Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

Moved by

[Earl Howe]

3: After Clause 4, insert the following new Clause—
“Duties as to reducing inequalities
In section 13G of the National Health Service Act 2006 (NHS England’s duties in relation to the reduction of inequalities)—(a) in paragraph (a), for “patients” substitute “persons”;(b) in paragraph (b), after “services” insert “(including the outcomes described in section 13E(3))”.” Member’s explanatory statement
The amendment extends NHS England’s duty in relation to the reduction of inequalities in access to health services to cover people before they are patients. It also makes it explicit that the duty to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.

[Earl Howe (Con)]

My Lords, in moving Amendment 3 I will speak also to the other government amendments in this group, in the name of my noble friend Lord Kamall. Of the many critical topics we discussed in Committee, our debate on health inequalities stands out as one that prompted unanimous and emphatic agreement from all Benches on the need for us to recognise in the Bill the centrality of the inequalities issue. My noble friend Lord Kamall and I took it as our mission to respond to the compelling points raised by noble Lords by bringing forward government amendments on Report, which I now do. These are issues and points of principle about which the Government—not least my noble friend the Minister—feel very strongly.

As the House will know, we think it important to empower local health and care leaders to pursue new and innovative ways to tackle disparities in the most appropriate way for their area. However, we should not miss the opportunity to ensure that this Bill reinforces those intentions in other ways. The amendments are designed to ensure that the Bill fully reflects the strength of the Government’s ambition to address disparities by levelling up every area of the country.

First, we will put beyond doubt that tackling disparities should be an integral factor when making decisions across the NHS. This was something that NHS England’s four purposes for ICSs made clear. The triple aim duty was always intended to support achieving those purposes, and these amendments strengthen the duty on NHS England, NHS trusts and ICBs so that, when decisions are made by NHS bodies, consideration will always be given to the effect of those decisions on disparities. What does that mean? It means that NHS bodies should consider the wider effects of their decisions on the inequalities that exist between the people of England with respect to their health and well-being and the quality of the services that they receive.

We are also going further by strengthening the more specific duties that complement the triple aim. Disparities are not limited just to health outcomes or access; they relate also to the experience of the care that is received. For example, the independent Commission on Race and Ethnic Disparities reported that Asian patients are more likely to report being less satisfied with GP services than their white, black African and black Caribbean counterparts. These amendments seek to strengthen existing duties as to reducing health inequalities on NHS England and ICBs by explicitly including patients’ experience of care, the safety of services and the effectiveness of services to create a more holistic duty that addresses how disparities manifest themselves in health and care.

When it comes to inequalities in access to health services, we can go further. The duties currently focus only on people who are already using or accessing health services. This fails to address those who do not or cannot access health services—and, as we powerfully heard in Committee, these include many socially excluded and marginalised persons, who are more likely to have preventable health conditions. The point is fully taken, and we have therefore tabled an amendment to ensure that the duties placed on NHS England and integrated care boards as regards reducing health inequalities require the consideration of inequalities in access for “persons”, rather than simply “patients”. The intention here is to improve outreach, as well as access by socially excluded and marginalised groups.

Lastly, we recognise the crucial importance of information on which to base targeted action. The Covid vaccination campaign was unprecedented in the way that it focused activity on every community across the nation, especially where there were disparities in the uptake of the vaccine. Fundamental to that success was the ability to collect and analyse data from across the system so as to target resources in the most effective way.

Our amendment will require NHS England to publish a statement describing certain NHS bodies’ powers to collect, analyse and publish information relating to disparities in health, together with NHS England’s view on how these powers should be exercised. Those bodies will be required annually to review and publish the extent of their compliance with that view. We hope and believe that this will power the evidence-based drive to reduce disparities in health across the country.

I hope that, together, these amendments provide the reassurances that noble Lords sought from their various amendments tabled in Committee. In conjunction, these changes will strengthen the ability and the resolve of the health and care system to take meaningful and impactful action. I commend them to the House and beg to move.

[Lord Kakkar (CB)]

My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.

The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.

Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership. But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.

--- Later in debate ---

[Baroness Thornton (Lab)]

My Lords, the noble Baroness, Lady Walmsley, expressed that very well indeed. From these Benches, I say how much we welcome these amendments and thank the Minister for introducing them. I also join the noble Lord, Lord Kakkar, in regretting the fact that our friend Naren Patel—the noble Lord, Lord Patel—is not with us today. His speech on this in Committee was outstanding, as his speeches always are. In fact, the whole debate was the House at its very best in expressing its view.

We welcome these amendments, and I was very pleased to add my name to Amendment 3 on behalf of these Benches. I was not as energetic as the noble Lord, Lord Kakkar, who put his name to all of them, but that was a symbol of the fact that we supported all these amendments.

We support them because, as people have mentioned, they recognise the importance of addressing inequalities from the top to the bottom of the National Health Service, and of monitoring, counting and research—not a tick-box exercise to say that you are tackling inequalities. As I have mentioned before, I am a non-executive member of a hospital in London. In fact, I have just completed three days of its workforce race equality training. That was three days out of my life during the course of this Bill, but it was definitely worth while. It absolutely was not always comfortable, and nor should it have been. It did indeed raise issues, many of which were raised in research published on 14 February by the NHS Race & Health Observatory. It basically says that the NHS has a very large mountain to climb in tackling race inequalities and inequalities across the board. It is a worthwhile report, which I am sure the noble Earl will be paying attention to in due course.

I also want to say how much I support my noble friend in bringing forward her amendments on the homeless. Coming from Bradford, I am particularly fond of a GP surgery called Bevan Healthcare, named after the founder of the National Health Service. It was started by my local doctor in Bradford, who spent his spare time providing GP services on the street to the homeless. From that, the NHS was commissioned to provide a GP surgery specifically directed to the needs of people who are itinerant and homeless, working girls and so on. It is still there, and it is a brilliant example of how to deliver the service, and of the money it saves the NHS at the end of the day. As I think my noble friend Lady Armstrong said, if you get this right then people do not end up in emergency care or worse.

We hope that the Minister will respond positively to these amendments. I thank him, his team and the Bill team, who addressed this issue thoroughly and with a great deal of success.

[Earl Howe (Con)]

My Lords, this has been a very fruitful discussion and I am most grateful to all noble Lords who have spoken. I especially thank my noble friend Lord Young of Cookham, the noble Baronesses, Lady Walmsley, Lady Thornton and Lady Hollins, the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, in his absence, the King’s Fund and the Health Foundation for their contributions, both inside and outside this Chamber, in shaping this debate and the amendments before us.

Without wishing to repeat what I said earlier, I commend the government amendments to the House as they will strengthen the ability and resolve of the health and care system to take meaningful action on tackling health disparities. I next thank the noble Baronesses, Lady Armstrong of Hill Top and Lady Morgan of Drefelin, and the noble Lord, Lord Shipley, for tabling their three amendments and for the focus they bring to the issues of housing and homelessness. I found the account of the experience in government of the noble Baroness, Lady Armstrong, and the work of Professor Aidan Halligan, whom I too remember with great respect, compelling. I agreed with so much of what she said.

