Health and Social Care Bill

Earl Howe Excerpts

Tuesday 28th February 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat as a Statement the Answer given by my right honourable friend the Secretary of State for Health to an Urgent Question tabled in another place earlier today about the Health and Social Care Bill. The Statement is as follows:

“Mr Speaker, I am glad to have this opportunity again to set out the purposes of the Health and Social Care Bill. It is to give patients more information and choice, so that they share in decision-making about their care. It empowers front-line doctors and nurses to lead the delivery of care for their patients. It cuts out two tiers of bureaucracy, and strengthens the voice of patients and the role of local government in integrating services and strengthening public health.

The values of the Bill are simple: putting patients first, trusting doctors and nurses, focusing on results for patients, and maintaining the founding values of the NHS. We are constantly looking to reinforce those values, strengthening the NHS to meet the challenges it faces. We know change is essential: we will not let the NHS down by blocking change.

Throughout the development and progress of this Bill, we have engaged extensively with NHS staff, the public and parliamentarians. The Health and Social Care Bill is the most scrutinised public Bill in living memory. With over 200 hours of debate between the two Chambers and 35 days in Committee, we have ensured that Members and Peers have had every opportunity to examine, understand and amend the Bill to ensure it does the best possible job for patients.

We have made this legislation better and stronger. We have made significant changes to the Bill, including in response to the NHS Future Forum’s work, and we will be open to any further changes that will improve or clarify the Bill. For example, so far in the Lords, the Government have accepted amendments tabled by a number of Cross-Bench, Liberal Democrat and Labour Peers.

Yesterday, my right honourable friend the Deputy Prime Minister and the noble Baroness, Lady Williams, wrote to their Liberal Democrat colleagues explaining their support for the Bill with those changes and some further amendments they wish to see. They said, for example, how we must,

‘rule out beyond doubt any threat of a US-style market in the NHS’.

I wholeheartedly agree.

The Bill is about quality, not competition on price. It will not permit any NHS organisation to be taken over by the private sector. It will put patients’ interests first. We will not permit any extension of charging. Care will be free and based on need. Where the doctors and nurses on the ground know that competition is in the best interests of their patients and where it is based entirely on the quality of the care and treatment provided and not in any way on the price of that care and treatment, then competition can play an important role in driving up standards throughout the NHS.

We will not see a market free-for-all or a US-style insurance system in this country. I believe in the NHS. I am a passionate supporter of our NHS. That is why I understand the passionate debate it arouses. But it is also why I resent those on the Benches opposite who seek to misrepresent the NHS, its current achievements and future needs.

We are using the debates in the Lords further to reassure all those who care about the NHS. I am grateful for the chance to reassure all my honourable friends in the House of the positive and beneficial effects of debate in the House of Lords, and of the work we are doing to secure a positive future for the NHS”.

My Lords, that concludes the Statement.

[Baroness Thornton]

My Lords, I thank the Minister for that Statement. We are in a slightly odd situation here. We have a letter from the Deputy Prime Minister and a distinguished Member of your Lordships’ House to MPs and Peers in their party concerning a matter of public policy involving a major piece of legislation currently before this House. I thought that we could not be further surprised by the parliamentary twists and turns of this Bill, but it is really a case of “Whatever next?”. Is it the first time that a serving Deputy Prime Minister has decided to send a letter suggesting amendments to his own Government’s legislation? This letter seems largely to concern Mr Clegg saying that he wants more amendments to the Bill and expects this House to deliver them so that Liberal Democrat MPs can support the said amendments in the Commons. It is not clear to me whether the Minister in the Commons, or even Conservative MPs, will do so as well. Remarkable!

I appreciate that it may be difficult for the Minister to answer this question, but I am going to ask it anyway. How exactly does he think that the Liberal Democrats propose to achieve this target set by Mr Clegg in this House when they are part of a coalition wedded to this Bill in all its glory—and Part 3, too—and the Lib Dems command 70 to 80 votes in the House on a good day? Who will deliver Mr Clegg’s amendments to Part 3 of the Bill, I wonder? Will it be done by consent with the Government or will it be by Division?

I would like to ease Mr Clegg’s dilemma in this matter and make a very generous offer. The Liberal Democrats can have our amendments to Part 3 of this Bill. We have a great set of amendments to Part 3 which would serve to deliver what Mr Clegg and the noble Baroness, Lady Williams, say that they seek on competition and, indeed, more. So I look forward to the Minister’s response to my offer.

