Health and Care Bill

Lord Lansley Excerpts

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

[Lord Patel (CB)]

My Lords, I support all the amendments in the name of the noble Baroness, Lady Cumberlege. She introduced them very comprehensively and I agree with what she said. My noble friend Lord Stevens of Birmingham added to it, so much has already been said and I need to be extremely brief.

I concur with my noble friend Lord Stevens of Birmingham that outside bodies, including professional organisations in medicine, oppose these powers and that they will lead to more chaos rather than solving problems. As a clinician, I find the unchecked powers for Secretaries of State over local service reconfigurations that the Bill proposes astounding. Local service reconfigurations should be driven by clinical advice and expert assessment of what services are needed to meet the health needs of a local community with patient safety at the heart, as well as considerations about what resources are available in terms of workforce, infrastructure and the proximity of alternative services.

The powers in the Bill would allow the Secretary of State to initiate service changes without any consultation. How can any Secretary of State feel sufficiently qualified to be making unilateral judgments about what constitutes “safe”? The existing, largely successful, processes, which have already been mentioned, take account of clinical advice and the views of local communities in the final decision have been effective. The noble Baroness gave the example of Kent and Medway stroke services, which were held up by the Secretary of State, not by the consultation. I strongly support these amendments and I hope that the Minister will think about removing the provisions from the Bill.

[Lord Lansley (Con)]

My Lords, I shall be brief. I put my name to Clause 40 stand part, and I think that is the best way to go. I shall add one or two things. First, as Secretary of State, I asked the now noble Lord, Lord Ribeiro, to lead the independent reconfiguration panel, and I never had cause to regret doing so. Secondly, I can say something which other noble Lords cannot, because I am on this side, and I am hoping that we continue to have Conservative Secretaries of State for many years hence. They will be much better off if they do not do this. If the Government take Clause 40 out, they will equally not regret doing so.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I described at Second Reading, or at some point in a meeting with the Minister, an attempt to save Ministers from themselves. I do not understand why on earth the Government want to put this burden on them. The Government have set out an ambitious programme for reform of the NHS. Why put in a clause that guarantees that that reform will be stalled? We know that reconfigurations—most of us have experienced the issue locally, if not nationally—are very difficult. There is always local opposition, often from some leading consultants, and to get it through you have to be very determined. The noble Lord, Lord Warner is right; once Ministers can intervene at any point—for example, if an MP’s local services are threatened with an unpopular change—even in the Lords, the pressure on them to intervene can be huge.

--- Later in debate ---

When the Bill receives Royal Assent and becomes an Act, it will be open season on the Minister and his colleagues. On any reconfiguration where the local MP is troubled, inevitably Ministers intervene, or they use the review device. Consider the issue of children’s heart transplants and the attempt over 20 years to rationalise it, and the utter failure of that approach; that is but one example of the kind of energy that you can get the moment Ministers have powers of intervention.

[Lord Lansley (Con)]

If anyone cares to look at it, it was also a very good illustration of the benefits of the Independent Reconfiguration Panel. Not only did it do something that Ministers could not do; it also did something that NHS management did not do. It is not that we are giving it back to the NHS to do what it likes—it genuinely does something independent.

[Lord Hunt of Kings Heath (Lab)]

Indeed, we have a rigorous process involving the overview and scrutiny committee, as has been said, plus an Independent Reconfiguration Panel. As the noble Lord, Lord Stevens, said, it is rather like the last debate: before us we have a set of amendments which seek to constrain the power of Ministers, and then an amendment which seeks to remove this power. I am clear that we should try to remove this power, and that this is the best course. It will be very interesting to hear from the Minister exactly why Ministers want to put this burden on them, and what benefit they can possibly see in it.

--- Later in debate ---

These amendments would ensure that the stop-start model—removing permission and then reinstating permission—that many trusts such as Watford General Hospital face over years would be less capricious. It would give foundation trusts more assurance to long-term planning, avoid the high level of emergency repairs and need for temporary provision, and, above all, be a more transparent and fairer way to deliver capital expenditure. Without the 2019 agreement, we risk putting foundation trusts back in the parlous stop-start model.

[Lord Lansley (Con)]

My Lords, I intervene briefly to say that I support the amendments in the name of the noble Lord, Lord Crisp. We are grateful to him for tabling them, and indeed for presenting them so very well.

I also rather enjoyed the opportunity from the noble Baroness, Lady Brinton, to think back to 2011, as I think it was, when I went to visit Watford General—I probably announced a new hospital then, but I cannot quite remember. She said the local connections were all funded by the local authority, and I seem to remember paying for the roundabout outside Watford General Hospital, because it was so instrumental to the process of the redevelopment. Anyway, that is by the way.

What I am really looking for from my noble friend on the Front Bench is to understand the mischief to which the Government’s proposals in Clause 54 are the remedy. Certainly, when I was Secretary of State—which is a long way back; we were not in deficit but we did not have a lot of money—the issue every year with the capital expenditure of FTs was that they always told us that they were going to spend a lot and then did not spend anything like as much. To account for that in the public accounting system, we had to make some heroic assumptions about how much less they would spend than they said they were going to spend.

It may be that the department is saying that the way we get round all this is to set very tight limits in the first place—to say where we think they are going and what we think they can spend. This, frankly, is a recipe for disaster for many trusts, because the reason they underspend is that there are so many difficulties in planning and executing capital expenditure projects.

I am trying to find out the purpose behind the Government taking such strong powers in relation to capital expenditure. I rather hope that they might see merit in the amendment from the noble Lord, Lord Crisp.

[Lord Stevens of Birmingham (CB)]

My Lords, I will be brief. In response to the noble Lord, Lord Lansley, in fairness, there is logic to the broad direction being set out by the Government here. As the financial health of foundation trusts improves, their ability to seek self-generated capital investment will, in all likelihood, be much higher, looking over the next four or five years, than it has been during the more constrained financial circumstances of prior years. So it is not unreasonable to have a set of measures in the Bill that would enable Ministers to ensure that the NHS sticks with the capital expenditure, voted for by Parliament, for the NHS in any given year; nor is it unreasonable on the part of the Government to seek to ensure that there is a mechanism by which that capital can be allocated fairly across the country according to need, rather than purely according to an individual institution’s ability to finance it.

All that being said, rather than this being a fundamental matter of principle in the way that our last two discussions have been, these amendments have a lot to commend them. They are entirely pragmatic and put the right safeguards around what should be only an emergency power. As the noble Lord, Lord Crisp, laid out, that was the basis on which a consensus was achieved back in 2019. It provides good incentives at trust level for sound financial management and, frankly, it provides a bit of a pressure release or a safety valve against an overly artificially constrained capital settlement in certain years or parts of the country.

I very much hope that, in the constructive spirit with which I think these amendments are being advanced, this is something that the Government might consider favourably.

--- Later in debate ---

Debate on whether Clause 68 should stand part of the Bill.

[Lord Lansley (Con)]

I am sorry to interrupt when the Committee was making such good progress. This clause brings into effect Schedule 10 as an NHS payment scheme, which is to replace the national tariff. Unlike the debates that we have just had about Clauses 39 and 40, I have initiated this stand-part debate not to argue that we should simply take it out but because I simply do not understand yet what the precise differences are that the Government intend between the national tariff and the new payment scheme. I am trying to find out more about it in order that we stand some chance, not least at Report, of seeing whether there is a reason to amend or simply approve what the Government are proposing.

We could have a long debate about this but I am not proposing to do so. If I may, I am going to ask a few questions of my noble friend but do not expect to receive all the answers straight away. These are often things that are easy to put down and send to noble Lords, because we will then have a chance at this stage to think about them before Report.

I can see one obvious difference. In new Section 114A, inserted by Schedule 10, new paragraph (b) includes in the payment scheme provision for payments for public health functions under the NHS Act 2006, which is specifically excluded in the tariff. I can see a difference. Beyond that, I start to lose track of what the differences might be.