Let me say straight away that the Government are committed to improving the health outcomes of inclusion health groups, as they are known. That is precisely why we tabled the amendment to expand the inequalities duty placed on NHS England and ICBs beyond simply patients to incorporate people who struggle to access health services such as inclusion health groups, but there is much more to say on this.

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Baroness Jones of Moulsecoomb (GP)]

My Lords, the Green group would like to throw its considerable weight behind the two noble Lords who have just spoken. What we saw last night was disgraceful, and I hope we never see it again.

[Earl Howe (Con)]

My Lords, in the absence of my noble friends the Leader of the House and the Chief Whip, I will respond very briefly to the noble Lords who have spoken by saying that I shall ensure that the comments and questions do reach the Leader, and are treated with appropriate seriousness. We have all heard propositions from both noble Lords on the Front Benches opposite with which there would be wide agreement in the House as to the way we should conduct ourselves. In a spirit of sympathy with many of the comments made, I hope noble Lords will agree that it is appropriate that we discuss this in the usual channels.

Amendment 284

Moved by

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, I thank the noble Baroness, Lady Finlay, for this amendment and other noble Lords who have contributed to this highly emotional and compelling debate about the welfare, care and medical treatment of critically ill children. I also thank Emma Hardy MP for ensuring that this key issue was debated in the course of the Bill’s passage through the Commons and the work that she, other MPs and noble Lords have undertaken with parents and medical staff to help build and develop the framework that is set out in the amendment where care and treatment are disputed: Charlie’s law, in memory of Charlie Gard.

The amendment seeks to mitigate conflicts at the earliest stages, provide advice and support, and improve early access to independent mediation services to prevent the traumatic and bitter legal disputes that we have all seen all too often. Noble Lords have highlighted these, as well as the benefits that the step-by-step processes set out in the amendment would provide for parents and doctors, which are of course central to the consideration of the child’s welfare and best interests. In particular, providing families with access to legal aid if court action takes place would, as the noble Baroness, Lady Finlay, pointed out, ensure that they do not have to rely on raising funds themselves, or on the financial support of outside interests.

Today’s debate has been powerful but has also demonstrated the difficulties with trying to address and resolve such deeply complex issues within the context of an already overloaded and skeletal Bill. Like other noble Lords, I have received the excellent briefing from the Together for Short Lives charity, which does such remarkable work on children’s palliative care to support and empower families caring for terminally ill children. While supportive of much of the amendment, the charity has what it terms “significant reservations” about proposed new subsection (4) on the issue of amending the court’s powers in relation to parents pursuing proposals for disease-modifying treatment for their child after the final court decision.

So, while there is obviously considerable support for the measures set out in the amendment, as we have heard today, the reservations about this and other provisions in the amendment, from Together for Brief Lives and other organisations, emphasise the need for the continued dialogue and discussion that we are not able to have today but which noble Lords have made clear is needed. This has been an excellent debate and I hope the Minister will be able to find supportive ways of taking this vital issue forward.

[Earl Howe (Con)]

My Lords, the noble Baroness, Lady Finlay, has brought a vital and sensitive debate before the Committee, for which I for one am very grateful. At the heart of each of these difficult cases is, as she said, the well-being of a child, and that principle has to remain uppermost in everyone’s mind. While the views of parents and guardians are routinely considered in everyday care, occasionally difficult disputes will arise. When they do, we should carefully consider how best to protect the interests of the child. I will start by saying that I fully agree with the noble Baroness that any failure to listen to the concerns of parents or a guardian would be bad practice.

However, I have a concern about the practical impact of this amendment. In cases of the care of children with life-limiting illnesses, the amendment would place the views of parents and guardians above those of clinicians and—let us be clear—the courts, which have a statutory obligation to act in the best interests of the child. Establishing a default presumption in favour of the parents’ views would fundamentally change the current balance. It would move away from the impartial assessment of the individual child’s best interests being paramount based on all the evidence in each specific case.

I understand the view that parents know what is best for their child and their wishes should be paramount. Sadly, though, I am afraid that I cannot fully agree with the proposition advanced in the amendment. It is sometimes the case that desperate parents in these tremendously difficult circumstances are subject to the flattering voice of hope and, as a result, are not acting in a way that is necessarily in the best interests of their child.

To protect the child, it is right that when every effort at resolution has been unsuccessful there is recourse to a judicial process that can impartially assess all the evidence as to what treatment is best for the child. I also fear that it would be difficult for a clinician to determine, in the wording of the amendment, “anyone else” who has an interest in a child’s care. In considering the provisions of the amendment, I note that a child’s medical data can already be provided to parents following a subject access request, so we do not feel that legislation here is necessary. I absolutely agree that specialist palliative care teams should be part of the multidisciplinary team for any child or adult with a complex life-limiting illness; their involvement is an integral part of good practice, and I would expect referrals in such situations. However, I do not agree that it is necessary to put that into law.

Let me say something about mediation. I listened with care to my noble friend Lord Balfe. We know that mediation can and often does play a vital role in facilitating better communications and creating a space where voices on both sides of a dispute can be heard in a non-adversarial way. Unfortunately, that does not provide a solution in every dispute. The Government are supportive of the many excellent mediation schemes already available, including through charities and the private sector. We agree that parents and clinicians should be able to access such schemes where they wish to do so. However, we are not convinced that legislation is the answer to these thankfully rare but nevertheless tragic cases.

The current lack of statutory prescription means that mediation can be tailored specifically to meet the individual needs of families and their children, clinicians and hospitals, reflecting the unique circumstances of each case. There is currently a wide range of work and research into avoiding such protracted disputes and improving the approach to managing conflicts, with the aim of promoting good, collaborative relationships between parents and healthcare professionals to seek resolution without lengthy and costly legal battles. Furthermore, on those rare occasions where disputes are heard before a court, the amendment seeks to extend legal aid. Legal aid is already available for best interests cases, albeit subject to a means and merits test.

I understand the strong views on the amendment across the Committee. I understand that these issues are ethically charged and I take them seriously. However, I also believe that the current approach properly balances the views of parents and guardians with those of clinicians and, above all, with the paramount importance of the best interests of the child in question. The sensitivities around this subject are acute but I hope that what I have said has clarified why I do not feel able to accept what I know is a well-intentioned amendment.

[Baroness Finlay of Llandaff (CB)]

My Lords, I cannot hide my deep disappointment at the response from the Government, because I think this situation will only get worse unless we recognise the difficulty of decision-making when you are faced with a child whose prognosis is poor, who has a very rare condition, where nobody has a test to predict what will happen, and where the parents feel that they are not being listened to.

Currently in the NHS we have clinical teams that change rapidly. The one person—often—who has continuity and has seen the child day after day is the mother; sometimes it is the father who is with the child all the time. But you get different clinical teams, and you may have a gap of five days between one doctor visiting and coming back, and they may say: “Oh my goodness, what a change.” But when you have a handover, you do not get a complete picture.