However odd the mode of delivery, it is important to ask whether this is a major announcement of a change in government policy and, indeed, was the text of the letter discussed with and agreed by No. 10 and Mr Andrew Lansley. This development has added to the considerable confusion about what government policy around the Bill is exactly, and I think that Ministers need urgently to clarify what precise changes are being proposed, what discussions have been held with the Deputy Prime Minister and whether these policy changes now represent government policy. I ask this because we know that Mr Clegg has to manage the challenge of the Lib Dem spring conference—and a challenge it is certainly shaping up to be. According to today’s media, the Liberal Democrat health activists are planning to put an emergency motion to the party’s spring conference urging their leadership to reject the provisions of the NHS reform Bill despite, presumably, the final changes advanced by Mr Clegg and the noble Baroness, Lady Williams, in this joint letter. Certainly this letter and that conference, combined with the growing tumult against the Bill—another royal college might bite the bullet and say that it wants the Bill to be withdrawn again; I think that there are only about two more to go—put the discussions that we will have on Part 3 in your Lordships' House next week in an interesting light.

This is an odd way to develop and announce policy—or is it shift in policy? Yesterday morning, the Minister, Simon Burns, was insisting the whole Government backed the Bill “as amended now”. At the same time sources close to Mr Clegg, whoever they may be, were insisting the changes that he is demanding are,

“significant and not simply reassurances”.

However, at the same time the PM’s spokesperson said,

“we do not see any need for further significant changes to the Bill”.

We need to know which of these is correct. I hope that the noble Earl will be able to enlighten the House.

This letter states that,

“we want to rule out beyond doubt any threat of a US-style market in the NHS. That is why we want to see changes made to this bill that have been put forward by our Liberal Democrat team in the House of Lords to make sure that the NHS can never be treated like the gas, electricity, or water industry”.

That is exactly what I have been saying all the way through this Bill. The letter proposes four broad changes. The first is that we should remove the reviews by the Competition Commission from the Bill. In fact, amendments to that effect where tabled by the Labour Party. Imitation being the greatest form of flattery, I am very happy that the Liberal Democrats are tabling them again. Secondly, the letter suggests that we keep the independent regulator for foundation trusts, Monitor,

“to make sure hospitals always serve NHS patients first and foremost.”.

Well, hurrah! We have an amendment down that does exactly that. Thirdly, the letter proposes to,

“introduce measures to protect the NHS from … threat of takeover from US-style healthcare providers by insulating the NHS from the full force of competition”.

Mr Clegg might just have noticed the threat that competition posed when he signed this Bill a year ago. Finally, it proposes,

“additional safeguards to the private income cap to make sure that foundation trusts cannot focus on private profits before patients”.

Well, the amendments that the Liberal Democrats have promoted so far on this certainly need some thought and some change. We would agree with them and we shall see. This is all familiar to us on the Labour side, because those proposals were part of the substance of our amendments in Committee which were so soundly and roundly rejected by the Minister. Is he about to resile from his earlier position and embrace the Labour amendments? I would appreciate some notice if that is what he intends to do.

I have a few questions. The document issued at the Conservative away day last Friday said:

“If we changed or altered the bill now, we would end up in a no man's land, and chaos”.

Can the Minister confirm that this is still the Government's position? Can he clarify whether the changes outlined in the Deputy Prime Minister's letter now represent government policy? His letter promises,

“additional safeguards to the private income cap”.

Can the Minister explain what these additional safeguards are, and why the Deputy Prime Minister feels that they are necessary? Why does the Secretary of State seem to have no regard for the views of health professionals and the public when it comes to making changes to this health Bill but is quite happy to make concessions to accommodate the Liberal Democrats before their spring conference? Will the Minister clarify whether these amendments to the Health and Social Care Bill are “significant”, as stated by the Deputy Prime Minister, or a “reassurance”, as stated by the Prime Minister's official spokesperson?

In 2009, the Prime Minister said:

“There will be no more of those pointless re-organisations that aim for change but instead bring chaos”.

