available resources are used as effectively and efficiently as possible.
Before a new payment scheme can be published, NHS England has a duty under the Health and Social Care Act 2012 to consult on the proposals for the new scheme, as it did with the tariff. NHS England is required to consult each integrated care board, each relevant provider and other such persons it considers appropriate. It opened the consultation on the proposals for the 2023 to 2025 payment scheme on 23 December 2022, which is scheduled to close on Friday 27 January 2023.
This brings me to the purpose of these regulations, which is relevant to how those consulted respond and what this means for NHS England. The purpose of this SI is to set these objection percentage thresholds at 66%, which will be reached if the requisite percentage of either integrated care boards or providers object. I believe this is a proportionate level to ensure that a qualified majority can require NHS England to reconsider its proposals, while minor objections cannot stop them. I also consider laying these regulations to be a relatively administrative process. The objection percentages are not changing compared to previous consultations on the tariff; we are maintaining the status quo with 66%. I commend these regulations to the Committee.
Lord Patel (CB)
My Lords, I thank the Minister for his comments. I too wish everybody a happy new year. My question is quite simple, and it reflects the discussions we had during the debate on the Act that we passed: is 66%, which is two-thirds, too high a level for the objections? It is a higher order to achieve than, let us say, 60%.
While we await the tariff, I reiterate, so that it is on record, that the important bit is not the level at which the trusts and ICSs can object but how the tariff will vary according to the needs of the population. When we had the debate, we focused on existing inequalities in health and how to minimise and reduce them. One way of doing that is to address the needs of the population who have greater need in healthcare, and therefore the tariff needs to be different. It is a high order to require 66% of ICSs, trusts or providers to object.
I would like the Minister to confirm that the tariffs will reflect the need for the levelling-up agenda to improve healthcare, particularly in more deprived populations, and to comment on why 66%, which is two-thirds, was chosen.
Lord Allan of Hallam (LD)
My Lords, I am pleased to be able to take the reins from my noble friend Lady Brinton, starting with this short but important statutory instrument. I echo the happy new year wishes and thank the Minister for his welcome. I understand that a key function that we perform in this House is to ensure that legislation is implemented in the way that Parliament intended as we put flesh on the bones of primary legislation through statutory instruments such as the one we are considering today.
Today’s statutory instrument is a small element of an important part of our modern health service infrastructure: the mechanism for pricing services within the NHS’s internal market. It was a prompt for me to read more pages of tariffs and rules than I ever intended or wished to do, which is mind-boggling and fascinating in equal measure. The subject of our debate today is not the substance of the payment scheme but rather the trigger for when the scheme might be reviewed if there are objections.
As the Minister pointed out, the Government’s intention is to maintain a 66% objection rate for triggering a further consultation period, which is unexceptional as it maintains the previous level. However, like the noble Lord, Lord Patel, I am curious as to why 66% was picked, particularly as I understand that it will not trigger a referral to the Competition and Markets Authority, which would have been a major step, but simply a further consultation period. There may be an argument for why a 51% or 60% threshold would not be appropriate, given that the threshold triggers something less significant than the previous regime.
I am also curious about the experience that we have had over the last decade or so while the other tariff scheme has been in place. Does the Minister have data on the levels of objections received in previous consultations? I suspect that they were much lower than the level we are talking about here but, as we review the scheme, it would be interesting for us to understand whether we were previously getting 10% objection levels, or 50%. I assume that there must be some experience of that within the National Health Service.
Like the noble Lord, Lord Patel, I would like more words about why 66% remains the effective level, and some information about objection levels we have experienced previously. That would be helpful to put our minds at rest, but I think we are all broadly supportive of the instrument as it stands.
Baroness Merron (Lab)
I thank the Minister for introducing this statutory instrument. It is a great pleasure to follow the noble Lord, Lord Allan, for the first time in his new role. I am sure there will be many more times, and we all wish him well. Of course, from these Benches, I echo the happy new year greetings. The new year gift to the Minister is that on no side are we opposing these regulations today. I am sure that will make him absolutely delighted as he starts 2023.
The consultation that we are talking about here is important because, as noble Lords have said, the NHS payments scheme governs how billions of pounds of taxpayers’ money is spent. Of course, quality of care and value for money have always to be at the core of our health service and its decision-making, and we need financial management within the health service to be able to deliver both quality of care and value for money in parallel—they are not an either/or. We saw during the pandemic what happens when the NHS strays from these principles, and we do not want to allow such events to happen again.
The former tariff system which these regulations form part of replacing sought to deliver a more competitive environment to drive up quality and to improve outcomes for patients yet, regrettably, it was often something of a rather rigid system that did not allow for the flexibility that individual commissioners actually needed. Therefore, giving local decision-makers the tools that they need to improve services in their areas is absolutely vital to ensuring that the NHS meets the needs of patients where they are, not where the system thinks they should be. The noble Lord, Lord Patel, raised an important point about meeting the needs of patients where there is variability across the country, and it would be helpful if the Minister could offer us some comment on that. With that in mind, a rigorous and effective consultation on changes is absolutely vital, because we know that, when done properly, payment schemes can deliver a meaningful impact on patient outcomes.
The payment by results incentives that were used by the last Labour Government made a significant impact on the elective waiting lists. We know that this may not be the appropriate way forward in every case and that options have to be carefully considered, but we are now in a situation where elective waiting lists are at record levels. So, given the reports that Ministers are considering bringing back payment by results incentives in some form or another, perhaps the Minister could give some comment on what plans are in place to do that.
I will ask a further question to get a sense on this. As we are talking about billions of pounds of public money—of course I believe that this SI and other discussions that we have treat this point with the gravity that it warrants—it would be helpful to hear from the Minister whether he considers that there is enough input through the Secretary of State into this process. I am of course not suggesting that Ministers should be setting payment levels for various treatments, but it would be helpful to have a sense about whether there is enough political input into how we might ensure that the extraordinary purchasing power of the NHS might incentivise innovation, prevention or, for example, buying British.