Covid-19: Lockdowns

Earl Howe Excerpts

Wednesday 9th February 2022 Lords Chamber

[Earl Howe (Con)]

My Lords, the noble Baroness, Lady Brinton, has indicated her wish to speak. This may be a convenient moment.

[Baroness Brinton (LD) [V]]

My Lords, this paper’s economist authors admit that it reflects their opinions. Extraordinarily, they chose to exclude the most recognised epidemiological research on excess deaths. It is not even peer-reviewed. The conclusions are contradictory to the established annual excess death protocols, published for years by the ONS and other national statistical agencies around the world. Which data should scientists advising the Government and Ministers rely on when making decisions about lockdown?

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

There is lots more that I could say—I was going to repeat some of the words of the noble Lord, Lord Ahmad —but we have had a very strong debate and there is a clear view across the House that this is not a partisan issue. Once again, the noble Lord, Lord Blencathra, is absolutely right. I will back him on this amendment, and let us ensure that the Government keep their word.

[Earl Howe (Con)]

My Lords, I am grateful to my noble friend for enabling us to debate the serious and important issue of ensuring that health service procurement and supply chains are consistent with the United Kingdom’s international obligations. I have listened very carefully to the contributions from all noble Lords who have spoken.

I begin by making clear what the regulation-making power under Clause 70 is designed to do, and not do. The Clause 70 power is limited in scope to healthcare services and, with the exception of some mixed procurements, will not extend to the procurement of goods. The vast majority of healthcare services procured by the NHS are provided by domestic suppliers or, indeed, by the NHS itself.

However, there is a wider point to address in response to the contributions of noble Lords. As a party to the Convention on the Prevention and Punishment of the Crime of Genocide, the UK is fully committed to the prevention and punishment of genocide as appropriate under the convention. Indeed, the UK is active in fulfilling its duties under the genocide convention. Given that the majority of mass atrocities occur in and around conflict, the Government believe that a focus on conflict prevention is the best means to prevent most mass atrocities. To that end, this Government adopt a consolidated, whole-of-government effort using our diplomatic, development, defence and law-enforcement capabilities to help find pathways to global peace and stability.

As my noble friend is well aware, it is the long-standing policy of the Government that any judgment as to whether genocide has occurred is a matter for a competent national or international court, rather than for Governments or non-judicial bodies. It should be decided after consideration of all the evidence available in the context of a credible judicial process.

Having said that, our policy on genocide determination does not prevent us taking robust action to address serious violations of human rights. The Government are clear that they expect all UK businesses to respect human rights throughout their operations, in line with the UN’s Guiding Principles on Business and Human Rights. In response to the guidelines, the UK is proud to be the first state to produce a national action plan, and we continue to develop our approach in line with the Modern Slavery Act 2015. Section 54 places a requirement on businesses with a turnover of £36 million or more to publish an annual modern slavery statement setting out the steps they have taken to prevent modern slavery in their operations and supply chains.

Following a public consultation, the Government committed to a package of measures to strengthen our transparency in supply chain requirements. This includes extending the reporting requirements to public bodies with a budget of £36 million or more to create public and private sector parity. The Government have led the way in this endeavour and, in 2020, the UK became the first country in the world to publish a government modern slavery statement, setting out the steps we have taken to identify and prevent modern slavery in our own supply chains. The noble Lord, Lord Collins, indicated that he had not seen evidence of action in this area. In November 2021, we published a progress report on how we have met the ambitious goals set out in that statement and, at the same time, each UK ministerial government department voluntarily published their first annual modern slavery statement. As the noble Lord mentioned, the FCDO and the Cabinet Office are also working together to introduce new guidance to UK government bodies to exclude suppliers where there is sufficient evidence of human rights violations in any of their supply chains. Further detailed guidance is being developed that will be mandatory for government contracting authorities.

The UK’s G7 presidency demonstrated how we are revitalising G7 co-operation to tackle the most pressing global challenges. At the meeting in Carbis Bay, in June 2021, G7 leaders reaffirmed their commitment to uphold human rights and committed to prevent, identify and eliminate forced labour in global supply chains. This was followed up by the G7 Trade Ministers’ meeting in October, building on those commitments to eradicate forced labour, protect victims and improve global supply chain transparency, including by upholding international labour standards in their own business operations and procurement policies. This is one of a number of recent, clear demonstrations of our continued leadership and commitment to ending human rights abuses in global supply chains.

The noble Baroness, Lady Brinton, indicated that she did not think that the Department of Health and Social Care in particular was doing enough in this area, but if we look at the health service specifically, we see that the Department for Health and Social Care published a statement in October 2021 explaining the steps it has taken to identify, prevent and mitigate modern slavery within its own operations and supply chains for all goods and services that it procures. This aligns with the Cabinet Office guidance advising public sector contracting authorities on how to assess suppliers in terms of mitigating the risk of modern slavery. Contracts are normally placed in line with the department’s terms and conditions, which include clauses requiring good industry practice to ensure that there is no slavery or human trafficking in supply chains.

My noble friend also asked why the 2021 modern slavery statement did not cover the Vaccine Taskforce, PPE, UKHSA—formerly Public Health England—or test and trace contracts. Some indication of preventive steps taken in relation to these areas were included in the statement, and, as was outlined later in that statement, all areas will be covered in 2022 statements.

My noble friend, and the noble Baronesses, Lady Brinton, Lady Harris and Lady Kennedy, the noble Lords, Lord Alton, Lord Collins and Lord hunt, my noble friends Lady Hodgson and Lady Sugg, and others, raised issues about Xinjiang, in particular. The Government have taken robust measures in respect of UK supply chains. We have introduced new guidance for UK businesses on the risks of doing business in Xinjiang, supported by a programme of ministerial engagement, and we have announced enhanced export controls, as well as the introduction of financial penalties under the Modern Slavery Act. Taken together, these measures will help to ensure that no British organisations —government or private sector, deliberately or inadvertently—are profiting from or contributing to human rights violations against the Uighurs or other minorities.

I am conscious that the noble Lord, Lord Alton, asked me a series of questions. If he will allow me, I will write to him on those that I am unable to answer today. The same applies to the points raised by the noble Lord, Lord Rooker, to whom I listened with great care.

For the multiple reasons that I have set out, I cannot accept my noble friend’s amendment. I hope, nevertheless, that I have been informative, and that he will have derived at least some reassurance from what I have said about the seriousness with which the Government view the issues around human rights violations, and the actions that we are taking.

[Lord Blencathra (Con)]

My Lords, I am grateful to every noble Lord and noble Baroness who has taken part in the debate, every single one of whom spoke in favour of the amendment, apart from my noble friend Lord Howe—I perfectly understand that he had to adhere to the DHSC brief. I am certain that, if every other noble Lord were to speak in the debate, each one would support the amendment as well.