The tariff under the 2012 legislation allows not only for payments for episodes of care but for services to be bundled; it allows for year of care budgets; I think it allows for—I cannot see any reason why it does not, and certainly work was done to look at this—outcomes-based pricing; and it allows for local price agreements or national prices. Many of the things which, on the face of it, the new payment scheme is designed to allow, seem already to be allowed. What are the differences?

My first question to my noble friend is this. There is no reference in the new NHS payment scheme to what are effectively national prices, such as the national tariff—if we ignore the word “tariff” and remember that it includes the word “national”. To what extent is the new NHS payment scheme designed to do away with national payments or national prices? In new subsection (3), there is different provision for the same service by reference to different circumstances or areas. We could therefore have regional and local pricing set nationally. That, to me, is an innovation, though I am not sure whether or not it is intended.

Secondly, the national tariff made specific reference to non-discrimination between providers by reference to their status, including, specifically, not paying private providers more than could be paid for a public sector or NHS provider. This new payment scheme refers to different provision for different descriptions of providers. Is it intended that the power should be taken back to pay different amounts to private providers than are paid for public sector providers?

On the payment scheme, there is a very complicated subsection, subsequent to that, that talks about provision of services resulting in

“a fair level of pay for providers of those services”

and refers to differences in costs and services provided. What is intended by that? On differences in services provided, I can see, for example, that if a price is being paid to one provider for a routine service and another provider—which may often be the NHS provider—provides intensive care back-up, the fact that this back-up is available should be reflected in the price they are paid, because, inherently, they have to provide additional resources for it. Is that what is intended? Are other differences likely to result from this?

I then come to my final, and in a way most important, question. I have discussed the point about the Government appearing—the noble Lord told me I was wrong about this—to have abolished the purchaser-provider split. Maybe I was wrong, because here, under the rules that are to be set, we find that they

“may allow or require a price to be agreed between the commissioner and the provider of a service.”

Under all this, the purchaser-provider split has re-emerged, somewhere in Schedule 10. Is that what this means, and is it to be agreed by negotiation or by reference to some other mechanism? One of the fundamental issues about the national tariff was that it was intended to be a negotiated outcome between NHS England and NHS Improvement, on behalf of the commissioners on one side and providers on the other. Who is going to engage in these negotiations and who will be the court of appeal, as it were, in relation to that? What is intended by the Government?

I ask all these questions because we just do not know any of the answers—I certainly do not, but maybe I am missing something. If the Government can share further information about some of these points, that would help me to know whether we want to help speed the clause on its way, or interfere with amendments on Report. I move that the clause does not stand part of the Bill.

--- Later in debate ---

[Lord Kamall (Con)]

I thank the noble Baroness and echo her gratitude to all the noble Lords who have turned up for this group of amendments.

Before I turn to specific amendments, it may be helpful to make a few general points about the new payment scheme and explain why this clause should stand part of the Bill. For many years, the national tariff improved access to services and drove up quality across the NHS. The new scheme will build on that success. NHS England will continue to make rules determining the price paid to a provider, by a commissioner, for healthcare services for the NHS, or for public health services commissioned on behalf of the Secretary of State. Also, expanding the powers to enable NHS England to set prices for public health services, such as maternity screening, will allow for seamless funding streams for different care episodes.

However, we need to update the NHS pricing systems to reflect the move towards a more integrated system focused on prevention, joint working and more care delivered in the community. This will support a move from a “payment by activity” approach, towards an approach that promotes integration and early intervention, while discouraging perverse incentives for patients to be treated in acute settings. It will allow flexibility over the current pricing scheme, and allow rules to set prices, formulas and factors that must be considered when determining the prices paid. I assure noble Lords that, when developing the scheme, NHS England will continue to consult any persons that it considers relevant, which will include ICBs, NHS trusts and foundation trusts, as well as trade unions and representative groups. I share the sentiments of the noble Lord, Lord Davies, about the valuable role that trade unions play in a free society.

I turn briefly to the points made by my noble friend Lord Lansley. On regional variation, the NHS payment scheme will encourage commissioners and providers within an integrated board area to work together to agree prices that are in line with the rules set out in the scheme. To date, only one provider has applied successfully for local modification, and closer working within ICBs should remove the need for disputes. On paying different providers differently, there may be scenarios where it is appropriate to pay non-NHS providers different prices from those paid to NHS providers, to take into account differences, different starting costs or a different range of services provided. There may also be cases where the financial regimes of different providers make it appropriate to set different prices or pricing rules. When setting any prices, NHS England will aim to ensure that prices paid represent a fair level of pay for the providers of those services, as well as fair pay between providers of similar services. We will not introduce competition on price rather than quality. We hope that these changes will increase the flexibility and reduce transactional bureaucracy at the ICP level.

I must disagree with the proposal in Amendment 199. While the Secretary of State will remain responsible for setting out overall funding for NHS England, NHS England, alongside Monitor, has set the rules successfully since 2013. I cannot see the benefit of this duty being transferred to the Secretary of State, beyond separating it further from those making operational decisions in the system. Following that logic, we must also reject Amendment 202A. However, I assure noble Lords that the payment scheme will be published in the usual way, and your Lordships will of course be able to table Questions, secure debates, hold us accountable and ensure that the mechanism is scrutinised.

I turn to Amendments 201B and 201C. As part of the broad consultation duties, we expect NHS England to work closely with trade unions and staff representative bodies, such as the Social Partnership Forum, NHS Providers, the Healthcare Financial Management Association and all the royal colleges, when developing the national tariff.

On Amendment 200, I assure your Lordships that the NHS payment scheme will be published by NHS England following consultation. The Secretary of State will also have the general power to require NHS England to share the NHS payment scheme before publication, not to publish a payment scheme without approval, and to share the contents of the scheme should that be necessary.

On Amendment 201A, in setting the rules for the payment scheme, NHS England will of course want commissioners to consider staff pay, pensions and terms and conditions. NHS England will continue to take account of cost growth arising from uplifts to Agenda for Change. New Section 114C makes it clear that, before publishing the payment scheme, NHS England must consult any person that it thinks appropriate. Again, in practice we expect this to include representative bodies and trade unions. NHS England must also provide an impact assessment of the proposed scheme.

I hope I can reassure noble Lords that the department and NHS England remain committed to Agenda for Change. Independent providers will remain free to develop and adopt the terms and conditions of employment, including pay, that best help them attract and keep the staff they need. However, we expect that good employers would set wage rates that reflected the skills of their staff.

On Amendment 202, it is right that the commissioners and providers of NHS services should be able to make representations and, if they feel it necessary, object to pricing mechanisms set by NHS England in the payment scheme. That is why we have retained the duties to consult commissioners and providers. We have also retained the ability for ICBs and providers to make representations and to formally object in response to consultations on the NHS payment scheme, as they can with the national tariff.

The current prescribed thresholds are set by the National Health Service (Licensing and Pricing) (Amendment) Regulations 2015, and the current objection thresholds since 2015 have been set at 66%. My department consulted on these thresholds in 2015 and it remains the Government’s view that they are proportionate, preventing the delay of future payment scheme publications and giving the NHS the certainty that it needs to plan for future financial years.

If I have not answered all the questions from my noble friend Lord Lansley and others, I ask noble Lords to remind me and I will write to them. This has been a very important discussion—as we can see by the attendance—and I hope I have given enough reassurance to noble Lords for them not to move their amendments and have explained why the clause should stand part of the Bill.

[Lord Lansley (Con)]

My Lords, I am most grateful for the Minister’s response to that short debate and for the other contributions. I shall certainly look at the Court of Appeal judgment—was it the Court of Appeal? —and try to work through precisely where the problems are. There are two ways of dealings with this issue. One is to scrap the national tariff and put in a new payment scheme. The other is to start with the national tariff and ask what the problems are and how we are going to deal with them, and I would quite like to work that through.

We may come back to this because there is an issue about how far the payment scheme is a national payment scheme and how far it becomes a local and varied one. That is a very interesting question, as is the way in which discrimination between providers may be implemented and for what purposes.

For the moment, though, I am very grateful to my noble friend for his response and for his promise to follow up on issues.

Clause 68 agreed.