Furthermore, in previous consultations on the national tariff, such as in 2014, the objection percentage was met, but how have the NHS and the department worked since then and engaged with stakeholders to prevent that from happening again, as far as possible? I was also pleased to read that the department will be monitoring and reviewing the implementation of this legislation. Can the Minister give us some more detail on what form this will take and whether the analysis could be made public? That follows on from the point made by the noble Lord, Lord Allan.
It is important that we get right these changes that we are considering today, and effective consultation is absolutely key. It is in the interests of everyone, because it will ensure better outcomes for patients. I therefore look forward to hearing from the Minister how this will be delivered.
Lord Markham (Con)
I thank noble Lords for their contributions to the debate. A number of issues were raised which, as ever, shows the diligence of noble Lords, particularly as I believe none were raised in the other place—so good for us. Let me try to address them.
Most of the comments were around whether 66% is the right threshold. My understanding is that it was kept at 66% because that is what historically the number has been, so it was decided to continue with that for reasons of continuity. At the same time, I accept the point that the consequences now in terms of it no longer being a Competition and Markets Authority review are not so high. To my mind, the real question is: what circumstances have we seen where it has fallen between 50% and 66%? Clearly, no one would ever say we should have a threshold of less than 50%, but should it be somewhere between those figures?
I think I need to give the disaggregated figures to be able to give a specific answer. I have aggregated the responses where generally there were much larger majorities. Looking at the last three years, for instance, in 2019-20, the figure for those responding positively was 66%, so right on the threshold; it was 78% in 2021 and 77% in 2021-22. So those figures are fairly high. However, if I may, I will come back with the disaggregated figures, because it is only those that give the real data.
The noble Lord is correct that the idea behind having the ICSs involved in these is very much to try to set them around local needs, to make sure that they are understanding that and reflecting some of the inequalities that might exist in their local area.
To address to some extent the point about ministerial or political input, obviously having those thresholds set does not stop Ministers being involved in the decision and seeing that, even if it is a lower threshold, the point raised about particular local circumstances can mean that something needs to be overruled. Funnily enough, it was something we have been talking about in terms of Ministers today. The Secretary of State was saying that with the procurement function, while it is seen by a lot of people as a bit dry and boring, you actually have tremendous buying power and can move the needle very significantly, whether in getting economies of scale in terms of purchasing and purchasing power, incentivising innovation or buying British—which is exactly the point that the noble Baroness, Lady Merron, made. I know that is very much understood by the current ministerial team. I cannot speak historically, but that is very much on our agenda at the moment.
On reviewing this legislation going forward, to look at how well it has worked, I am happy to commit to making sure that we have a further opportunity to reflect on the findings. We would probably need to give it at least a year, maybe more, but we can then have an opportunity to see whether the system has worked in the way we hoped. By definition, that works only if there is then some sort of transparency in terms of the feedback, so that noble Lords can see it and reflect on it. I am happy to take that on; I think it is a wise way forward.
With that in mind, and if I can come back with the detail on those percentages, I will welcome my new year’s gift—may those gifts keep flowing, but I suspect maybe they will not. I appreciate the input from noble Lords today. I hope that we will feel that we have struck the right balance going forward and, crucially, that we are getting the local input we need to set the right process going forward.
Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022
(1 year, 11 months ago)
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Lord Markham
That the Grand Committee do consider the Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022.
Relevant document: 15th Report from the Secondary Legislation Scrutiny Committee
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I thank noble Lords, and declare what is a kind of interest, in that my wife, as many noble Lords have heard me mention before, is an international dentist. For my sins, I had the joy of helping her to fill out one of these international GDC registrations—so I have a little bit of knowledge in this space. It was not the most riveting exercise of my life, but I do have some knowledge.
I beg to move that the order be approved. International dental care and nursing professionals form a vital part of the NHS workforce and make an important contribution to the delivery of healthcare in the UK. The GDC and the Nursing and Midwifery Council are the independent statutory regulators for the dental and nursing and midwifery professions in the UK, and nursing associate professionals in England, respectively. They set registration standards for healthcare professionals who wish to practise in the UK.
International professionals who wish to practise here must meet the same rigorous standards that we expect of UK-trained professionals. We believe that it is in everyone’s interests that such professionals can use registration processes that are a fair test of their professional competence and that provide them with a clear route to registration. We are reforming the legislative framework for the regulation of healthcare professionals to better protect patients, to support our health services and to help the workforce to meet future challenges. Ahead of this, action is required to provide the GDC and NMC with greater flexibility to amend their international registration processes. This will help the regulators ensure that future international registration pathways are proportionate and streamlined, while continuing to robustly protect patient safety.
We plan to take forward all the proposals we consulted on and have made one small amendment to the order in the interests of patient safety. This relates to the requirement that a qualification relied on by international applicants to the dental care professionals register can no longer be a diploma in dentistry. This change introduces fairness and consistency between the UK and international routes, as UK-qualified dentists cannot apply to join the DCP register using their dentistry qualification. The GDC also expects that increasing the capacity of the ORE exam will support international dentists applying to join the GDC’s register. The amendment will allow the GDC to process applications from dentists to join the register as DCPs that are received up to the day before the order comes into force. This guarantees that any live DCP title applications submitted before the legislation is passed will be processed.
I draw the Committee’s attention to an issue raised by the Secondary Legislation Scrutiny Committee, which noted that the Committee may wish to seek reassurance on how appropriate safety standards will be maintained. The primary purpose of professional regulation is to protect patients and the public from harm. Any new or amended registration pathways will be based on applicants meeting the same standards of training and knowledge as UK-trained professionals. These standards are set by the independent regulators in consultation with the professions, the public and education providers.
The order provides the GDC with greater flexibility to apply a range of assessment options for international dentists and dental care professionals. The GDC will have much greater freedom to update its overseas assessment fee, content and structure, now and in the future, as these will no longer be set in legislation that requires Privy Council approval to be changed. The requirement that dental authorities provide the ORE is removed, allowing the GDC to explore alternative providers. Candidates who were affected by the suspension of the exam during the Covid pandemic will be provided with extra time to sit it.