I am grateful for the particularly powerful speech of the noble Lord, Lord Rooker, on determining the provenance of goods. Just as an aside, I can tell the House that, before Christmas, I thought I would impress my wife by trying to buy a couple of Oxford pillowslips myself, without troubling her. I wanted something with a thread count of over 400—for my delicate little skin, of course—and it took me hours and hours on the web to try to find a supplier among the major retailers that could guarantee that it would not be from Xinjiang province. I ended up contacting one supplier and asking, and three weeks later it replied by email guaranteeing me that the cotton was not from Xinjiang. I bought the pillowslips, and I still do not know whether or not I have been sold a pup—but they are quite nice against the skin. The noble Lord is right: we can tackle this problem only if we can trace provenance, and using DNA or other scientific evidence may be the best way to do that.

I do not want to go down the route of criticising some of the initial contracts that the Government entered into, as some noble Lords have done. There is no doubt about it: we were ripped off by some of them, we bought some duff equipment, and there will have been some dodgy contracts. But I remember that, at the time, every medic was calling out, “Get us PPE from wherever you can!” The whole world was scrabbling to get PPE. If your house is on fire, you do not spend ages on the web trying to find the cheapest fire bucket; you buy whatever you can. So I do not want to spend time on whether those contracts were value for money; that is for another day.

Someone asked: when did genocide start? I recall that the noble Lord, Lord Adonis, who was in the Chamber briefly, made a powerful speech a few months ago, saying that when genocide was happening, the whole world noticed that it was happening but did nothing about it, and then afterwards said that it must not happen again. We knew that Jews were being exterminated, and after 6 million were killed we said, “It must never happen again”. We knew what Pol Pot was doing, and afterwards we said, “It must never happen again”. We knew what Stalin was doing, and afterwards we said, “We must never let it happen again”. Then there was Srebrenica, and afterwards we said, “We must never let it happen again”. We know that genocide is taking place in Xinjiang province, yet we are just putting in place systems that may, one day, eventually, stop us trading with some of the people there who are committing genocide. That is not good enough. We must act faster than that.

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

I hope that the Minister will be able to accept what I regard as sensible amendments to move us toward a strategy to deal with the treatment and prevention of oral ill-health.

[Earl Howe (Con)]

My Lords, I am very grateful for the contributions to this debate from noble Lords, bringing us to a set of issues which many of us have been grappling with for a number of years.

I turn first to Amendment 224, and the access issue. The point I must stress before any other is that this Government are committed to improving access to dental services across England. With that aim, we are working closely with NHS England to increase dental capacity as rapidly as possible. Since the start of the year, the threshold for dental activity in NHS practices has again increased and is set at 85% of pre-pandemic activity, allowing more patients to be seen. Building on this, NHS England recently announced an extra £50 million to urgently provide hundreds of thousands of additional appointments.

Beyond recovery from the pandemic, we recognise the need to reform the NHS dental contract to increase access. NHS England is leading on dental system reform and working closely with key stakeholders to deliver this. I think it was the noble Baroness, Lady Merron, who asked about dental morale. Much of any dip in morale has to do with what is seen as a delay in introducing the new dental contract, which has been promised for a number of years. There are all sorts of very valuable reasons for that delay, which the profession is being consulted on, but I understand that dentists are keen to see a new structure of remuneration.

That is a summary of the current backdrop. Noble Lords should be in no doubt of the Government’s continuing commitment to improving the provision of NHS dentistry across the country. What we are doing demonstrates that commitment, and for that reason we do not feel that a requirement to publish a statement on this work is necessary.

This brings me to the amendments on water fluoridation. This Government want to see more of the population benefit from fluoridation, which we know reduces oral health inequalities and the burden on NHS services. I will first address Amendments 259B and 259D, tabled by my noble friend Lord Reay, which take us in a different direction. I realise that he feels strongly about the issue, but in relation to Amendment 259B, the clear advice that I have received is that there is no evidence of harms to the environment from water fluoridation schemes. There are existing safeguards in place to protect the environment and public health.

As part of their overall responsibilities, water companies are already required to comply with relevant environmental legislation. The Town and Country Planning (Environmental Impact Assessment) Regulations 2017 and other legislation set out the thresholds and criteria for which an environmental impact assessment is already required. The installation of water fluoridation plants in some areas may already fall within this scope. The Environment Act 2021 will, when brought into force, place a duty on the Government to have due regard to the policy statement on environmental principles in our policy-making. New and revised policies will need to take into account their impact on the environment. The Environment Agency also monitors the ecological health of our rivers at a large number of sites. If there had been or were to be a failure in the safeguards, the agency could detect this through its routine monitoring programme.

Turning to Amendment 259D, I emphasise to my noble friend that the scientific evidence around fluoridation is kept under constant review. Several authoritative scientific reviews have looked at the general health effects. The common finding of such reviews is that there is no convincing scientific evidence that fluoride in drinking water at levels used in fluoridation schemes is a cause of adverse health effects. This view is shared by the UK Chief Medical Officers, who issued a joint statement last September supporting water fluoridation as a safe and effective public health intervention to improve oral health.

I listened carefully to my noble friend, but the Government are committed to keeping the evidence under review, and it would be inappropriate to carry out evidence reviews focusing on studies from a specific time period and a specific part of the world, as he suggested. Keeping the evidence under review is what we will do but the Secretary of State is also required to monitor the effects on the health of the population living in areas with water fluoridation schemes and then publish a report no less than every four years. The next report is due in March of this year.

My noble friend suggested that the water fluoridation elements of the Bill have somehow been slipped in without adequate time for debate. In fact, the White Paper setting out proposals for the Health and Care Bill, published in February 2021, highlighted the current difficulties faced by local authorities and set out our intention to use the Health and Care Bill to give the Secretary of State the power to directly introduce, vary or terminate water fluoridation schemes. So the water fluoridation elements of the Bill have been there from the outset and open to debate.

Both my noble friend and the noble Lord, Lord Storey, referred to the Childsmile initiative in Scotland and asked why we cannot have a scheme in England. In fact, daily supervised toothbrushing programmes in England can already be entered into by local authorities or the NHS. There are already some schemes around the country; I visited one myself when I was dentistry Minister. Public Health England has published guidance in this area to help local authorities who are interested in schemes. Against that background, I hope that my noble friend will feel at least a little reassured, and sufficiently so to refrain from moving his amendments when they are reached.

On Amendments 260 and 262, the public voice on further fluoridation remains important and we are committed to ensuring that the population continues to have its say on any future water fluoridation schemes. We are bringing forward plans for an initial expansion of water fluoridation schemes over the next three years. We will consult the public on these plans later this year, subject to the successful passage of the Bill and funding being confirmed. The outcome of that consultation will inform regulations to be drafted later this year. These regulations will be subject to the affirmative procedure.

Underpinning any scheme expansion is the need to undertake feasibility studies and to secure funding, as well as public consultation against which we do not have certainty and cannot pre-empt the outcome. As such, we cannot at this stage set out a programme of expansion; because of that, any programme drafted in advance of the completion of these steps would be so heavily caveated and subject to change that its utility would be substantially undermined. I am of course very happy, as is my noble friend Lord Kamall, to update the House as expansion plans are developed and agreed. However, we do not believe that this needs to be specified on the face of the Bill.