Health and Care Bill

Lord Lansley Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 24th January 2022 Lords Chamber

Non-clinical organisations should have the core costs of providing services to the NHS realistically funded, and provider organisations should be enabled to budget over sensible periods of time. That way, they will be able to provide a more reliable and higher-quality service. On financial grounds alone, it is in the interests of the NHS to invest constructively in the non-clinical sector in order to ensure that high-quality services are available when and where they are needed. If enabled to do this, the sector would provide remarkable value for money for the NHS.

[Lord Lansley (Con)]

My Lords, I am pleased to follow the noble Lord and I endorse the points he makes about the diversity of provision, which is certainly something that we should aim for; I am not sure how we will make sure it is in the Bill, but we will get to that later on. I will not dwell on the other amendments; I will simply explain why I oppose Clause 70 standing part. I was pleased to see that the noble Baroness, Lady Thornton, shares that view, although she may do so for different reasons.

This gives me an opportunity to explain something that I have been saying to Ministers—not necessarily these Ministers but their predecessors—for the last two or three years: if the NHS took the view that the structure of the procurement regime that was applied to it was a constraint, cumbersome and the various other words that it used, Ministers could do something about it very quickly because, in the legislation, they have the power to change the regulations. So why do they not do so? I also want to explain that the existing regulations do not impose some of the constraints that it is argued they do. That begs the question behind my opposition to the clause standing part: why are we legislating in this way in this clause, when the effect is to remove a power to make regulations relating to the procurement regime in order to then put into the Bill a power to do just that? It really does nothing much more than that.

Of course, in truth, we do not know what these new regulations will look like because they have not been published, as the noble Lord, Lord Hunt of Kings Heath, rightly said. The issue lies in the regulations because, as I will demonstrate, what mattered to the service, as it turned out, was not what was in Section 75 of the 2012 Act but what was in the subsequent 2013 procurement, choice and competition regulations. I am sorry, but this is going to take a few minutes.

Clause 70 does nothing much more than refer to the fact that there should be transparent and fair processes, that “managing conflicts of interest” should take place and that compliance should be verified—I do not know quite what that means but it is probably a good thing. It also makes reference to general procurement objectives. You might ask what those are, since they are not specified in Clause 70 itself.

If one goes back to the previous legislation, one gets to the point in the NHS (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013, which are also revoked later in Clause 70. In the regulations, there is a paragraph that says what the procurement objectives are:

“for the purposes of the NHS … a relevant body must act with a view to … securing the needs of the people who use the services … improving the quality of the services, and … improving efficiency in the provision of the services”.

I rather hope that we are not yet encountering anything to which people would object. It then goes on to say:

“including through the services being provided in an integrated way (including with other health care services, health-related services, or social care services).”

Frankly, we have had years now of people explaining that the legislation did not allow them to do things in an integrated way. But when one looks back to 2013 and the regulations brought in, they say that the objective is to do things in an integrated way. I slightly wonder why the NHS did not do that, rather than complain that it could not.

Let me go on. When looking at the general requirements of procurement subsequently in that regulation, it includes the provision to

“act in a transparent and proportionate way, and … treat providers equally and in a non-discriminatory way”,

and wants projects delivered with “best value”. So far, again, there is nothing to which people object.

In Regulation 3(4) we hit something that people might object to. In defining what quality and efficiency look like, the regulations go on to say that the services should be

“provided in a more integrated way”—

which we have already heard about, and it repeats exactly that point—

“enabling providers to compete to provide the services”.

This may be where the objection came from, in which case my argument to Ministers is this: if that is what you do not like in the regulations, omit it from them. Ministers could have done it literally in a matter of weeks.

What is the other objection to the existing structure of the legislation? Section 75 of the Health and Social Care Act 2012, about the power and what it should be used to do, talked about good practice in procurement and the right to patient choice. I mentioned in a previous group the importance of, in my view, putting the right to patient choice into the provider selection regime, but we will come on to that again at a later stage.

Here is a third point, and something to which I think some people objected to, and have objected to subsequently; that providers

“do not engage in anti-competitive behaviour which is against the interests of people who use such services.”

I might say that if the anti-competitive behaviour is in the interests of the people who use those services, it is not necessarily objectionable. However, when one looks further, Regulation 10 of the subsequent regulations describes the circumstances in which anti-competitive behaviour might be justified:

“unless to do so is in the interests of people who use health care services … which may include … the services being provided in an integrated way”.

We keep coming back to this.

The other point I would make—she is not here, but the noble Baroness, Lady Blackwood, said it at Second Reading—is that the NHS objected to the fact that it was required to engage in compulsory competitive tendering. Section 75 of the 2012 legislation says that the regulations may

“impose requirements relating to … competitive tendering”,

as well as to the management of conflicts of interest, but it does not require the regulations to be made at all, and it certainly does not require the regulations to include compulsory competitive tendering, and nor do the subsequent regulations published in 2013 require that.

All of that leads me to the conclusion that Section 75 of the 2012 Act simply creates a power; it does not need to be changed for new regulations to have been made. Section 75 says that subsequent 2013 regulations may be objectionable to people in so far as they refer to qualified providers and to competitive tendering. If that was the problem, you should revise the regulations, publish them, take out the bits you object to and give the NHS a provider selection regime that fits their anticipated needs. The objectives are all there: quality, efficiency, best value, fairness, proportionality and an integrated service—and an integration, if that is what this Bill is all about, was already there in the 2012 legislation.

My question to my noble friend for before Report, and the question asked by the stand part debate, is: why are we doing what we are doing in Clause 70? Cannot we do it perhaps more simply and effectively by amending the existing legislation, rather than by trying to do wholesale repeals, introducing something that we will not know what it looks like until after this Bill has passed through this House?

[Lord Sharkey (LD)]

My Lords, Amendment 213 is in my name and that of the noble Baroness, Lady Thornton, and I am very grateful for her support. I can be briefer than I was expecting to be, given what the noble Lords, Lord Lansley and Lord Hunt, have said in the last few minutes.

My amendment addresses another instance of an attempt by the Government to bypass parliamentary scrutiny, and it proposes in response an enhanced form of parliamentary scrutiny. As the noble Lord, Lord Hunt, remarked, the DPRRC report on the Bill notes that the delegated powers memorandum says that, although initial consultation has been carried out by NHS England on the content of the procurement regime, full analysis has not been completed and there has not been time to produce a more developed proposal. Clause 70 gives the Minister the power to impose a new procurement regime, without giving any details of what it might be. This is the clearest possible example of the Government taking powers to make policy without specifying at all what that policy may be.

The DPRRC rejects the inclusion of regulation-making powers as a cover for inadequately developed, or undeveloped, policy. What is worse, the delegated powers memorandum says that a Cabinet Office procurement Bill will most likely follow this Bill, and it may require some amendments to the regulation-making powers that we are discussing in this Bill. The regulatory powers in question are to be subject to the negative procedure. I think we all, except for the Government Front Bench, would recognise that the negative procedure is emphatically not effective parliamentary scrutiny.

What we have here is a skeleton clause, with regulation-making powers of very broad scope. There is nothing in this clause, or in the Bill more generally, which would in practice constrain how broadly these powers could be used in constructing a procurement regime. It would probably be better, from the point of view of parliamentary scrutiny, to leave out Clause 70 entirely, as the noble Lord, Lord Lansley, my noble friend Lady Walmsley and the noble Baroness, Lady Thornton, propose, and wait for the full policy to be set out in the Bill, as promised to follow soon from the Cabinet Office.

If the Minister can advance compelling reasons why this Bill should be the vehicle for setting up the procurement regime by regulations, there is one route we could take, as set out in my amendment. This amendment imposes the super-affirmative procedure on the delegated powers proposal. The super-affirmative procedure is designed and used to deliver a measure of real scrutiny in circumstances that require it. In proceedings on the recent Medicines and Medical Devices Bill, the Minister very helpfully summarised the super-affirmative procedure as follows, saying that the

“procedure would require an initial draft of the regulations to be laid before Parliament alongside an explanatory statement and that a committee must be convened to report on those draft regulations within 30 days of publication. Only after a minimum of 30 days following the publication of the initial draft regulations may the Secretary of State lay regulations, accompanied by a further published statement on any changes to the regulations. They must then be debated as normal in both Houses and approved by resolution.”—[Official Report, 19/10/20; col. GC 376.]