I understand that the GDC will first consult on the new rules in its international registration processes, which will come into force 12 months after this order is in force. It plans to increase the capacity of the ORE exam and support greater numbers of international dentists to join the register more quickly.
The order also includes a charging power, so that fees can be charged to international institutions for the cost of recognising their qualifications. This will support the GDC in registering individuals either based on an assessment of their qualifications, skills and training or by recognising the qualifications they hold.
On changes to the Nursing and Midwifery Order 2001, the NMC will have the flexibility to use two pathways in addition to its test of competence, which will remain its primary registration assessment. The first is recognition of an international programme of education. The second is qualification comparison, whereby the NMC may ascertain whether an international qualification is of a comparable standard to a UK one. The draft order also clarifies the NMC good health and good character declaration requirements. I commend this order to the Committee.
Lord Hunt of Kings Heath (Lab)
My Lords, I first declare an interest as a member of the General Medical Council. I welcome this order and pay tribute to the NMC and the General Dental Council for their work—and particularly to my noble friend Lord Harris, who so eminently chairs the GDC.
As the Explanatory Memorandum makes clear, this is in a sense an overture for a suite of orders that the Minister will bring in relation to all the registering bodies, essentially to streamline the fitness-to-practise processes—in the case of the GMC, to enable the statutory registration of physician associates and anaesthetist associates—and to update the governance of these bodies.
I noted in paragraph 10.4 of the Explanatory Memorandum the statement:
“The Department’s view is that it is for the regulators as independent bodies”.
I ask the Minister to assure me that in those new arrangements and governance processes the Government are as committed to these bodies continuing as independent entities as they have said during the consultation process.
I also raise with the Minister the one area in which I think the consultation produced disagreement in relation to the proposals, which is in regard to the DCP register and the fact that, as I understand it, dentists qualifying overseas are not to be allowed to come on to the DCP register. This was raised in Committee in the Commons. The Minister said:
“The change introduces fairness and consistency between UK and international routes because UK dentists cannot qualify or apply to join the DCP register using their dentistry qualification in other countries.”—[Official Report, Commons, Delegated Legislation Committee, 6/12/22; cols. 7-8.]
The point I want to put, which has been put to me by a dental practitioner, is that we are biting off our nose. We are disallowing future working by dentists from overseas in the professions covered by the DPC. The dentist said to me:
“I am working alongside four experienced dentists, three in the UK under the Homes for Ukraine scheme and one under the Afghan resettlement scheme.”
If this change occurs in the future, I think that they may be covered by the current grandparenting provisions. However, if this were to happen in the future,
“their livelihoods and contributions that they could make to our society would be severely constrained. Even with excellent English, overseas dentists are waiting some time … to sit the overseas registration exam”,
which allows them to practise as dentists, although I know that the GDC is considerably improving their performance to allow them to. The dentist went on to say:
“In the meantime, if the GDC implements this restrictive measure, overseas dentists could then take employment only as trainee dental nurses”,
which is really wasteful of their abilities.
I would like further clarification from the Minister about why this is taking place. Given the workforce challenges in the dental profession at the moment, I question whether this is the time to implement a new provision simply because dentists in the UK cannot be recognised in other countries. Perhaps the Minister would be prepared to look at this again.
Lord Harris of Haringey (Lab)
My Lords, the noble Lord, Lord Hunt, has effectively declared my interest for me. However, just for the record, I declare that I am chair of the General Dental Council and have been for the last 15 months or so. I am grateful to the Minister for introducing and bringing forward this order. I think we will all benefit from the fact that he has some familial insight into the issues that we are looking at here and in other matters.
I hope that the Minister will accept that this order has been quite a long time coming. It was already long awaited when I was appointed 15 months ago, and the discussion has been going on since at least 2017. This particular order has been introduced twice in the past few months, before the present order; it had to be withdrawn and introduced again, for various technical reasons.
I start by saying clearly that the General Dental Council welcomes this order. However, I want to take this opportunity, in Grand Committee, to make it clear what this order does and does not do. As I think has been said by all noble Lords who have spoken so far, internationally qualified dental professionals make a vital contribution to the UK dental workforce. In recent years, more than one-third of newly registered dentists have qualified overseas, and current workforce pressures would be immeasurably greater without the contribution that they make. However, the current processes for international registration are cumbersome and inefficient. Existing legislation imposes considerable constraints on the GDC’s ability effectively and efficiently to assess the skill and knowledge of internationally qualified dental professionals. For dentists, there is an overseas registration examination with a very rigid structure and, because of the statutory framework, a very limited range of providers. This results in places not always being available for candidates who want to sit the exam.
Quite properly, nothing in this order reduces the high standards required of international candidates seeking to join the UK register. I am sure that the Minister will want to reaffirm that that remains the Government’s priority. Certainly, public protection is, and remains, central to the purpose of the General Dental Council. The standard applied to international candidates is, and should be, equivalent to that applied to people who register based on UK qualifications. Nobody will want to see those standards compromised, least of all the GDC, and the changes made by this order protect those standards but will enable modernised and more flexible approaches for assessing whether candidates have met them.
The order brings in some immediate changes, 21 days after it has been made—so we are probably talking about March this year. From that point, a number of changes will happen immediately. At the moment, the overseas registration examination is in two parts: the first is effectively a written process, and the second a practical test of skills. It is a requirement of the existing legislation that the second part must be concluded within five years of the first part. During the Covid pandemic, part 2 exams had to be suspended and, through no fault of their own, some candidates missed the opportunity to take part 2 because the five-year time limit had expired and therefore lost the opportunity to be registered, because you cannot simply start again. Those affected will now have restored to them the opportunity to sit the second part of the ORE. That is welcome, and it addresses an injustice for those affected as a consequence of the pandemic.