Amendment 261 relates to cost-sharing for new schemes. There are no current proposals for cost-sharing. However, given the cycle of legislation and the infrequency with which these opportunities present themselves, we have taken the decision to include such measures now to provide flexibility for this in future. I can assure the House that, should we bring forward any plans to cost-share in the future, we would seek to fully engage with relevant groups at the earliest opportunity. Any plans to cost-share with public sector bodies would also be subject to regulations on which there is a requirement to consult.

I would say to the noble Baroness, Lady Walmsley, that funding for both new and current health improvement initiatives is within the overall capital budget allocated to the department over the next three years. We will be undertaking a business planning exercise before this funding is made available from April 2022, and we will confirm this is due course.

The noble Baroness asked about the effect on water bills. There will be a cost associated with water fluoridation schemes that will need to be met either through taxation or other means. However, we know that in the end this is a cost-saving measure; the money spent to implement these schemes will save the nation money in the longer term and will benefit health. As I said, currently there are no plans to cost-share with water companies or indeed any other public sector bodies. However, given the opportunity presented by the Bill, we are enacting the relevant provisions.

--- Later in debate ---

[Baroness Bennett of Manor Castle (GP)]

I raised the issue of the lack of public trust in tap water and the fact that that is a public health issue and could be magnified. Could the Minister comment on that and suggest what the Government are planning to do about it?

[Earl Howe (Con)]

I apologise to the noble Baroness, because she was making a significant point. I am not sure that I share her perception that those who buy bottled water in supermarkets necessarily do so as a reflection of their lack of trust in tap water; a lot of it has to do with some myths around the benefits of bottled water. However, be that as it may, I will take advice and write to the noble Baroness. I am not sufficiently sighted on the issue she raised and the evidence behind it, so it is probably appropriate if I look into it and write to her.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a very interesting debate. On dental access, a number of noble Lords—my noble friend, the noble Baroness, Lady Bennett, the noble Lord, Lord Storey, and the noble Baroness, Lady Walmsley, among others—commented on the great difficulty that many people have at the moment in getting access to an NHS dentist. The noble Lord, Lord Storey, focused in particular on children, which is my particular concern. More energy needs to be put into developing a dental strategy. On thoughts of contracts, anyone who has been a dental Minister will know that the problem with contracts is that dentists always overperform, and the Treasury then claws back in future years, leading to unhappiness and misery in the profession. The fact that the pilot schemes, on which I think work is being based for a future contract, have now stopped, or are going to be stopped, is a great pity, and it does not show positive intent.

On fluoridation, I was delighted that the noble Lord, Lord Young, intervened. A couple of debates ago I was watching on the screen, and he chided me for what I thought was a perfectly formed piece of legislation at the time, many years ago. He talked about his experience as a Minister 42 years ago. I think it was because of his work that I, 37 years ago, as secretary of the Edgware/Hendon Community Health Council, organised public meetings in part of the Borough of Barnet on fluoridation, prior, we hoped, to the then area health authority implementing a fluoridation scheme. Although the public meetings came out strongly in favour of fluoridation, of course nothing happened. I am afraid that the experience in Barnet and Edgware and Hendon was repeated up and down the country, which is why I applaud the Government for doing what they are doing now.

The noble Baroness, Lady Northover, spoke very eloquently about the evidence from deprived areas. Sandwell, next door to Birmingham, is high up in most indicators of poor health, except in dentistry. That is because, unlike Liverpool, Birmingham City Council took the decision in the 1960s to fluoridate the water supply and Sandwell got the benefit. The result is that, in general, oral health in the West Midlands is very good indeed.

I listened with great interest to the noble Lord, Lord Reay. He mentioned the Jauncey judgment, which unfortunately I remember. I remind him that, although Lord Jauncey ruled that Strathclyde Regional Council was exceeding its powers in seeking to fluoridate the water system, he accepted that the amount of fluoride it wanted to put into the system would have no significant adverse effect on health, that fluoridation had been shown to be harmless and that it would be effective. When we quote Lord Jauncey, we need to quote the whole judgment, rather than just whether Strathclyde was found to have the power to put fluoride in the water.

I will not repeat what the noble Earl, Lord Howe, said. In only September, the Chief Medical Officers spoke in their judgment about the effectiveness and safety of fluoride. I was very glad to hear the point the noble Earl made about expansion; I am very glad that it is on the Government’s mind. I look forward to the consultation, which I take will be a national one, if there is going to be an expansion; that is very good news indeed.

On cost sharing, I register that this Bill is full of little clauses which give Ministers powers to do something in the future, when they know what they want to do. I mention procurement regulations in Clause 70 at the same time; I think that is going a bit too far. Having said that, I beg leave to withdraw my amendment.

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, we on these Benches said everything we needed to say on this matter in support of the noble Lord, Lord Mawson, when we had the substantial debate. I do not know when it was—last week, I think. These two amendments flow from that. We probably could have taken them then, but I am sure that the Minister will have useful things to say.

[Earl Howe (Con)]

My Lords, we return to the very important theme of subsidiarity, to which the noble Lord, Lord Mawson, has brought us in both his amendments and his powerful speech, born of his immense experience in the real world.

I will begin with Amendment 159A, if I may. One of the main reasons for introducing this Bill was to ensure that existing collaboration and partnership working across the NHS, local authorities and other partners was built on and strengthened. This relates especially to the framing and monitoring of assessments and strategies. We intend for these assessments and strategies to be a central part of the decision-making of ICBs and local authorities. That is why we are extending an existing duty to ICBs and local authorities to have regard to the relevant local assessments and strategies. Furthermore, the integrated care board and local authorities will both be directly involved in the production of these strategies and assessments through their involvement with both the integrated care partnership and the health and well-being boards. As a result, they have a clear interest in the smooth working of the ICP.

More widely, there are already several mechanisms to ensure that ICBs and local authorities will have regard to the assessments and strategies being developed in their areas. First, health and well-being boards have the right to be consulted by ICBs and give NHS England and ICBs their opinion on whether the joint forward plans take account of the joint local health and well-being strategy. Likewise, as part of its annual assessment of ICBs, NHS England must consult each health and well-being board on how well the ICBs have implemented the relevant joint local health and well-being strategies.

There are what one might call insurance policies embedded in these arrangements. Each ICB must also include in its annual report a review of the steps it has taken to implement any relevant joint local health and well-being strategy. It must also consult the health and well-being board when undertaking that review. Finally, NHS England has formal powers of intervention if an ICB is not complying with its duties in any regard. Putting all this together, we think that it is sufficient to ensure that ICBs will have regard to both ICP and health and well-being board plans.