According to the Library, the last recorded insertion in a Bill of a super-affirmative procedure was by the Government themselves, in October 2017, in what became the Financial Guidance and Claims Act.

I repeat that, if the Minister really can convince us that he has a compelling reason to have this new procurement regime set up by regulations in the Bill, my amendment would provide the opportunity for detailed parliamentary scrutiny. If he cannot accept that, then we would be wise to take out Clause 70 in its entirety.

--- Later in debate ---

[Lord Kamall (Con)]

We do not believe that they are, but clearly there is a difference of opinion about it.

I would like to turn, however, to the point made by my noble friend Lord Lansley on Clause 70. The regulations that we create under Clause 70 will have a broader scope than those currently created under Section 75. The provider selection regime will include public health services commissioned by local authorities, thereby recognising their role as part of joined-up health services delivered for the public. While we always want to act in the interests of people who use our services, our regime recognises the reality that in some cases integration, rather than competition, is the best way to achieve this for the health service. Finally, removing the section and creating a new bespoke regime, is—despite the scepticism of the noble Lord, Lord Warner—what the NHS has asked for. There is strong public and NHS support for scrapping Section 75 of the 2012 Act—

[Lord Lansley (Con)]

I am sorry—it is getting late—but will my noble friend at least, at some point, tell us: did Ministers ever challenge the NHS on whether what it was asking for required primary legislation? Did they ever ask, “What are you trying to achieve?”—and then let us, the Government and Parliament, who actually pass the legislation, see how it should be achieved? Or has Parliament in practice now become merely the cypher for the NHS?

[Lord Kamall (Con)]

I take the point that my noble friend makes, and I completely understand the concerns; that is why it is important that I take many of the concerns raised today back to the department.

Clause 70 inserts a new Section 12ZB into the NHS Act 2006, allowing the Secretary of State to make regulations. I have a lengthy explanation here but, frankly, I am not sure that it will pass muster. If noble Lords will allow me to go back to the department—I may be a sucker for punishment, but I accept the concerns and I will go back—

Health and Care Bill

Lord Lansley Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Lord Rennard (LD)]

My Lords, I support Amendments 109 and 226 in this group, both of which are in my name and that of the noble Lord, Lord Hunt of Kings Heath. I will address them from the perspective of people with diabetes and with the support of the Juvenile Diabetes Research Foundation and Diabetes UK.

It is just over 100 years since insulin was discovered. Before 1921, a type 1 diabetic would live for no more than a year or two from when the condition became discernible. In the 1920s, my father, a World War I veteran, developed diabetes, and he was very fortunate that this was the decade in which insulin was discovered. It was so successful that it enabled him to have a long and happy life—indeed, I was born when he was 71, and my younger brother was born when he was 73.

Much progress has been made in the treatment of diabetes over the last 100 years, but we are not making the most of technological developments relating to insulin use and diabetes management. I have struggled with these issues myself, and I have learned much about them since I became dependent on insulin in 1994. I personally have enormous reason to be grateful to the diabetic team at St Thomas’ Hospital, just over the river from us, but not everyone with diabetes gets that standard of care, and progress with the adoption of the most recent technology is simply too slow.

There have been great developments in wearable medical technology, such as insulin pumps, flash glucose monitoring and continuous glucose monitoring. We are making progress with such innovations and in NICE’s obtaining approval for them, but they are often not widely accessible. Access to technology, including linking a person’s insulin pump and a continuous glucose monitor, may help a person to self-manage their condition in the absence of routine NHS support. The long-term cost savings are demonstrated by the wider use of such technology in insurance-based systems, where the outlay must be justified by reducing the costs of later complications, which can be very considerable.

Diabetes probably now takes up 10% of the NHS budget, and 80% of the cost of diabetes relates to complications, with the largest costs arising from excess in-patient days, cardiovascular disease and damaged kidneys and nerves. The latest technology may enable parents of young people with type 1 diabetes to obtain a full night’s sleeping soundly, knowing that their child’s glucose monitor will issue an alarm and wake them up if they experience a severe high or low-glucose episode. New technology has been shown to support blood glucose stability and to lower average blood sugar levels, reducing potential health complications and hypos or hypers, which can lead to coma or even death if not treated. There are great benefits to physical and mental health from better long-term control of blood sugar levels.

Research by JDRF shows that barriers to the uptake of this technology include the fact that many clinicians are not trained in it and that the pressure on appointments means that there is often not time to discuss treatment options. Amendment 109 would require NHS England’s oversight framework for integrated care systems to include a metric on the percentage of diabetes patients in their area accessing diabetes technology. An embedded requirement that would better support the prescription of technology would incentivise better training for clinicians and encourage more time to be provided in appointments to discuss technological treatment options and any potential fears or concerns of the patient.

Amendment 226 concerns the promotion of self-management using the latest technologies. We need it in order to reduce the number of people with diabetes suffering from complications, which may include sight loss and problems with their feet, presently resulting in around 6,000 amputations per year. When in hospital, people with type 1 diabetes require five times more secondary care support than people without diabetes, so it is essential that the NHS invests in technology that can significantly reduce the instances of hospitalisation and adverse health outcomes for people with type 1 diabetes.

[Lord Lansley (Con)]

My Lords, I thought those were very interesting and helpful remarks from the noble Lord, Lord Rennard. They serve to remind us of the importance of self-management in securing the best possible outcomes for patients. I just add the thought that, when the Government promulgate regulations relating to patient choice, one of the things we want to include is shared decision-making between clinicians and patients. In my observed experience, that too can deliver better outcomes. I think we have made significant progress in recent years in encouraging shared decision-making, and I hope we will see that come forward.

In moving Amendment 72, the noble Lord, Lord Warner, touched on a range of issues. I will not go down one or two paths, but I highlight that we will need to think hard about the interconnections between the question of patient choice and how far patients continue to be given choice. We need to ensure that it is not just talked about in the constitution or in regulations that say it is generally a good thing. For choice to happen in practice, subsequent clauses in the Bill relating to procurement, such as Clause 70, need to enable a choice of providers. The noble Lord made that perfectly clear.

The clause relating to payment systems—Clause 68, if my memory serves me correctly—still needs to have a “money follows the patient” approach. It is not me saying that these are all good things; they were put in place by the Blair Government, not the coalition Government, who did not do away with them but entrenched them.

I am worried. I will just make this point about Clause 70, the effect of which is to repeal Section 75 of the 2012 legislation. Included within that was that one of the requirements of the procurement regulations would be to support the right to patient choice, and the Government are proposing to repeal that.

The Minister may well, perfectly correctly, say, “That may be so, but we have the power in this Bill to set regulations relating to patient choice”, but this is separate, and, in the event, we may find that the link is broken between procurement and payment and patient choice. The net effect would be that patient choice is vitiated. I am worried, for exactly the reasons that I think the noble Lord, Lord Warner, is worried, that what has been around for some 18 years in one form or another—the expectations on the part of patients that they can exercise choice—may not be able to be exercised in practice because the preference of the NHS in many of these localities is to operate as a monopoly and not to give any opportunities for that choice actually to function.

Our debate on this group would be far better and easier to have—and might not even be needed—if the Government published the regulations under Clause 68 in draft so that we can see what they are proposing to do. They have not done it; between now and Report they could do it. When we get to Report, we are going to have a very difficult—certainly from my own personal point of view—set of conversations about how patient choice is to be exercised, how the NHS is to get best value from its procurement, and how trusts and providers are to be paid appropriately, rather than simply go back to block budgets. How do we get out of that debate? The answer is: let us see what the regulations the Government are proposing—in this case relating to patient choice—actually look like, and let us see it before Report.

Health and Care Bill

Lord Lansley Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, I had not intended to speak but, animated by the contributions of colleagues who, like me, were there at the conception of NICE, I thought I would offer a couple of contextual remarks to this group of amendments, supporting their underlying motivation, which is to ensure the spread of best practice as fast as possible across the National Health Service.