It seems to me that the Secretary of State has seen a clear example of unmitigated chaos in the latest incarnation of his Health and Social Care Bill. Really, this is a most unloved and unwanted piece of legislation and the Bill should be dropped. In conclusion, the Minister has my deepest sympathy in dealing with this Statement, because it seems that it puts him between the rock of Andrew Lansley and the hard place of the noble Baronesses, Lady Jolly and Lady Williams, and their colleagues—probably not a comfortable place to be. Actually, this is not the way to treat Parliament and its consideration of this Bill. It is not the way to treat the people who work so hard for the NHS and, indeed, it is not the way to treat our NHS.

[Earl Howe]

My Lords, the noble Baroness said that she was surprised by the letter in question. I can tell her that nothing in the letter was in any way a surprise to me, for the simple reason that it reflects the very constructive discussions that I have had with my Liberal Democrat colleagues, which are a natural part of good government. I can only conclude that she does not recognise that such discussions are a part of good government, but it certainly is the case with the coalition. As far as I am concerned, Mr Clegg needs no permission to bring members of his party up to date with progress on the Bill or to make it clear, as he does, that he is fully behind it.

The noble Baroness asked about the changes that Mr Clegg and my noble friend Lady Williams have outlined in the letter that they would like to see. I simply direct the noble Baroness’s attention to the Marshalled List for the Bill; there are a number of amendments already tabled and discussions continue on a number of other issues. Are the changes that have been made significant? I say to her that any amendments we accept are significant, and the amendments made to the Bill are largely about reassurance to those noble Lords who are unclear, uncertain or worried about the Bill and what it says. They are about delivering greater clarity and making sure that the Bill delivers on its intentions. I have been very happy to accommodate the concerns of Peers of all parties who have come to speak to me—not simply my Liberal Democrat colleagues—because the function of this House is to make Bills better, and we are certainly doing that with the Health and Social Care Bill. A prime example of that, surely, was the fruitful discussion that we had across the party divide on the Secretary of State’s powers and duties, and I believe that the resolution of that matter was very satisfactory.

With regard to the issues themselves, it would not be appropriate for me to give a running commentary. The place for debate on each issue is surely our debates on Report. We are in the middle of the Bill; we should not attempt to engage in substantive discussion on matters of policy now when we still have four more days of Report ahead of us. We are open to constructive discussions with Peers of any party to make the Bill better, just as we listened, contrary to the assertion of the noble Baroness, to members of the public and members of the medical profession in their thousands during the listening exercise last year. We listened, paused, reflected and amended the Bill extensively. I am sure that the noble Baroness knows that nothing has changed in that respect, and my door is open to her as it is to anyone else.

[Baroness Jolly]

My Lords, I thank the Minister for his ever-open door and his willingness to listen. Will he further explain to the House how he believes that the NHS will be stronger for the scrutiny from all sides of the House? How does he believe that the objections of the Royal Colleges, such as the Royal College of Nursing, the BMA and other professional bodies have been met as a result of this cross-party scrutiny?

[Earl Howe]

My Lords, I completely agree with my noble friend. I feel that the debate and discussions that we have had in your Lordships’ House have made this a better Bill, as I said a moment ago. Again, a prime example of that is the clauses relating to ministerial accountability. With regard to the Royal Colleges, we have made all sorts of improvements, such as those in response to concerns about the integration of services, education and training, research, health inequalities, ensuring that competition is never an end in itself and a number of other important issues. I am glad that these changes were all welcomed by a wide range of Royal Colleges.

[Lord Campbell-Savours]

My Lords, in the light of what the Minister has just said, if I came to him over the next couple of days and handed him a document about the problems that it is felt will be experienced in specialist services, would he then deal with it before the completion of Report and let me have an answer?

[Earl Howe]

I would be happy to talk to the noble Lord about specialised services, and I speak as the Minister in charge of that policy area. If he would like to contact my office, I would be very glad to see him.

[Lord Crisp]

My Lords, like, I suspect, every other Member of your Lordships’ House, I very much respect the way in which the Minister has handled the Bill and his willingness to engage in debate. I sit here as a Cross-Bencher listening to what seems to be the healing of a rift between the coalition parties, if I may put it like that, but I also see—my postbag is full of this, as I am sure everyone else’s is—a rift with the medical profession, the nursing profession, midwives and others. Even though this approach may deal with some of the issues that they have wished to raise, I do not see that it will deal with the much more fundamental issue of the loss of trust and unity that seems to have been created as part of the passage of the Bill. Can the Minister say something about how he believes that that will be handled? These issues go far beyond your Lordships’ House, as we all understand.