The second immediate change, which my noble friend Lord Hunt of Kings Heath has referred to, is that new applications to the dental care professional register must be based on the primary qualification appropriate for the professional title being applied for. That stops a loophole whereby applicants who are qualified only as dentists have been seeking to register as a DCP. The Committee needs to know that there has been a flood of such applications in the last year: some 1,075 international candidates for registration as DCPs have been approved, which is more than the total number currently on the DCP register from any source. That enables them to practise in this country without going through the more appropriate ORE process for registration as a dentist. There is also now a considerable backlog of applications all seeking to make use of the loophole before it is closed to new applicants 21 days after the order is made. This change is important and overdue. The lack of clarity about what individuals are qualified to carry out in terms of their professional duties is not helpful, and therefore the loophole needs to be closed. The delays and the flood of applications to try to avoid the deadline are causing considerable operational issues for the GDC in managing all overseas registration, and indeed registrations of UK-qualified dentists.
At the same time, the order is going to give the GDC some new powers, although they will take some time to have practical effect. The requirement for assessments of international dentist applications to be conducted by a dental authority—effectively, a dental school—will be removed. Over time, that will give the GDC much greater flexibility in procuring providers and potentially in designing new assessment models. For example, it might be possible to look at the question of whether the first stage of the overseas registration examination has to be taken in this country or whether it could be taken overseas. That flexibility will be sensible, given the current problems in finding suitable providers. However, it is important to stress that this will not have an immediate effect while current contracts remain in place.
The GDC will also gain the power to make detailed rules about how applicants should be assessed. There will be a requirement to consult on these rules and, critically, the current requirement for Privy Council approval will be removed. The practical effect is that the rules can be more flexible and responsive to changing environments, not the least of which is that the fee can reflect the cost, which at the moment is not necessarily the case until it has received Privy Council approval.
The point is that the order is a vital enabler of reform but does not in itself deliver it. Removing the overly prescriptive constraints is a vital first step towards creating a more effective system but it does not and cannot provide an immediate increase in the dental workforce. The rule-making powers in the order do not come fully into effect for 12 months, and even then it will take time to develop new approaches, consult on new draft rules and procure the supply of the necessary services. Alongside that we have the continuing uncertainty about the different provisions that currently apply to people who can currently benefit from the continuing recognition of EU qualifications. If the Government choose to close that route as a result of the review that they are required to undertake this year, significant additional capacity will be required in the GDC’s assessment processes. Any indication today from the Minister as to whether the existing arrangements for applicants from the EEA will continue would be most welcome.
The order provides provisions for the GDC to explore alternative processes for the recognition of international qualifications. Incidentally, it should not be confused with the powers included in the Professional Qualifications Act that allow for the mutual recognition of qualifications through international agreements: they are outside the scope of this order.
Enabling the recognition of international qualifications is not as straightforward as it might at first appear—and there is certainly no quick solution. New processes for the quality assurance of education and training to secure public protection will be needed, alongside new fee structures. This type of recognition may need to be specific to an institution and qualification. It is not, therefore, a quick solution to workforce challenges. The approach taken would have to be fair to those who undertake the UK qualifications, and indeed to the institutions providing them. Also, any route to recognition would need to be applicable globally and take into account the very different standards and approaches to qualifications around the world.
The key point is that none of these changes will solve the wider problems of access to NHS dentistry. The role of the GDC is to register dentists and dental care professionals who are fit to practise in the UK. But there is a separate process before they can work in the NHS. They still need to go through the performers list validation by experience process to practise in the NHS for each UK nation in which they want to practise. So streamlining the ORE process does not in itself deliver more NHS dentistry. I appreciate that the Minister did not assert that that would be the case, but I have heard that view expressed in various quarters, perhaps by former Ministers, which makes it necessary to reinforce the point.
More significantly, if the NHS dental contract fails sufficiently to incentivise UK-qualified dentists to provide NHS dental services, it is not immediately obvious that overseas-qualified individuals faced with the same set of incentives will choose differently from their UK-qualified counterparts. The BDA in a recent briefing warned that
“NHS dentistry is facing existential threat”,
that even before the pandemic
“only enough dentistry was commissioned for half the population in England”
and that the proposed package of changes to the NHS contract announced by the Government in November was “modest” and “marginal” and would
“do little to arrest the exodus of dentists from the service, or address the crisis in patient access.”
Those were the BDA’s words, but I hope that the Minister will be able to give us some assurance on the nature of the discussions that will take place on the future of NHS dentistry and the NHS contract.
To conclude, these changes in the international registrations order are welcome, but they will not address the fundamental issues.
Lord Patel (CB)
My Lords, I will be very brief, because many of the points I might have made were more eloquently made by the noble Lord who just spoke.
The only thing I will say is that, from my experience when I chaired the previous assessor of postgraduate medical training, the Specialist Training Authority, which was established following the EU rules, the same problems occur in recognising equivalence of training. It is easier to recognise a qualification, but when you recognise equivalence of training, it has to take into account, as already elucidated, not just the knowledge but the experience and skills that practitioners can have.
It is even more difficult when you try to certify somebody or accredit somebody with a qualification that is highly specialised—including in dentistry. For instance, they might not be a general dentist but you might want to recruit them because they have specific, high-quality training in a very specialised area. Assessing their equivalence is then made that much more difficult. So the points are well made about an order that I welcome for its simplicity—but it does have drawbacks that need to be addressed, and one way to do that would be to give the General Dental Council more authority to implement its own processes to assess qualifications, experience and training.
I turn now to the nursing and midwifery side, which is a slightly different issue. We should distinguish between qualifications and certifications. While we train nurses as graduate nurses—and that applies to midwives too—not all countries have graduate programmes in nursing and midwifery. They are trained and certified to be fully trained midwives, and having the Nursing and Midwifery Council to assess qualifications, experience and training makes it that much more difficult.
Lord Allan of Hallam (LD)
My Lords, I do not have any direct professional interest in the subject at hand, but as somebody who lives in London and needs dental care, and as a parent, I am grateful to those dentists and midwives from all over the world who have provided me with excellent service through the years. We should be grateful to them all.
From these Benches we also broadly welcome the order the Minister is putting forward. It is clear that we should make it possible for all suitably qualified healthcare professionals to practise in the UK and it is, frankly, a waste of an individual’s talent and a detriment to public interest if there are unnecessary delays or barriers to registration. The noble Lord, Lord Hunt of Kings Heath, described dentists coming here from countries such as Ukraine and Afghanistan who can make a significant contribution, and we need to enable them to do so rather than disabling them from doing so.