The emphasis is on collaboration. Implicit in that concept is the two-way street on the sharing of ideas and exemplars that the noble Lord, Lord Mawson, called for and illustrated in his examples. Given the strong collaborative measures in the Bill and the strong foundations of collaborative and partnership working across the NHS, local authorities and other partners on which this Bill is built, we do not think that further provision is required. We would expect an ICP to resolve disagreements through discussion and joint working rather than additional, potentially burdensome procedures.

Amendment 210A brings us once again to the role of non-statutory organisations in helping to create and sustain healthy communities. I want to stress straightaway that the Government hugely value the contributions of the voluntary, community and social enterprise sectors to the health and well-being of the nation. We recognise their important role in supporting the health and care system.

The Government fully expect that commissioners will also recognise this contribution and role going forward. This role will be particularly important in efforts to recover performance and move beyond a purely reactive service to building a sustainable and personalised health and care system, something the non-statutory sector is uniquely placed to offer. I think the lessons learned, so well described by the noble Lord, Lord Warner, in the previous set of amendments, are widely accepted nowadays.

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

I therefore hope that, in responding, the Minister will be able to explain to the Committee why the provisions in the Bill have not taken account of these important points, and points of agreement and good practice. I hope that he will reflect on the fact that these amendments improve the Bill and will feel able to take them forward.

[Earl Howe (Con)]

I am grateful to the noble Lord, Lord Crisp, for bringing this debate before the Committee. I have listened to him and other noble Lords with care. Before I turn to the detail, it may be helpful if I explain the reason why Clause 54 is in the Bill.

Clause 54 originated as a legislative proposal made by NHS England and NHS Improvement to the Government in 2019. In making this recommendation, NHS England, under the leadership of the noble Lord, Lord Stevens, worked closely with representatives of the foundation trust sector. The key principle behind this clause is a recognition that the interests of the whole system should be prioritised in decisions about capital spending while also respecting the freedoms and accountabilities of NHS foundation trusts.

The noble Lord, Lord Crisp, asked whether it was our intention that the power in the clause would be a last resort—absolutely yes. Clause 54 is a reserve power to be used only in extreme circumstances to avert the risk of a foundation trust pursuing its own private capital objectives—if I can put it that way—that are not prioritised at a system level. I say to my noble friend Lord Lansley that that is the potential mischief that the clause is trying to address.

The control will operate in the context of the new NHS capital regime, introduced in 2020-21, at ICS area level with planning at a system level to take a holistic view of the local healthcare needs and balancing the allocated operational envelope for providers at that level. Having a power to set capital spending limits for NHS foundation trusts, as can already be done for NHS trusts, ensures an equitable distribution of capital to better enable the investments with highest priority and that achieve the greatest benefits for patients.

At this point I will push back, in the nicest possible way, at the noble Baroness, Lady Walmsley, about the actual level of capital spend. At the spending review 2021, capital spending was set to increase over the Parliament to £32.2 billion for the period from 2022-23 to 2024-25. That includes a £5.9 billion capital investment for the NHS to tackle the backlog of non-emergency procedures and modernise digital technology. As a result, the Department of Health and Social Care’s core capital budget will reach its highest real-terms level since 2010.

[Baroness Walmsley (LD)]

Governments always tell us how much money they have spent, but the question is always: has it met the demand? The money that the Minister has just mentioned is to try to cover the backlog of elective procedures; it does not cover the backlog of repairs.

[Earl Howe (Con)]

There will be money to address the backlog of repairs within that total.

Of course, it is our intention that a capital limit would be imposed by NHS England only if other ways of resolution had been unsuccessful. I will take the Committee through some of the detail, because it is important.

Amendments 188 to 192 would further restrict how the power can be applied. Amendment 188 would modify the clause by inserting “individual trust”. This modification is unnecessary because new Section 42B already ensures that an order relates to a single trust.

Amendment 191 would limit the order to one financial year, but, instead of that, the guidance prepared by NHS England will set out that any capital expenditure limits will apply to individual, named foundation trusts. We envisage that most will apply for the period of budget allocation, which is a single financial year.

Amendment 189 would insert steps that NHS England must take before applying the control and limit when an order may be made. The amendment also links the power with the capital planning function held by ICBs in new Section 14Z54. That plan may not always relate to a single financial year and can be amended in year; for example, for big capital projects, the plan could be set for several years, and in such a scenario it would be difficult to determine whether a foundation trust exceeded the plan in the early years. Amendment 189 would undermine the ability to impose the limit in a timely way and would mean that any limit could realistically be applied only when an overspend had already occurred or was committed to. That would risk funding being unfairly taken away from other areas.

Amendments 190 and 192 contain a requirement to lay a report before Parliament alongside a statutory instrument containing the order. That would cause significant delays in the power’s application. There is already a requirement in the Bill for NHS England to publish any orders which place a capital limit on a foundation trust and for guidance to set out the circumstances in which it is likely to impose a limit. We expect the guidance will also state that representations made by the trust will be published by NHS England.

As I mentioned, it is our strong view, supported by NHS England, that the powers and safeguards in the Bill create a proportionate and fair balance. These measures will ensure that if a foundation trust were actively to pursue capital expenditure that is not aligned with local priorities or affordable within local budgets, there is a means to prevent this as soon as possible.

[Lord Crisp (CB)]

I thank the Minister for that reply. I have one point to make and one question. My point is that an NHS foundation trust may cover an area that is bigger than one ICB, and some of the bigger ones obviously do, so it does not quite work in the way that the Minister talked about. My question, and it is my final question, is: will officials re-engage with NHS Providers on behalf of NHS foundation trusts to discuss this matter further in the light of what we are saying so forcefully to the Government about pragmatic solutions to find a way forward to achieve the right balance and what the Minister has said in his response?

[Earl Howe (Con)]

I had not quite finished the remarks I was going to make, so perhaps the noble Lord will bear with me. I was trying to say that the measures will ensure that there is certainty for all providers about their capital expenditure. It will also prevent the need unfairly to take planned funding away from other providers, such as NHS trusts, where NHS Improvement and, in future, NHS England, set routine capital expenditure limits just to keep expenditure within system control totals, or national capital limits when a foundation trust exceeds its capital limit. Operational detail of how capital expenditure limits are set is best dealt with, we think, in guidance, where we can ensure flexibility and future-proof the provision, rather than in the Bill.

I hope that those remarks are helpful and will persuade the noble Lord to withdraw his amendment this evening. I say to him, as I did at the start, that I have listened carefully to the points he has made in support of his amendments, and points made by other noble Lords, and I undertake to take these points away for further consideration between now and Report. I am aware that my officials are working closely with NHS Providers on a number of issues, and I very much hope that we can resolve any points of difference to everyone’s satisfaction.

[Lord Crisp (CB)]

I thank noble Lords who have spoken in support of the amendment, for the very clear message that has been given. I also thank the Minister for that reply and those final remarks about thinking about this further and discussing it as appropriate with NHS Providers. On that basis, I am very happy to withdraw my amendment.