[Earl Howe]

The noble Lord is right. The stance taken by a number of medical bodies and members of the medical profession is of course a matter of great regret to me and my ministerial colleagues. I say to them and to the noble Lord that once the Bill has been approved by Parliament, as I sincerely hope it will be, that will be the time to re-engage with the medial profession and work with it to ensure that the Bill delivers on the promise that we have held out for it and that we still believe in. The principles that the Bill embodies, which the medical profession has always said that it supports, can then be given substance in the form of the improvements that we would like to see delivered to patients. From all the comments that I have heard from doctors and others who are in doubt about the Bill, most of their concerns revolve around its implementation and what it will mean in practice, rather than the principles that it enshrines. We need to look forward collectively and work together to make the NHS work better.

[Baroness Meacher]

My Lords, I, too, applaud the noble Earl for the way that he handles this very difficult Bill in very difficult circumstances. I am sure he is aware that there is a lot of concern about the Bill in the field of mental health, particularly as private provision gathers pace. Can he give any assurance to mental health professionals and services up and down the country about what in the Bill might protect mental health services in the future?

[Earl Howe]

Several things in the Bill are new. One is the duty to reduce health inequalities, which is very important in mental health. Another is the duty to promote integration of services. Again, we have had many debates on that and there are mechanisms that we propose to use to support greater integration of services.

I also believe that the worries about competition are misplaced. Competition is a tool that commissioners can use, or decide not to use, in the interests of patients. It is no more than that. The Bill does not change competition law or increase the scope for competition to be used in the NHS. It leaves the decision-making to commissioners on whether competition does or does not serve the interests of patients. There is a lot of misapprehension about what the Bill does, not just among those in the mental health world but more widely. I hope that that reassurance is helpful.

[Baroness Williams of Crosby]

I apologise to the Minister for being the cause of another late night for him. I apologise because, obviously, the Statement relates to some extent to the letter that I co-signed with the Deputy Prime Minister. I simply say, as have many in the House, that the Minister has shown amazing patience. Indeed, his door is always open; a number of us stumble our way through it and we are extremely grateful.

I shall say just two more things about the point raised by the noble Lord, Lord Crisp. First, a great deal of the concern that has been expressed in public was expressed before some of the very recent changes, which are not widely realised or well understood among the public or the media.

Secondly, it is probably fair to say that Chapter 3 has been the centre of much of the concern about the Bill. There are other things in it that many people will widely recognise and accept, not least the work on education, training and research. This is not yet widely known, even within the medical profession. It may be that there is a great deal to be said for making a further attempt to get across exactly what changes have been made to the Bill. I think that would carry with it a rather different attitude among the public and the media from what has existed in the past few weeks.

--- Later in debate ---

[Earl Howe]

I am very grateful to my noble friend and agree with everything that she said. Many of the changes that the Government have made to the Bill—not just those made in your Lordships’ House but those that were made last year—have not been fully appreciated, or appreciated at all in some quarters. The changes that we have made are not sufficiently understood even by those who recognise that amendments have been made to the Bill. Without naming names, I have spoken to very senior members of the medical profession who have had no idea at all about some of the amendments that we have made to bring greater clarity to the Bill and change it substantively. As my noble friend knows, we did that in particular with Part 3 of the Bill. There is no doubt that there is a job of work to do to put over the correct messages to the medical profession and to reassure its members that this Bill does not represent a threat to them or to the NHS—quite the reverse.

[Lord Patel]

My Lords, although many of the comments that have been made relate to amendments that have yet to be presented to the House, particularly to Part 3 of the Bill relating to competition, does the Minister agree that there are other amendments relating to other parts of the Bill that are of broad concern to people outside the House: namely, those relating to public health issues and how public health will be delivered, and that we also need to address those amendments?

[Earl Howe]

Of course, I acknowledge the point made by the noble Lord. It is a matter of regret to me that the commentary on the Bill hardly ever focuses on the proposals it makes for public health, which have generally commanded widespread approval. However, I recognise that there are concerns around the detail of those proposals. That is why we are here as a Chamber to address those concerns. I am sure that when we come to the amendments referred to by the noble Lord, this House will not be found wanting in the way that it explores those issues and resolves them.