Of course, there are necessary checks to protect patient safety, but what we are saying with this statutory instrument is that we believe that the professional bodies, such as the General Dental Council and the Nursing and Midwifery Council, are the bodies most competent to determine what those checks should be and to set out the right testing and assessment processes to allow applicants with overseas training and experience to apply their skills here. In this debate I have learned a lot from the detailed experiences of the noble Lords, Lord Hunt of Kings Heath, Lord Harris of Haringey and Lord Patel, about what this means in practice. It seems to me to be the right decision that we should empower those bodies even further and give them the flexibility that they need to be able to adapt over time as circumstances allow, balancing out the need for safety but also the need to get people on to the register as quickly and reasonably as possible. We agree with the Government on the broad thrust of these provisions and that the additional flexibility is important.
I raise one question with the Minister. Do the Government have any criteria in mind for assessing whether this change has been successful? For example, have they looked at the cost and speed of applying to register before and after the additional flexibility is granted and after the new processes are brought in? The noble Lord, Lord Harris, correctly reminds us that this will not be immediately, but certainly over this multiyear process, if we are to make this change, it would make sense to look at the situation before and after. I note that paragraph 14.1 of the Explanatory Memorandum points out that the instrument itself has no monitoring provisions, but with any legislative change it is helpful for that to be the case, and I hope that the Minister will be able to describe some criteria that the Government have internally for deciding whether this has been successful.
Finally, I end on a note of caution about the safety standards. Sadly, something will go wrong; somebody will be registered in future who should not be registered. When that happens, the fact that we are all supportive of this today means that we will all own that decision, and we should not say that this is wrong because of a single bad case. Overall, we are making the correct decision. The correct risk assessment is that we trust bodies such as the General Dental Council and the Nursing and Midwifery Council to make decisions.
As the noble Lord, Lord Hunt, correctly pointed out, this is part of a process; we will be going further, and other professional bodies will be given similar flexibility. That is the right decision now and will be the right decision in future. Even if and when something sadly goes wrong under the new procedures, as I said, we will need to remember that, overall, we took this decision because we wanted to see more of those people—the kinds of people from whom I have certainly benefited—on the registers in the UK providing the professional services that they can.
Baroness Merron (Lab)
My Lords, I thank the Minister for bringing this order before us. On these Benches, as across your Lordships’ House, these changes are welcomed as sensible and as part of a suite of measures that we will continue to consider. Certainly, the increased flexibility that they bring to the work of the General Dental Council and the Nursing and Midwifery Council by amending the registration and examination processes and procedures so that they are as effective and practical as possible is very welcome. This is about harnessing the capacity and meeting the standards that are needed so that we can ensure that we have the right professionals in place. The noble Lord, Lord Patel, raised important points that I hope the Minister will consider on how the practicalities of this need to be done.
I am grateful to my noble friend Lord Harris, who laid out what the order does but also what it does not do—in our deliberations it is important that we understand that. I noted his comment that there was no ministerial claim that this will solve a workforce crisis, but, as my noble friend Lord Hunt said, we have a challenge in getting a workforce in place to provide the services that we need. In that regard, it is important that we consider the changes today in the current context of the health system in the United Kingdom.
It is important to say that, sadly, in 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that one in 10 nursing roles is unfilled across the service overall. As we have spoken about many times in your Lordships’ House, the number of NHS dental practices fell by more than 1,200 in the five years before the pandemic, and there are 800 fewer midwives than just three years ago. That is the context in which we are discussing this.
I turn specifically to the order. If, as expected, the GDC begins recouping costs incurred around international registration, including charging applicants more to take the overseas registration exam, could the Minister give an indication of what effect this might have on the number of dentists operating in the UK? I am sure he understands that, given the number of dental deserts that we already face, we cannot afford to lose the capacity of any further dental professionals.
As well as the overseas registration exam, non-EEA dentists also have to go through the performers list validation by experience process to practise here. The Minister will be aware that stakeholders expressed concern about dentists’ PLVEs being disrupted—for example, by being endlessly rearranged or cancelled—and that that is acting as something of a deterrent to working here. Can the Minister confirm whether there is recognition of that difficulty, and whether the department is looking at what needs to be done to make the process as coherent and smoothly run as possible?
In the other place, the Minister of State committed to write further on the breakdown of positive and negative responses to the consultation that was carried out. Can the Minister of State’s response be made available to Members of your Lordships’ House so that we might also better know what stakeholders were thinking when they responded to the consultation on these changes?
The Government’s Explanatory Memorandum states that policy changes that the regulations make following this order
“may potentially impact international applicants and existing registrants with different protected characteristics, particularly with regards to age, sex and race”
but does not provide detail on what that impact might be. Can the Minister offer any insight into this, if the department has correctly forecast what the regulators are planning?
As we have discussed today, the intent of the order is that there will be changes to application processes and so on. Can the Minister indicate what plans there are to review and audit changes to ensure that there is consistency of decision-making, fair treatment of all applicants and the achievement of the right standards?
In conclusion, while we all support the substance of the order, I hope the Minister can give an assurance that its impact and implementation will not be beset with logistical hitches and unforeseen consequences, because we are keen to ensure that changes are made to deliver the right result to get the workforce more into place than it has been hitherto. I look forward to hearing what the Minister has to say about how the order may assist that, if not entirely cure it.
Lord Markham (Con)
I thank noble Lords for their contributions to the debate. I shall attempt to answer the questions set. As ever, I will happily follow up in detail afterwards.
I accept the premise that no one believes that this is a silver bullet that answers all the issues around recruitment and workforce needs. At the same time, I think there is a belief that this is one of many things that can, hopefully, help increase access at the end of the day. I reiterate our commitment to independence, in answer to the question from the noble Lord, Lord Hunt. That is fundamental to this issue and, hopefully, something that the noble Lord, Lord Harris, has recognised through this process.