I was also motivated by the noble Baroness, Lady Watkins, who spoke earlier about the Crimean War, to recall that this is not a new problem. The world’s first controlled clinical trial took place in 1754 on board HMS “Salisbury”, when the Royal Navy was trying out the use of citric fruit—in lemons and limes—to combat scurvy. That experiment showed that scurvy could be tackled with lime juice, and it took the Navy 41 years to mandate its introduction more widely—fortunately, just in time for the Napoleonic Wars, which is why some argue that, contrary to Winston Churchill’s dictum that it was “rum, sodomy and the lash” that contributed to the Navy’s success, it was in fact lemon and lime juice.

The point is that this is not a new problem. We have been grappling with this but, despite that, we have seen the remarkably quick adoption of new clinical practices over the last two years during Covid, as new randomised control trials, following in the wake of the 1754 example, have shown the benefits of treatments such as dexamethasone. My point of context is that we need to be clear, if this group of amendments is to advance, about the terminology incorporated in the amendments. These will inevitably be, if they find their way into the Act, litigated against in the High Court and Court of Appeal.

In the drafting, there is reference to the marketing authorisations given by NICE, although I think it is the MHRA that provides marketing authorisations. There is a clear distinction to be made between the technology appraisals NICE undertakes and the development of guidelines. Although a number of noble Lords have referenced the importance of the guidelines, it is worth saying that a quick look at the NICE website reveals there are 1,591 guidelines, pieces of advice, quality standards and all the rest of it—most of which have not been subject to the full cost-effectiveness and affordability assessments that the gold standard technology appraisal performs. Before there could be a legal mandate for those guidelines, there would be some very significant methodological considerations for NICE. Without those, the risk is that mandating those guidelines would take resources away from other parts of needed care, such as mental health and community nursing—Cinderella services that have not been subject to those same processes.

We should also recognise that, vital though NICE is, the bigger contribution to the diffusion of best practice will probably be made in other ways. Certainly, reporting could help. Although one amendment makes the perfectly reasonable proposition of an annual report from integrated care boards on their adoption and uptake, that still feels a slightly 20th-century solution. If you go to Oxford University’s superb www.openprescribing.net, you can see your own GP practice and your own CCG’s prescribing patterns against the national norm, including, as the noble Baroness, Lady Finlay, said, for the DOACs, the anticoagulating medicines. Those technologies are already available, and the role that clinical pharmacists are now playing, including the thousands of new clinical pharmacists hired to work alongside GPs to improve their prescribing habits, is also likely to have an important influence.

Finally, there is this question of whether, just occasionally, conflicts of interest might arise on the part of prescribers or clinicians over the medicines or devices being used. The noble Baroness, Lady Cumberlege, has drawn attention to this in her important work, and that is perhaps something the House might return to at a later date.

[Lord Lansley (Con)]

My Lords, I want to intervene at not too much length. I welcome these amendments and am grateful to my noble friend Lady McIntosh of Pickering for bringing hers forward. It enables us to touch on a subject which those of us involved in the Medicines and Medical Devices Act will recognise. This is a short version of the debates we had then, but it gives us an opportunity to update a little on those and me an opportunity to ask my noble friend on the Front Bench a few questions arising from that. We are all grateful to the noble Lord, Lord Stevens of Birmingham, who clarified some of the terminology, which saves us going wrong. But I want to do a bit of clarification about some of the amendments as well.

The timing of this is terrific. We are discussing this today and NICE published the outcome of its methods review yesterday, so we can respond immediately. My starting point is to applaud NICE for having taken up and accepted the proposition that there should be a modifier in relation to its appraisals and assessments on severe diseases. We can argue about the precise detail, but it has taken that up.

Secondly, randomised control trials are terribly important but they are not the whole story. NICE has rightly accepted it should look at more real-world evidence and that, too, we can welcome, but it leads me directly to a question. Part of that real-world evidence, and one of the reasons it is not going directly to NICE, though NICE can use it, is the innovative medicines fund. NHS England published its proposal for the innovative medicines fund in July and said that it would consult on it, but it has not done so yet. My first question to my noble friend is therefore: when will NICE and NHS England consult on the innovative medicines fund?

The third point on NICE’s methods review is that it will take account of the wider impacts of the treatments it appraises. That is terribly important, especially given the present opportunities for personalised medicines and gene-based treatments, when one looks at how these can impact substantially on people’s lives from a relatively early stage and the contributions they can make to society and the economy. That is all good news.

The press release from NICE, however, did not draw specific attention to where it had proceeded in a way that its stakeholders did not support. It has maintained a reference-case discount rate of 3.5%, although NICE itself admitted that there was evidence that a lower discount rate would give significant benefits. It said that there would be wider implications for policy and fiscal complexities and interdependencies if it were to do this, which I think means “The Treasury said no”. We need to think very hard about whether a discount rate as high as 3.5% is appropriate for NICE’s application of its appraisals. I ask my noble friend, though he will not be able to give me the answer to this: who is telling NICE that it cannot adopt what it regards as the evidence-based discount rate for the appraisals it undertakes?

[Lord Hunt of Kings Heath (Lab)]

My Lords, on that basis, I have seen it said elsewhere that NICE has referred to its “national stakeholders.” I can only assume that they are Her Majesty’s Government.

[Lord Lansley (Con)]

Given NICE’s remit, it might be the Welsh Government as well, but the noble Lord may well be correct. We are all surmising, but I think we are probably not too far off the mark. It gave us an opportunity to respond to that.

So far as the amendments are concerned, the proposition that approved treatments should be adopted by the NHS is a proper one. What, of course, has not been brought into the debate is that the world has moved on, even in recent years. NHS England has taken what I think is an appropriately substantial interest in the approval of treatments, the uptake of treatments and their adoption by the NHS. When it started out, people said, “Oh dear, NICE is going to approve a treatment and then NHS England is going to tell people not to use it because it is going to cost them a lot of money.” In fact, we all agreed in the debates on the Medicines and Medical Devices Bill that there was everything to be said for NHS England, NICE and the pharmaceutical industry working together early, proactively, for the planned introduction of new medicines, including taking account of their cost. That is an NHS England role, not a NICE role. NICE does gold standard appraisals, but it does not take responsibility for the fiscal consequences of those appraisals, so all these things need to be put together. The pricing decision should not be something that comes out at the end.

One of the things I have been going on about for a decade or more—actually, 15 years—is that we should not end up in a position where there is an effective medicine that is properly approved by the MHRA and authorised for use; clinicians can use it and they know it is the right thing for their patient; but, because of the absence of an appropriate pricing decision, the answer to the patient is “no”. We should not arrive at that position. With NHS England and NICE working together with the pharmaceutical industry, we stand a better chance of the answer not being “no” in those circumstances as long as the resources are, indeed, available.

I do not think, on the face of it, that we should be legislating to change the medicines mandate from where it is now. My noble friend Lady McIntosh, in introducing her Amendment 54, referred to devices. The amendment does not refer to devices, but it should refer to devices. My further question to my noble friend the Minister is: when are we going to get a proper funding mandate on devices, which I think I was promised during our deliberations on the Medicines and Medical Devices Bill but we have not yet formally had it? Some good work has been done on some devices each year, but I am hoping that we will get a proper funding mandate on devices.

On formularies, my noble friend did not actually refer to the British National Formulary. Of course, NICE has had responsibility for the BNF for about seven or eight years, and even if it is not a legislative method, there is everything to be said for the NHS and clinicians looking to the BNF and NICE’s role in the BNF.

My noble friend and the noble Baroness, Lady Finlay of Llandaff, were quite right about the adoption of NICE guidance and standards on the use of them in clinical circumstances. However, via the regulator—the CQC—we already have a process by which the CQC looks at quality standards produced by NICE and incorporates what NICE itself isolates as the essential aspects of the standards that, in order to provide safe and effective care, must be reflected in the practice of a health provider.