[Lord Martin of Springburn]

The noble Earl has repeated a Statement made in the other House by a Cabinet Minister responsible for health. We have also heard mention of the Deputy Prime Minister supporting the noble Baroness’s amendments. The Deputy Prime Minister is clearly a Cabinet Minister. Therefore, we have two Cabinet Ministers in the picture. If everyone is so enthusiastic about the Liberal Democrat amendments —the noble Baroness, Lady Thornton, was kind enough to tell us that those follow her proposals, and imitation is the best form of flattery—does it mean that everybody is happy? However, the only piece of the jigsaw that I am concerned about is whether that means that the Conservative Party will support the relevant amendments. If that is the case, they will all go through on the nod and everybody will be happy. Perhaps the noble Earl can tell me whether I am wrong and I have missed something.

[Earl Howe]

Far be it from me to say that the noble Lord, Lord Martin, would ever miss anything; he is too wise a head for that. I see nothing strange or amiss in a party leader wishing to address his parliamentary colleagues on the eve of a party conference to bring them up to date on a major Bill and its progress in the House and to set out some of the remaining concerns that he has that we need to settle. These concerns came as no news to me as I have been talking about them regularly not only with Liberal Democrat colleagues but with other Members of your Lordships' House and members of the medical profession. I see nothing amiss in the letter spelling out those concerns. How we arrive at a resolution of those issues is yet to be seen. As I have said, amendments have already been tabled which we shall debate. It is possible that more will be tabled over the days ahead—I do not rule that out at all. However, the noble Lord should not forget that there are non-legislative ways of reaching the destination that some of my noble friends would like to get to. There are many ways of achieving some of these objectives. It is entirely possible that we shall agree amendments to do that but that is not by any means the only course open to us.

[Lord Greaves]

My Lords, I am a little confused about all this, and I wonder if my noble friend the Minister can help me. I received the letter yesterday. At the top it stated, “Keep this completely secret and do not tell anybody”. I switched on the television and there it was. I am confused because I watched and listened to the exchanges in the House of Commons this afternoon, which, I have to say, were a great deal more vigorous and bad-tempered in many ways than the exchanges here; and I congratulate the noble Baroness on the Labour Front Bench who did a much better job of responding on this matter than her colleagues in the House of Commons.

However, here we have the Labour Party, which in government made major strides towards introducing competition, privatisation and commercialisation of the health service, and now has been very strong indeed in opposing those matters when it comes to the Bill. I do not understand that. The other thing that I do not understand is that if what the noble Baroness says is correct—that many of the things she and her colleagues have been putting forward at Committee stage and have been saying outside this House are now being put forward by Liberal Democrats in the amendments that we were told about in the letter from my noble friend and my party leader—why is she not standing up and offering her help, with some enthusiasm, instead of being so grumpy about it all and the way in which this has been done? There seems to be huge confusion on the Opposition Front Bench and in the opposition party, and I wonder if my noble friend can suggest any gentle therapy that it might take up to help it with this problem.

[Earl Howe]

I am very happy to pick up that challenge from my noble friend; in fact, I have been using all my charms and skills on the Benches opposite without any effect at all. I feel that I may have arrived at an impasse. My noble friend is absolutely right because the situation that we inherited from the previous Government was in many ways one that we embraced—it was they who opened up choice in the NHS and indeed put a right of choice into the NHS constitution. However, they did not roll out competition and choice in the way that was appropriate and right, because it cannot be right to impose competition on the NHS whether it wants it or not. It cannot be right for there to be preferential prices for the private sector, with the NHS being disadvantaged. It cannot be right to have an explicit target of increasing private sector provision in the NHS, which is what the previous Government had. It cannot be right for private providers to cherry-pick the easy cases and leave the NHS with the hard cases. We do not approve of fragmenting care pathways.

We do not think that the previous Government thought nearly hard enough about how this was all to be regulated, which is why we want a sector-specific health regulator. That is the reason for having Monitor and is why we think the provisions of Part 3 make sense because they are in the interests of patients and the NHS. I still hope that in our debates I can engender some movement on the Benches opposite to recognise that we are actually trying to improve the situation that we inherited for the benefit of everyone.