Probably the point I would like to devote most time to is the one about the DCP register. I must admit that it is something I brought up specifically and wanted to go around the houses on. I absolutely understand the issue: are we cutting off our nose to spite our face? On the equivalence argument—our dentists cannot apply overseas—part of that, as it was described to me, was also the feeling that even in the UK our dentists cannot use the DCP route, so to speak, in that they might be a qualified dentist but want to use some other qualifications, rather than be a dentist. So it was felt that there was no consistency there either.
State Immunity Act 1978 (Remedial) Order 2022
(1 year, 11 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Goldsmith of Richmond Park
That the Grand Committee do consider the State Immunity Act 1978 (Remedial) Order 2022.
Relevant document: 7th Report from the Joint Committee on Human Rights
The Minister of State, Foreign, Commonwealth and Development Office (Lord Goldsmith of Richmond Park) (Con)
My Lords, I beg to move that the Committee has considered the State Immunity Act 1978 (Remedial) Order 2022. This instrument, which is subject to the procedure set out in Schedule 2 to the Human Rights Act 1998, was laid before Parliament in draft on 7 September 2022. It will be made once it is approved by both Houses. The instrument responds to the declaration of incompatibility in the judgment of the Supreme Court in Benkharbouche v Secretary of State for Foreign and Commonwealth Affairs.
This remedial order amends the State Immunity Act 1978 to allow a category of claimants to bring claims against their diplomatic mission or consular post employers. The remedial order will remove the incompatibility identified by the Supreme Court of the State Immunity Act with Articles 6 and 14 of the European Convention on Human Rights. It will apply from the date of the Benkharbouche decision in the Supreme Court on 18 October 2017.
Four former employees of diplomatic missions—Benkharbouche, Janah, Buttet and Ahmed—have been pursuing cases against His Majesty’s Government in the European Court of Human Rights, on the grounds that the incompatibility prevented them from bringing employment claims against their employer states. One case has recently been settled, and one was dismissed by the court. In the other two, His Majesty’s Government conceded and, in determining adequate redress, the court found fault with the extended delay for His Majesty’s Government to lay the remedial order.
The remedial order has been pending for some time, having been announced in the Written Ministerial Statement from the noble Lord, Lord Ahmad, of February 2021, following the judgment in 2017. This order will prevent further claims against the Foreign, Commonwealth and Development Office. The order will apply from the date of the declaration of incompatibility which, as I said, is 18 October 2017. The Government are aware of approximately 55 other claims against diplomatic missions in London working their way through the courts; the order would allow such historic cases to be brought before the employment tribunal and reduce the risk of future claims succeeding.
I thank the Joint Committee on Human Rights for both of its reports on the proposed order. The Government responded to the Committee’s first report in September 2022. In November 2022, the Government noted the contents of the second report and are grateful to the Committee for recommending that Parliament approve the remedial order.
To conclude, state immunity derives from the principle of sovereign equality of states. This principle, enacted in the UK by the State Immunity Act 1978, is based in part on the European Convention on State Immunity 1972, to which the UK is a party. The State Immunity Act 1978 contains a number of exceptions which recognise the distinction between a state’s actions of a sovereign character, such as making treaties, and actions of a commercial nature, such as buying goods and services or employing some staff. The intention of the order is to ensure the UK’s legal obligations are in line with international law and thus ensure that claims can be brought against the relevant states and thus prevent further claims against the UK. This should mitigate any potential future risk to the Government. I commend the order to the Committee.
Baroness Northover (LD)
My Lords, I thank the Minister for introducing this order, which we support. As he says, this order relates to how foreign states are granted immunity from prosecution for employment claims brought against them by workers in embassies based in the UK. He referred to the Supreme Court decision in 2017 which concluded that the UK was in effect granting more immunity than was internationally required. Thus certain categories of employees, such as domestic workers, were wrongfully denied the right to take their cases to court, which was incompatible with the European Convention on Human Rights.
Lord Collins of Highbury (Lab)
My Lords, I echo the noble Baroness’s comments. Obviously, state immunity is a principle of international law which I am sure that the whole Committee supports, but we do not believe that it should be unnecessarily extended. That is why we are here today considering this remedial order.
As the noble Baroness pointed out, it is nearly a year since Nigel Adams, the Minister for Asia at the time, announced this order being placed—and, of course, it is five years since the Supreme Court judgment. The delay has consequences, which clearly need to be addressed. I certainly echo the noble Baroness’s comments on the Joint Committee’s report, but I shall make a couple of points on that report that she did not address—it may be being dealt with elsewhere.
I refer to the recommendations on paragraphs 59 and 62 about consequential actions once the order has been addressed. I am particularly concerned, if guidance is to be issued, about whether that guidance is ready. I hope that it will not be delayed. Could the Minister also reassure me that appropriate consultation will take place or has taken place on any draft guidance for how we exercise sovereign authority in relation to employment contracts—and, as it says in paragraph 62, in relation to what amounts to being
“conduct in the exercise of sovereign authority”?
That is a really important element of consequences of this action.
I pick up the point that the Minister mentioned on the retrospective element of the order. What assessment has the department made of the number of potential cases that may emerge? It is not just a question of known cases. This is a window that could—be exploited is not the right word—give people the opportunity to raise cases that previously have not be raised. Can the Minister give us a proper assessment of that?
Finally, echoing the questions of the noble Baroness, Lady Northover, what assessment have we made of the decision of the European Court of Human Rights in relation to the two cases where, despite the Government saying that they acknowledged that there had been a breach of the articles, it was felt that the compensation was totally inadequate? Does that have implications? First, can we be given an assessment as to why that sort of compensation was deemed to be inadequate? Secondly, does that also have implications for the retrospective element of the order?
In conclusion, I repeat what the noble Baroness has said. We welcome this provision, which is overdue—but it is here, and we certainly support its implementation, as reflected in the Joint Committee’s report. We welcome it and hope that it will be implemented speedily. I hope that the Minister will be able to answer my specific questions about the consultation that will take place on any guidance that is issued.