My question to the noble Baroness, Lady Finlay of Llandaff, is: if she thinks that is not sufficient, how much further should the CQC actually go in adopting quality standards? At the moment, it has compromised and said, “We will take the essential steps, because those are a few, generally about five, specific things that we can look at to see whether they are being done, in which case, okay; or are they not being done, in which case it clearly needs improvement, or may not be meeting the standard.”

[Baroness Finlay of Llandaff (CB)]

The noble Lord asked me a question to which I feel obliged to try to respond, but I really want to answer the question with a question: does the CQC have enough powers to benchmark as it would want to do, and to publish those benchmarks? I hear the concerns of my noble friend Lord Stevens in relation to fear of litigation and how that is an objection to the amendments, but I am also quite worried that that is potentially a way of avoiding adopting the guidelines themselves, thereby inhibiting a change in practice and a move to best practice.

While there are sources of information that those who are very health-literate, IT-literate, and so on, can access to establish their own benchmarks about what is happening, many people, particularly those in the most deprived areas of the UK, do not have any knowledge of even where to begin looking for these things. That was the motivation behind the amendment: to try to make sure that in the poorest and most deprived areas, people would still be able to access this. That would drive up standards gently but would not create a mandated requirement that a NICE guideline is adopted, for the reasons I outlined previously.

[Lord Lansley (Con)]

I can see that my noble friend is eager to come in but I will conclude by answering the noble Baroness. I am not an expert, but I think the CQC has the powers—since it presently does it—to take account of the NICE quality standards and to incorporate specific indicators from those quality standards as part of its regulatory review. If the CQC was to attempt to introduce large-scale application of the guidance as a question in a regulatory review, I do not think the issue would be whether it had the power to do it, but whether it would make the headline conclusions it reaches in relation to healthcare providers increasingly difficult to interpret. At the moment, they are relatively straightforward to interpret. There is a small number of specific indicators in relation to services provided and they are either doing them or they are not. With guidance, it becomes much more complicated and many more value judgments have to be applied about the circumstances in which they are or are not complying. So, there is a real difficulty in going far beyond where we are now.

I will listen with great care when my noble friend the Minister responds to the questions I have asked.

[Lord Mackay of Clashfern (Con)]

My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord has said that the Bill came because this is what the NHS wanted. But we must be clear who in the NHS wanted it, and it is obvious that it was the senior chief executives at the local level and NHS England. No wonder primary care has been completely squeezed out of it. Listening to this debate, it seems to me that the proposals from NHS England never had any scrutiny. Ministers just accepted this and, because NHS England does not engage externally, there has not been the testing that you would normally get, and we are having to do it now. Frankly, the wheels are falling off. It is tempting to invite the noble Lord, Lord Lansley, to come in, because clearly CCGs were all about putting primary care in the driving seat. This seems to be removing them altogether and it is worrying.

[Lord Lansley (Con)]

My Lords, in response to that, may I say that when I was shadow Secretary of State for several years, GPs consistently told me that if only they were given the responsibility, they could do it so much better than primary care trusts? So we gave them the responsibility in ways that were very like the locality commissioning that was the endpoint of the GP fundholding of the noble and learned Lord, Lord Clarke of Nottingham. To be fair to them, there was less money, but no sooner did they take this responsibility than NHS England said, “Hang on a minute, you’re not doing what we’ve told you to do.” It took about 18 months, perhaps slightly less, before NHS England effectively said, “You have no further autonomy. You’re going to be in the sustainability and transformation plans,” which are the forerunners of ICS. I do not think that the clinical commissioning groups ever got the chance to do what they were asked to.

We have now reached the point where, as the noble Lord, Lord Warner, rightly says, they are being written out of the script, but they are not complaining, which is very interesting. They are not complaining because they do not want to be responsible for the budgets; they want to be responsible for the patients. They always said that they wanted to decide how locality commissioning should be done and the good ones have put tremendous things in place in terms of population health management, patient pathways and commissioning linked to those patient pathways. That is why, if we can do something with this Bill, it is to retain all that locality commissioning with GP input. But be prepared for the ICS, the big battalions, to go away and fight with the barons in the big hospitals.

[Baroness Thornton (Lab)]

I wish you good luck.

Health and Care Bill

Lord Lansley Excerpts

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

[Lord Kamall (Con)]

I hear the strength of feeling from the noble Lord. I will take this back to the department and discuss it with my right honourable friend the Secretary of State. I hope noble Lords are reassured by that. I may not get the perfect answer, but I will try. I understand the strength of feeling on this issue; no one can fail to do so. Let us put it this way: it was not subtle but direct. It is really important that, as the Minister here, I take this back and reflect the feeling of the House in my conversations with the Secretary of State, and his subsequent conversations with NHS England. I will take that back and look at the consultation process and the CCGs consulting all the relevant local authorities.

I understand the point made strongly by the noble Lord, Lord Scriven, that we have to be careful about prescribing in a top-down way how to work locally. I have always been a strong believer in localism and making sure that powers go down to a local level rather than being taken away. Let me again assure the noble Lords, Lord Scriven and Lord Hunt, and other noble Lords that I will take this back, because clearly there is concern. I had not appreciated the strength of that concern. At Second Reading the noble Lords, Lord Stevens and Lord Adebowale, said, “We are already doing this. It makes sense to go ahead and put it on a statutory footing”. But I have now heard the other side of the argument, and it suggests that I should go back and have a stronger conversation with, in effect, my boss—my right honourable friend the Secretary of State. I hope that gives some reassurance.

On Amendment 44, in the name of the noble Baroness, Lady Thornton, I assure your Lordships that we intend to provide as much stability of employment as possible while ICBs develop their new roles and functions. I hope that noble Lords are aware that there is already an existing commitment that staff transferring into ICBs will transfer across on their current terms and conditions in line with the NHS Terms and Conditions of Service Handbook. NHS pension rights will also be preserved. As a result, staff transferring into ICBs will not see any change to their existing conditions.

However, the Government are concerned about forcing ICBs to adopt conditions and practices that the ICBs do not believe work best for new staff. We believe that it is important to give ICBs flexibilities relating to staff terms and conditions; they are there for a reason. For example, when it is difficult to recruit and staff are going elsewhere, this would include allowing ICBs the flexibility to diverge from collectively agreed pay scales in order to attract staff from elsewhere or with unusual or valuable skills, or to reflect local circumstances. It will also give ICBs the flexibility to support joint working and bring in staff currently working in local authorities or foundation trusts, for example, supporting integration and the joint working approach that the Bill hopes to encourage.

I also note that ICBs having the independence and flexibility to choose whether to adopt collectively agreed pay conditions and pensions for new staff is not unique, as the noble Baroness, Lady Thornton, acknowledged. NHS foundation trusts, which are already free to exercise their discretion in adopting such conditions, overwhelmingly choose to honour and apply such terms to their staff unless there are good reasons to diverge.

On the proposals for very senior managers, existing procedures are in place to ensure that the most senior staff within the NHS are appointed with fair and equitable salaries. Proposals to pay very senior staff more than £150,000 must be similar to those for other equivalent roles or be subject to ministerial oversight.

The Government are in the process of finalising the procedures that will apply for ICBs. The specifics may differ but the effect and intention will be the same: to afford ICBs agency in setting pay at competitive rates so that we can continue to attract the most senior and experienced leaders, while putting adequate checks and balances in place to ensure appropriate use of taxpayers’ money and keep senior public sector salaries at an appropriate level. The Government believe that this amendment, which also asks for ICPs to approve annual salaries in excess of £161,000, is unnecessary. I am happy to have further conversations.

I now turn to the amendments on how the ICBs will function once established, starting with that in the name of the noble Lord, Lord Davies of Brixton, which relates to the question of treatment outside the ICB area. The new clause in question provides that NHS England must publish rules for determining the people for whom integrated care boards have responsibility. Importantly, this clause ensures that everyone in England is covered by an ICB.

We intend that the rules set by NHS England should replicate the current system for CCGs as closely as possible. This means that the ICB will be responsible for everyone who is provided with NHS primary medical services in the area—for example, anyone registered with a GP. It will also be responsible for those who are usually a resident in England and live in their area if they are not provided with NHS primary medical services in the area of another ICB.