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Earl Howe (Con)]

My Lords, I am most grateful to the noble Baroness, Lady Barker, for bringing Amendment 20A before the Committee today, and to the noble Baronesses, Lady Walmsley and Lady Thornton, for their very wise insights. I do not think there can be anyone in Committee who does not agree that delivering high-quality reproductive healthcare is critical for the health service.

This is definitely a priority area in the Government’s work on the women’s health strategy for England. Proof of that, I hope, is that on 23 December 2021 we published Our Vision for the Women’s Health Strategy for England. The vision is informed by analysis of the call for evidence, which ran for 14 weeks from March to June 2021.

On reproductive health specifically, the vision sets out our ambition that

“women can access services that meet their reproductive health needs … and women’s experiences of services and reproductive health outcomes are improved”.

As a bit of further background, we were clear that the strategy should be evidence-based, so the vision is in fact underpinned by the analysis of what we heard through the nearly 100,000 responses to the call for evidence. We owe it to women and girls across England to get it right, and when we publish our full strategy later this year we will set out our ambitions in more detail and will follow that up with full delivery plans where appropriate.

Joined-up national policy and clinical leadership are essential to the delivery of women’s reproductive health services. I can assure the Committee that this is also recognised as a priority by NHS England and NHS Improvement. We continue to work closely with NHS England and NHS Improvement on the development of the women’s health strategy for England. We will also be working closely with NHS England and NHS Improvement on the Government’s forthcoming sexual and reproductive health strategy to ensure that, together, the women’s health and sexual and reproductive health strategies take a holistic and comprehensive approach to improving women’s reproductive health. The sexual and reproductive health strategy will consider how we can strengthen leadership and accountability in relation to reproductive health, as well as how we improve access to contraception.

Self-evidently, NHS England regards these as major areas of work. We do not, however, think it appropriate in the Bill to require NHS England to appoint an additional national clinical director specifically for reproductive health. The first reason is because, within the current NHS England and NHS Improvement, the role of national clinical director for maternity and women’s health already exists. This position is responsible for clinical advice and leadership on obstetrics and gynaecology matters, which are of course important areas of women’s reproductive health. The post is currently held by Dr Matthew Jolly. The national clinical director works alongside the national speciality advisers for gynaecology and four other national speciality advisers, covering broader aspects of obstetrics and public health. Creating an additional post of national clinical director for reproductive health is likely to be counterproductive, in that it may lead to duplication or less clarity over responsibilities and clinical leadership.

Secondly, as a point of principle, we should try to resist the urge to specify the clinical directors that NHS England should appoint. If we make a habit of doing that, it strips it of its operational autonomy. It is better to allow it to determine the directors it needs, based on the challenges it faces.

The noble Baroness, Lady Barker, rightly pointed out the disparities that exist between different groups of women in this country. I can only express my agreement with the points that she made on that subject. It is essential that we recognise that women are not a homogenous group. The different characteristics that make up each woman’s identity can lead to multiple, sometimes overlapping barriers to accessing healthcare and can contribute to disparities in health outcomes.

When we launched the call for evidence that I mentioned, we said that we wanted to better understand where there are disparities between men and women and between different groups of women. As set out in the vision, a key priority running through this work is to ensure that all women have equitable access to and experience of services and that disparities in outcomes are reduced.

In addition, NHS England and NHS Improvement regularly review their clinical leadership, including national clinical director and national specialty advisor roles, to ensure alignment with strategic priorities for the NHS and patients, as set out through the NHS Long Term Plan, and to support areas in which NHS England and NHS Improvement are taking forward major programmes of work or areas identified as priorities for improvement. In other words, this is not a static landscape. I hope that the noble Baroness will be reassured by this and so will be able to withdraw her amendment.

[Baroness Barker (LD)]

My Lords, I thank noble Lords who have contributed to this debate. I realise that time is at a premium, but it was useful to air these issues. I thank the Minister for his full response, although it was not entirely unexpected.

I do not doubt that NHS England has a number of clinical directors, but the stats speak for themselves: 45% of pregnancies are either unplanned or ambivalent and abortion rates are at their highest level. Whatever we have at the moment is not working. The call for this director came from the Faculty of Sexual and Reproductive Healthcare and RCOG; they are people who know this subject in great detail.

I know that across the NHS there are different initiatives trying to bring a greater understanding of gender in medicine. For example, for NHS England I know that the Government are working with the Royal College of Physicians to try to bring about a greater understanding of gender in medicine in the form of training for medical students. But this area of medicine is one in which information, and particularly digital transformation, is already having a significant impact and could have an even greater impact on outcomes. That in itself is a challenge to practitioners, and NHS practitioners are not always the best at dealing with that sort of challenge to their existing practice. Therefore, there is perhaps a case for refreshing the clinical leadership of NHS England in this respect.

If the stats do not improve, we will definitely have to look at this before too long. I listened to what the Minister said about the two strategies that are coming out and I will look at them with a keen eye. In the meantime, I beg leave to withdraw this amendment.

Covid-19: Vaccinations for School Pupils

Earl Howe Excerpts

Monday 17th January 2022 Lords Chamber

[Lord Kamall (Con)]

I think the noble Lord is being slightly unfair in the sentiment of his question. We have to remember that, when it came to vaccinating children, there was a huge debate around, first, whether it was ethical to do so and, secondly, whether the vaccines used for adults were effective in children. We could not really do any of that until we had sufficient data. It would have been irresponsible just to have pushed ahead without the data. Once we got the data, we started the vaccination programme for 16 and 17 year-olds and then for 12 to 15 year-olds, and we are pushing through as much as possible. Parents can book for their children on a national booking service. We expect many more parents to do so.

[Earl Howe (Con)]

My Lords, the noble Baroness, Lady Brinton, has indicated her wish to speak virtually, and I think this is a convenient point for me to call her.

[Baroness Brinton (LD) [V]]

My Lords, many parents are still saying that they have not heard when their clinically extremely vulnerable five to 11 year-olds will get their vaccinations, despite the JCVI saying that they should. Last week’s update to the GP green book now includes severely CEV children as eligible for the third primary dose, which is progress. However, there is no news for CEV young children not classed as severe, so can the Minister please say what he will do to ensure that GPs will call all these children for their vaccinations as soon as possible?

Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I am very grateful to the noble Baroness, Lady Walmsley, because she has helped me to clarify my thinking about this group of amendments. Basically, they have good intentions and they make good points about the things that need to happen, but I am not absolutely certain they need to be in the Bill. I am also particularly grateful to the noble Baroness, Lady Finlay, for her very well-informed contribution about what actually goes on. There are of course problems in relationships between the devolved nations and NHS England, some of which are down to not being very well organised, some of which are down to arrogance on the part of the bigger ones, and some of which are down to the funding not actually being available—and some of them might be politically motivated too.

Amendment 17 opens some new thinking on the subject of integration, and accepts that devolution has given us different systems for care in Wales, Northern Ireland and Scotland, but seeks to ensure that what is done in one part of the UK—that is, England—does not adversely impact on other parts. The intention to bring collaboration between the nations is, of course, commendable.