Lord Goldsmith of Richmond Park (Con)
I thank noble Lords for their contributions and very much welcome their support for the remedial order. I shall address the questions raised by the noble Lord, Lord Collins, and the noble Baroness, Lady Northover, around the delay. We responded to the criticism in the committee’s first report by acknowledging that the delay was suboptimal. We have committed to work with the Ministry of Justice on procedures to mitigate the risk that this could happen again.
The judgment of incompatibility was delivered in 2017, as has been noted. While there is no set timeframe to address such incompatibilities, a delay of five years is clearly not ideal. However—I do not say this as an excuse, but it is certainly a factor—the preceding five years have been busy, with unprecedented pressures on parliamentary time, ministerial time and officials, not least of course as a consequence of the pandemic.
The committee’s second report picks up on this issue. Paragraph 48 notes that it is awaiting confirmation of the detail of those procedures. It further notes that they should be put in place for all government departments and that it is unclear how the Government’s intention for a Secretary of State to notify Parliament when an adverse judgment is received would address the committee’s concerns. The Government have existing procedures in place through which they engage regularly with the staff of the Joint Committee on Human Rights to discuss plans to respond to judgments identifying incompatibilities in legislation. We believe this engagement should be sufficient to allay the committee’s concerns.
The noble Baroness, Lady Northover, and the noble Lord, Lord Collins, raised potential guidance to employers and employees. As the Committee knows, the committee suggested that the Government consider issuing guidance for employers and employees on two areas: first, what amounts to entering into a contract in the exercise of sovereign authority; and, secondly, what amounts to state conduct in the exercise of sovereign authority for the purposes of the Act.
The Government have considered the committee’s comments and we understand the concerns raised that employers and employees should have greater certainty about what counts as sovereign authority in these areas. However, on balance, we do not consider it appropriate for the Government to issue guidance here, because it is ultimately for the courts to interpret these provisions based on the cases that come before them.
I note none the less that the Government broadly agree with the views set out by Lord Sumption in his judgment in the Benkharbouche case to the effect that, in general, purely domestic staff of a diplomatic or consular mission are unlikely to be employed based on contracts entered into as an exercise of sovereign authority and that dismissing an employee for reasons of state security would constitute state conduct in the exercise of sovereign authority.
The noble Lord, Lord Collins, asked how many cases the Government expect to see. I mentioned in my opening comments that there are 55 known cases, but we just do not know how many other cases there might be. I have asked my colleagues, but we do not have a number in the department; the unknowns are, I am afraid, unknown. However, as I said, there are 55 known cases and I think we can extrapolate from that.
I confirm that the order will apply from the date of the declaration of incompatibility, namely 18 October 2017. As I said, the Government are aware of approximately 55 other claims against diplomatic missions in London working their way through the courts. The order would allow those cases to be brought before the employment tribunal. Further delay in bringing the remedial order into force increases the risk of future claims against the FCDO succeeding.
I reiterate my thanks to those present for their support for this order and their insightful contributions—
Lord Collins of Highbury (Lab)
I hear what the department’s view is in relation to guidance but my question was not simply about whether guidance would be issued; it was about whether it was felt necessary by the department or appropriate departments to consult worker organisations or, for that matter, foreign embassies. Has there been any consultation on whether such guidance might be necessary?
Lord Goldsmith of Richmond Park (Con)
I note the noble Lord’s point. The Government’s view is that it is not necessary for the Government to produce that guidance. Therefore, I do not believe—I will need to check this afterwards—that there has been a consultation. Were guidance to be issued, then of course there would need to be a process, and that would include consultation. However, because of the position the Government have taken, I do not believe there has been such consultation. I hope that answers the noble Lord’s question. If I am wrong, I will get back to him in writing. In the meantime, I hope the Committee will support this order.
Architects Act 1997 (Amendment) Regulations 2022
Baroness Bloomfield of Hinton Waldrist
That the Grand Committee do consider the Architects Act 1997 (Amendment) Regulations 2022.
Relevant document: 20th Report from the Secondary Legislation Scrutiny Committee
Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, these regulations, which were laid before both Houses of Parliament on 14 November 2022, are part of the new framework for the recognition of internationally qualified architects in the UK, using powers provided in Sections 4, 6 and 13 of the Professional Qualifications Act 2022. Before I go into the background, I should declare my interest: my daughter is a properly qualified and registered architect working in the UK.
I will start by providing some context and background to these important regulations. To provide business with confidence about the availability of international talent following the UK’s exit from the EU, the Government chose to continue the recognition of EU architectural qualifications in the same way as we did when we were bound by the EU’s mutual recognition of professional qualifications directive. This has allowed the architecture sector to continue to recruit EU-qualified architects while government and the regulator, the Architects Registration Board, prepared for the recruitment of international talent from across the globe.
Last April, the Professional Qualifications Act 2022 came into force. It introduced a new framework for the recognition of internationally qualified professionals in the UK, including supporting a new framework for the recognition of international architects. It is therefore now time to end remaining alignment to EU law and allow the Architects Registration Board to use its own expertise to decide which qualifications it wishes to recognise.
These regulations can be considered in two parts. First, they end remaining alignment to EU law in the Architects Act 1997. This means the law will no longer require the Architects Registration Board automatically to recognise EU architectural qualifications. Instead, the regulator will be able to assess qualifications and decide whether it deems the recognition of the qualifications appropriate.
These provisions will create not only a level playing field for EU and non-EU architects but a level playing field between the UK and the EU, as the UK’s post-Brexit recognition of EU architectural qualifications has, by and large, not been reciprocated by the EU. The existing unilateral recognition of EU qualifications is intended to be replaced by a reciprocal arrangement under the EU-UK Trade and Cooperation Agreement. The Architects Registration Board and the Architects’ Council of Europe have already submitted a joint recommendation to the Partnership Council to achieve such an agreement.
Secondly, the regulations enable the Architects Registration Board to enter into regulator-led recognition agreements with its counterparts in other countries. The Government recognise that the required expertise for recognition agreements at this level sits with the regulators. It will therefore be for the Architects Registration Board to seek out suitable counterparts and to negotiate and conclude recognition agreements with them. The Architects Registration Board has already done a fantastic job of negotiating two such reciprocal agreements: one with the National Council of Architectural Registration Boards in the USA and a trilateral agreement with the Architects Accreditation Council of Australia and the New Zealand Registered Architects Board.