It is important to remember that no one will be denied healthcare on the basis of where they live. We want to ensure that, under the new model, bodies that arrange NHS services—decision-making bodies—are required to protect, promote and facilitate the right of patients to make choices with respect to services or treatment. This means allowing patients to choose to be treated outside their ICB area. Choice is a long-standing right in the NHS and has been working well for some time. The Bill continues to protect and promote it. However, I am afraid that we have concerns about this amendment, as it places a requirement on providers rather than commissioners. It would not be reasonable to expect providers to provide services regardless of whether they were funded by an ICB to do so, and it is important that ICBs should be able to make decisions about with whom they contract and where they prioritise their resources.

On Amendment 53, in the name of the noble Baroness, Lady Walmsley, I hope I can assure the Committee that the Government are committed to ensuring continuous improvement in the quality of services provided to the public. As your Lordships will be aware, there is already a wider range of duties in relation to the continuous improvement of services. Clause 20 imposes on ICBs a duty as to the improvement in quality of services. Furthermore, the ICB must set out how it proposes to discharge that duty at the start of each year in its joint forward plan and explain how it discharged the duty at the end of each year in its annual report. I hope this goes some way to meeting the noble Baroness’s concerns.

Clause 16, which this amendment seeks to alter, recreates for ICBs the commissioning duties and powers currently conferred on CCGs in the NHS Act 2006. It ensures that ICBs have a legal duty to commission healthcare services for their population groups. It also recreates Section 3A of the 2006 Act, which provides the commissioning body with an additional power to commission supplementary healthcare services in addition to the services they are already required to commission. This power enables ICBs to arrange for the provision of discretionary services that may be appropriate to secure improvements in the health of the people for whom it is responsible—or improvements in the prevention, diagnosis and treatment of illness in those persons—so it is important that the clause remains as it is currently drafted.

The Bill will ensure that the existing local commissioning duties conferred by the NHS Act 2006 will transfer over to ICBs. This is set out in proposed new Section 3, which is also to be inserted by Clause 16 on page 13. I hope that the noble Baroness, Lady Walmsley, will be reassured that it rightly uses “must” rather than “may” when referring to the arranging of services. I can therefore assure the Committee that ICBs will continue to commission the services previously delivered by CCGs. That will ensure that service delivery for patients is not impacted.

Amendment 159 in the name of the noble Baroness, Lady Wheeler, touches on the important relationship between ICBs and ICPs. I remember that, when we had an earlier consultation, the Bill team had a diagram about how ICBs and ICPs would work together; It might be helpful if I ask for that to be sent to noble Lords so that all of us can have more informed conversations about the intentions of the amendments and the issues that noble Lords want to raise. I will make sure that that is done.

This amendment would add a requirement for the Secretary of State to make regulations to establish a dispute resolution procedure if an ICB fails to have regard to an assessment of needs, an integrated care strategy or a joint local health and well-being strategy in respect of the ICB’s area. The Bill was introduced to ensure that existing collaboration and partnership, working across the NHS, local authorities and other partners, is built on and strengthened; I recognise the concerns raised by the noble Lord, Lord Scriven.

We intend for these assessments and strategies to be a central part of the decision-making process of ICBs and local authorities. That is why we are extending an existing duty on ICBs and local authorities to have regard to relevant local assessments and strategies. The ICB and local authorities will be directly involved in the production of these strategies and assessments through their involvement with both the ICP and health and well-being boards at place—that is, at a more geographical level. As a result, they have a clear interest in the smooth working of the ICP.

More widely, there are several mechanisms to ensure that ICBs and local authorities will have regard and not intentionally disregard the assessments and strategies being developed at place in their areas. First, health and well-being boards have the right to be consulted.

[Lord Lansley (Con)]

I just had a flashback moment. I remember being asked, or volunteering, a decade ago to produce a chart of the various organisations under the 2012 Act. I think that the King’s Fund did a rather good job of doing it back then; perhaps it might do it again, although it will find that it is more complicated this time.

The noble Baroness, Lady Thornton, asked a perfectly reasonable question that might simplify the process. If health and well-being boards do the same job as integrated care partnerships, in large measure, why cannot integrated care partnerships and health and well-being boards be the same organisation?

[Lord Kamall (Con)]

I remember hearing in an earlier discussion on the Bill that nothing prevents that where they coincide. My noble friend and I have had conversations about health and well-being boards and where they sit. Given that, and given my noble friend’s experience of this issue, perhaps we could have a further conversation on this matter before the next stage to clarify some of the issues that he rightly raised in previous conversations.

At this moment, we believe there are mechanisms to ensure that ICBs and local authorities have regard to and do not disregard the assessments of the health and well-being boards. As my noble friend points out, that is for further conversations.

As noble Lords know, NHS England must also consult each health and well-being board on how the ICB has implemented its joint health and well-being strategies, so there is another level of reassurance there. The 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 and must consult the health and well-being board when undertaking that review. NHS England has formal powers of intervention if an ICB is not complying with its duty in any regard. That is sufficient to ensure that ICBs will have regard to both ICP and health and well-being board plans, but I understand the concerns raised.

Health and Care Bill

Lord Lansley Excerpts

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

I strongly welcome Amendment 17 and say “Please take notice of the devolved nations, even though the populations are smaller”, but there are, I am sorry to say, real problems with Amendments 301 and 205, and I hope the Government will come up with a solution and make sure that we have the health service that Aneurin Bevan wanted to instigate, which was for everybody at the point of need.

[Lord Lansley (Con)]

My Lords, I will intervene briefly, if I may, to support my noble friend in her Amendment 17. I am glad to follow the noble Baroness, Lady Finlay of Llandaff. I will not follow her in discussing the financial settlements between NHS England and NHS Wales; there is a lot to that. But I confess that I rather share her view that it would be a stretch too far for us to seek to legislate in this Bill for matters that are the subject of devolved powers for the parliaments in Wales and Scotland, even though the issues are very interesting and the points that were made, not least by my noble friend Lady Fraser, were perfectly sensible and rational objectives.

I will confine myself to Amendment 17 and say there are good reasons why my noble friend and the Government might adopt it. It seeks to amend what is presently Section 13O of the National Health Service Act. The differences are important. First, if one looks at Section 13O as it stands, it requires the board—NHS England for these purposes—to

“have regard to the likely impact of those decisions on the provision of health services to persons who reside in an area of Wales or Scotland that is close to the border with England.”

It is perfectly reasonable that it should do that, but that is not, as the debate has illustrated, the extent of the issue.

Speaking entirely personally, my late father-in-law was resident in Anglesey. He needed cancer services, so—perfectly sensibly—he went to Clatterbridge in the Wirral. My noble friend Lord Hunt is of course a former Secretary of State for Wales. He will be very familiar with the way in which services between north Wales and Cheshire, which he formerly represented, were provided. That is one straightforward example.

A number of noble Lords will recall the debate when I was Secretary of State about paediatric congenital heart services. In north Wales, they were provided in Liverpool, if I remember correctly. In south Wales, they were provided in Bristol. Those are one or two aspects of a necessary relationship for specialised services between different parts of the United Kingdom. At the border, there is a relationship in day-to-day healthcare services. There is an arrangement for that, and we do not need to interfere with it in this legislation. Shropshire CCG presently runs it on behalf of NHS England.

NHS England and NHS Wales have a statement of values and principles which, as far as I could see on looking it up, was last renewed in 2018. I think it is due for renewal. Basically, it relates to about 21,000 patients from England who are registered with Welsh GPs. About 15,000 patients resident in Wales are registered with English GPs. There is a transfer and a netting off of costs between them of about £6 million, and arrangements exist for referrals between the two countries. So we do not need to interfere with any of that, but the legislation needs to cover in particular this first point: that we are concerned not only with those who live in the areas bordering England and Wales; we are concerned with people in England and in Wales more generally, as well as with people elsewhere in Scotland and Northern Ireland.

The second point is that the present drafting excludes Northern Ireland. Clearly, there should be a role for NHS England. It should be prepared to consider its functions in relation to the provision of services—obviously where required and requested—by the Administration in Northern Ireland.