I note that Amendment 205 places some requirements such that

“Welsh Ministers, Scottish Ministers and a Northern Ireland department must make regulations providing that the choices available to patients in England by virtue of regulations under section 6E(1A) or (1B) of the National Health Service Act 2006 (inserted by section 69 of this Act) are available to patients for whom they have responsibility.”


Again, we can understand the need for consistency, but I am unclear about how that will play out against the devolved nature of healthcare—so I think the case will have to be made out for that and, indeed, why that would be included in the legislation.

In a similar fashion, Amendment 301 looks to establish interoperability around the use of data across the whole UK. Again, that is a wholly worthwhile intention, and one that I would hope that the various authorities could collectively work on and agree. Once more, what the role is for primary legislation to address this point is not entirely clear, and I welcome the discussion. I look forward to hearing what the Minister has to say.

[Earl Howe (Con)]

My Lords, I begin by thanking my noble friend Lady Morgan for raising these important matters both via this Committee and by engaging—as I understand she has recently—with my honourable friend the Minister of State for Health. I am also grateful to all other noble Lords who have spoken so powerfully and knowledgably on these issues.

There is no escaping one overarching reality in this policy area, to which the noble Baroness, Lady Thornton, has just alluded. As a Government of the whole United Kingdom, Ministers are responsible for all people of the UK; that is a given. However, while the core principles of the NHS are shared across all parts of the United Kingdom, it is the devolved Governments in Scotland, Wales and Northern Ireland who are responsible for developing their own health policies. Health is largely a devolved matter in the UK, and the commissioning and provision of health services for people in Scotland, Wales or Northern Ireland will continue to be a matter for the devolved Governments.

It will not surprise my noble friend to know that the UK Government continue to respect existing devolution settlements, so our aim is close collaboration with the devolved Administrations to deliver the best outcomes for the people across the four nations. This means that, while we are sympathetic to the spirit of these amendments, I am afraid that we cannot accept them.

I shall address the detailed issues. On Amendment 17, I agree with my noble friend that there is more we can do to align our healthcare for the good of patients across the United Kingdom. We are already exploring several projects to support the NHS to work more closely across the UK, and this includes refreshing the current memoranda of understanding between all four Governments and working with the Office for National Statistics to establish a number of UK-wide datasets. Steps like that will improve transparency and collaboration for the good of all patients across the UK. We do not believe that these steps require primary legislation, but we will keep that question under review. We will also continue to work with NHS England to ensure that a number of groups that it currently hosts, such as the rare diseases advisory group, and their specialised commissioning processes, also meet the relevant needs of the devolved Administrations.

Turning to Amendment 205, we know that choice of healthcare is an important right for patients across the UK. The NHS Constitution for England, for example, enshrines the patient’s right to informed choice. We will be preserving the important right for patients in England to choose their first elective outpatient appointment, GP and GP practice through regulations made under powers provided by the Bill. NHS England works closely with the devolved Governments, including on commissioning and ensuring access to specialised services. Requests for patients to have treatment in other nations are generally to secure continuity of care, to provide care close to patients’ support mechanisms, or because of specialist expertise.

The health services in Scotland, Wales, and Northern Ireland already have the power to contract with any NHS provider in England. As my noble friend Lord Lansley rightly pointed out, they already have in place arrangements for commissioning specialised services from English providers, including cross-border agreements, referral schemes and service-level agreements. Taking further steps, as suggested in this amendment, would place a significant burden on a smaller number of providers, particularly those along borders, with consequences for the smooth running of those health systems. From a legal perspective, such a change would be a significant impingement on a devolved competence and would require the consent of the devolved legislatures. Of course, patients matter most, but such a change would also be unlikely to greatly benefit them, since they are already served by existing arrangements.

Amendment 301 deals with data interoperability. The UK Government are committed to working with officials across the devolved Administrations to explore the benefits that healthcare data can provide while working collaboratively to respect the devolved nature of this work. As in other areas, we are looking at ways to improve collaboration on data matters and address issues with data sharing. There are commitments within the data strategy for health and social care to work across central government and the devolved Administrations to improve appropriate data linkage, thus supporting people’s health care outcomes. This builds on the work of units such as the Joint Biosecurity Centre, and the newly established UK Health Security Agency.

That work will help us to collaborate to solve public health issues, improve disease surveillance and overcome any behavioural or structural obstacles to appropriate data sharing across our respective health and social care systems. In addition, we are speaking to the Office for National Statistics about collecting data on performance and outcomes across the UK. We are pursuing this with it, working in concert with the devolved Administrations. The ONS has assured us that it does not need additional powers to gather such data.

The problems encountered by the daughter of my noble friend Lady Fraser in proving her vaccination status are being actively addressed on both sides of the border. I must concede that the problems are not fully resolved yet, but understand that a Covid status pass from Wales, Scotland or Northern Ireland will be recognised in England and vice versa.

[Lord Bradley (Lab)]

My Lords, I am sorry to interrupt, but I have been meaning to ask this question for a while. Will that also apply to students who currently study abroad and had their first vaccinations abroad, and who then come back to work in their home country? Will that be connected to the NHS app as well?

[Earl Howe (Con)]

Rather than give a wrong answer to the Committee, I had better take advice on that and write to the noble Lord, if he will allow it.

I say to the noble Baroness, Lady Walmsley, that if we look at this area in general, we are clear that we must and will continue to work closely with the devolved Administrations to ensure a fully interoperable, UK-wide approach to healthcare, including in relation to the provisions in this Bill.

It is worth adding that the devolved Administrations already have powers in legislation under Section 255 of the Health and Social Care Act 2012 to request NHS Digital to collect and analyse data, so they have that ability if they wish to exercise it. I am very grateful for my noble friend’s interest in this important area. I assure her that we will continue to keep listening to ways in which we can make the NHS work for all four nations of our union. It is vital that we do so and implicit in the collaborative processes we are engaged in. However, for the reasons I have set out, I ask my noble friend to understand why I am unable to accept this amendment.

[Baroness Morgan of Cotes (Con)]

I thank my noble friend very much for his response. Although this has been a short debate, it has been a very good one. It has certainly been very helpful in noble Lords on all sides sharing their experiences and thoughts. It has raised some important issues and some comments on drafting. I am grateful to noble Lords for them. It has also enabled your Lordships to share some practical experiences, not least about the NHS Covid app. It sounds as if it is moving towards a resolution.

I was slightly amused that some of those who said that these issues do not need to be addressed in the Bill are often those who say that other issues need to be addressed in primary legislation so, when we are talking about consistency, we all need to think about that.

I am very grateful to my noble friend for saying that he agrees that more needs to be done and is being done to align healthcare across the United Kingdom and for stressing the importance of collaboration. I will, of course, withdraw this amendment, but the amendments in this group raise important issues and I hope that discussions can continue. As the noble Baroness, Lady Walmsley, I think, said, this is about practical, positive treatment and outcomes for patients, which is what we all want to see regardless of where they live.