The provisions made by the regulations will enable the regulator to maintain a good supply of international talent while scrutinising qualifications. This will provide the public with the reassurance that only those who are suitably competent will be allowed to practise in the UK. The regulations are key to ensuring that the UK maintains its global reputation as a world leader in the field of architecture by attracting the best talent to the UK and making it easier for UK architects to export their services to other countries. I hope that noble Lords will join me in supporting the draft regulations and I commend them to the Committee.
Baroness Pinnock (LD)
My Lords, I do not know much about architects, but what I do know is that it seems we are creating a problem that did not exist until we had the Brexit legislation. Two of the most prestigious buildings of recent years in France are the Millau bridge over the River Tarn, a fantastic and amazing piece of architecture designed by Norman Foster, and, earlier, the Pompidou Centre in Paris, the work of another great British architect, Richard Rogers. Our global talent was already being exported and used by our nearest neighbours in the EU. With the Brexit legislation, we have contrived to say, “We can’t recognise these qualifications any more. Mutual recognition will go out the window, and we will have to start again and create new mutual recognition arrangements.”
The dilemma that the Government have created is set out well in the Secondary Legislation Scrutiny Committee report. It says:
“DLUHC says … that architects with EU qualifications who are already on the ARB register will not be affected”,
which is fine. It goes on:
“In addition, a briefing note by the ARB states that in the absence of”
a mutual recognition agreement
“with the EU, the ARB has decided unilaterally that, in practice, it will continue to recognise EU qualifications listed in the former Mutual Recognition of Professional Qualifications Directive until a new MRA is agreed”.
So, while we are going through all this, architects are saying, “Blow this. We want to continue to have mutual recognition agreements with the EU so that’s what we’re going to do.” The Government have created unnecessary dilemmas for us here. All I can say is good luck to the architects. There is global recognition that we have great architects in this country. To try in any way to restrict them using their talents in countries across the world, but particularly in our nearest neighbours, is a foolish restriction of their ability to work.
We also lose the concomitant advantages of that. An architect brings with them a design team, a construction team and all the rest of it. So good luck to the ARB in saying, “We’re not listening. We’re just going to continue recognising the professional qualifications that existed prior to the Brexit legislation.”
Baroness Hayman of Ullock (Lab)
My Lords, I thank the Minister for her introduction to this statutory instrument. We have heard that it will form part of the new framework for the recognition of internationally qualified architects in the UK. I welcome the opportunity to speak on this specific but quite important change for mutual recognition agreements with counterpart regulators in other countries. We believe that the changes are needed and we will certainly not oppose these measures. However, I have a few questions for the Minister.
During debates on the Professional Qualifications Bill, these Benches asked for certain amendments around statutory consultation, particularly around regulations under Clauses 1, 3 and 4. Following that, the amendments introduced the statutory consultation requirements. It would be helpful if the Minister could inform the Committee how the department has met those requirements with regard to these regulations in front of us today.
The Explanatory Memorandum states that monitoring will be done by the Architects Registration Board. Can the Minister confirm whether this means that it will be doing it in its entirety, and that the department will therefore not be involved in monitoring the implementation of the regulations themselves?
Finally, on mutual recognition agreements, the Secondary Legislation Scrutiny Committee mentioned in its report—as did the Minister—the agreements that will come into force with countries such as Ireland, the USA, Australia and New Zealand. However, also in response to the Secondary Legislation Scrutiny Committee’s report, DLUHC said that the UK is currently seeking a new MRA with the EU under the EU-UK Trade and Cooperation Agreement. I wondered if the Minister was able to provide your Lordships with any kind of update or progress on how that is going, or when we are likely to see an outcome from it.
Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, I thank both noble Baronesses for their valuable contributions to this debate. However, I do not agree with the noble Baroness, Lady Pinnock: we are not restricting talent. This instrument allows the UK to import global talent from across the world, and we are still in conversations with the EU. We are not precluding any future relationship with the EU; that will still be covered by the future TCA negotiations, which are still ongoing.
I do not understand the noble Baroness’s complaint that the ARB will continue to recognise EU architectural qualifications, because we recognise that the UK still needs to import such talent from the EU. For the moment, for a time-limited period, we will continue to recognise EU architectural qualifications, to help to bridge the gap between this legislation and the new agreement under the EU-UK Trade and Cooperation Agreement coming into force.
In answer to questions from the noble Baroness, Lady Hayman, about the consultation, we did indeed consult on those issues, as we said we would in the Professional Qualifications Act. We conducted the public consultation on the proposed amendments between 4 November 2020 and 22 January 2021, and the Government’s response was published. The consultation received 404 responses from individuals and organisations, 60% of whom were UK-qualified architects, 14% were internationally qualified, and the remaining 26% were organisations involved in the industry. They recognised the benefits of providing international architects with a route to recognition which would not be long and expensive. The majority of respondents agreed that enabling the ARB to recognise qualifications that it deems equivalent to the UK standard, and providing a single cohesive system of recognition, would be beneficial to UK architectural practices wishing to recruit international architects.
In answer to the noble Baroness’s other question, it is indeed the ARB which is totally responsible for regulating its own industry, because it has the skills to do so. The ARB has the resource and capacity to deliver all of these new regulator-to-regulator agreements. The department provided it with additional funding so that it might be able to support the system adaptation for work on all the international agreements that it is still negotiating. As I think I said in my original speech, we have already concluded negotiations with counterparts in the USA, Australia and New Zealand. Subject to these regulations, the regulator expects to sign and implement two agreements in the first quarter of this year. We obviously are still in conversations with the EU, and we are hopeful that we will reach agreement on those particular issues.
I thank both noble Baronesses for their thoughtful contributions. To conclude, these regulations will enable the Architects Registration Board to build on the fantastic work that it has already been doing to promote the UK as an attractive destination for the best global talent and to encourage UK exports, not just to Europe but throughout the rest of the world. I hope that the Committee will join me in supporting these regulations today. I beg to move.