Finally, the drafting of Amendment 17 rather sensibly says not only that one should consider the impact on people living in Wales, Scotland and Northern Ireland but that one should think about the provision and delivery of additional services for people living in those areas. Amendment 17 makes this clear in 1(b):

“(b) services provided in England for the purposes of”

the health services in Wales, Northern Ireland and Scotland. In so far as any of those Administrations were to make a request or, under the concordat that exists, to look for support for services, that is something that NHS England would have the necessary legislative cover to support.

I appreciate drafting, if I may say so, and even at this stage my noble friend has drafted a very good amendment which I am rather hopeful that my noble friend on the Front Bench will also commend.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in very clearly introducing these amendments, the noble Baroness, Lady Morgan, said that this group might not get feisty. I hope that we can manage to be very civil and calm in tone. None the less, there is a degree of disagreement—to which I am going to contribute.

In concluding her remarks, the noble Baroness said that this is a UK institution, embodying UK values. That seems to deny the reality of devolution. It is entirely possible that at least one of these countries could be an entirely separate nation very soon. That is the practical reality.

Once again, I was struck by the similarity with the climate change debate we had earlier. Sometimes people say, “Well, the scientists will tell us what to do about climate change”. Of course, this cannot be true, because how you get to 1.5 degrees involves a huge number of political choices around the allocation of resources. Similarly with health, many different routes and choices are involved in the effort to produce as healthy as society as we can. Whose health are you talking about? These are all political choices.

The noble Baroness, Lady Fraser, said that this was about data, not delivery. Of course, we know that very often what is delivered is what is measured, and if you choose to measure different things, maybe that is because you are seeking to deliver different things.

Like other speakers, I do not have any particular problem with Amendment 17, but I do with Amendment 205 and, in particular, Amendment 301, which says:

“The Secretary of State may … specify binding data interoperability”


and

“Scottish Ministers, Welsh Ministers and Northern Ireland Ministers must arrange for the information”.

I do not speak for the Scottish Government—albeit that they have some Green elements—but I would be surprised if they accepted that kind of wording. I do not wish to redraft on my feet but, if the Minister were looking to redraft, I suspect that something like a direction to the Secretary of State to “work with the Scottish, Welsh and Northern Ireland Ministers to agree” would definitely be preferable.

However, I agree with the noble Baroness, Lady Finlay, who gave us some very detailed and informed comment, that the best way to achieve this is by institutions at an operational level working together to find ways to link things up. If we take the example given by the noble Baroness, Lady Fraser, about her daughter’s situation, we can all be very annoyed that that apparently rather simple situation has not been sorted out. But I do not think drafting law in your Lordships’ Chamber is the way to sort that problem out. That needs to be at a very different level, and it needs to be sorted out as soon as possible.

Health and Care Bill

Lord Lansley Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

Moved by

[Lord Lansley]

4: Clause 3, page 2, line 8, at end insert “and insert “, including in achieving improvements in the outcomes recorded in the NHS Outcomes Framework””

[Lord Lansley (Con)]

My Lords, I am very glad to have this opportunity to contribute to the Committee’s discussions. We turn to the mandate, which noble Lords will recall is the means by which the Secretary of State principally holds NHS England to account for the delivery of its functions and responsibilities in relation to the NHS.

This becomes more important as time goes on, for two reasons: first, because NHS England will incorporate within its own activities more of the functions pertaining to the NHS, particularly the powers and responsibilities of NHS Improvement; secondly, because in the past there was a sense in which some transparency was associated with the bodies across the NHS. NHS Improvement represented the interests of NHS service providers and NHS England represented the interests of the commissioning of services—that is, the public interest and the population health interest. These are to be incorporated in one organisation; that is the essence of the integration that NHS England and NHS bodies have sought to achieve, contrary to the structures of the 2012 legislation. I wish them success with it, but it does not enhance accountability, either to Parliament or the public. Therefore, the mechanisms for accountability must be as clear as we can make them.

As it happens, since 2013 I do not think Secretaries of State or Parliament have used the mandate in the way it was intended they should. On a number of occasions, the Secretary of State has not used the mandate on an annual basis but has run it on, and we therefore have before us—as we will see in many places in this legislation—an acceptance of how practice has developed and that the legislation should come into line with it.

On a number of occasions, I will simply throw up my hands and say, “Fine, if that is how the NHS wants to do things, let us put the legislation into that structure to enable the NHS to do its job in the way it wishes to.” Indeed, I suspect that those outside this House who are looking at the current situation in the NHS are saying, “What is the relevance of us engaging in all this legislative activity at this moment?” Part of the answer is that legislation impacts on the day-to-day activities of people in the NHS much less than they might imagine. Secondly, one of the things we can do sensibly is to say that, even before the pandemic and the additional extreme pressures that the NHS has had to face, it had developed its own way of working, it wants the legislation to fit with that and I think it is probably helpful to the NHS to do that.

There will be other places, and we will come to them later, some of which I mentioned in my Second Reading speech, where I think the Government are looking to go beyond and to change what the NHS has done by way of practical integration, practical implementation and practical decision-making. I think we should resist some of those. I do not think it helps the NHS, at a time of such extreme pressures, for there to be some of these innovations, and maybe we need to call a halt to some of them.

One of the things, however, that the Government are not intending to do is to dispense with the mandate. The mandate is, in my view, more important for the future, for reasons of the importance of the transparency of accountability for the NHS for the performance of its functions. Since we went into recess before Christmas, NHS England and NHS Improvement have published their operational guidance for 2022-23. I think they have actually set out a pretty admirable and comprehensive set of objectives, but only a minority of those objectives are outcomes related. Many of them are, quite understandably under current circumstances, very focused on the volume of activity and the targeting therewith—in particular, for example, that the level of elective activity should rise to 110% of the pre-pandemic level and that diagnostics should increase to 120% of the pre-pandemic level. This is absolutely instrumental if we are to deliver on or get back to remotely the kind of waiting time figures we experienced in the earlier part of the last decade—I might say back to 2012-13, when we reduced waiting times to their lowest level.

The point is that there is a great danger, which we have seen in the way Secretaries of State have structured the mandate in recent years to focus on process, on targets and on volume and to devote insufficient continuing attention to the outcomes that are achieved. I gladly make clear that, while I move this amendment, I do not think it is the way the legislation should be framed. What I am looking for from my noble friend is the Government’s acknowledgement that, even as they focus on waiting times, targets, productivity, volumes and the mechanisms by which the volumes of activity in the NHS can be increased in the years ahead, we must not lose sight of outcomes.

What I mean by that is that we have seen a number of examples in the past of how the pursuit of waiting time targets led to significant problems in terms of hospital-acquired infections, which really threw the NHS off course for more than one or two years. So, in the NHS outcomes framework there is a domain relating to safe care, which I think enables us to focus on things like hospital-acquired infections and continuously to measure the outcomes we are achieving in relation to that.

The same is true in relation to preventing premature mortality. This, happily, is an area where, by focusing on outcomes, we can demonstrate that we are meeting internationally comparative high levels of performance. Of course, that does not relate only to cancer, but it is one of the reasons why we do not have a separate debate for Clause 4. I was prompted to put this amendment forward partly because of Clause 4, however. I am glad that it is in the Bill—it was part of a debate we had more than 15 years ago, when John Baron was with me on the shadow health team in another place—but the point is that we were always focused on one and five-year survival rates for outcomes in relation to cancer. What Clause 4 does is enable us to focus on outcomes in that respect.

--- Later in debate ---

I hope I have been able to give your Lordships some reassurance of our intentions regarding the mandate. I therefore hope that my noble friend will feel comfortable withdrawing his amendment.

[Lord Lansley (Con)]

I am most grateful to my noble friend for that response and to all those who contributed to this short debate. It was a helpful opportunity to reinforce the desirability of the mandate itself being used positively as a mechanism for accountability, particularly where outcomes are concerned.

I entirely take my noble friend’s point that what we are looking for should not be confined to the parameters of the NHS outcomes framework. As time goes on, the possibility of developing what are effectively population health outcomes is exactly where we need to go. My worry is that, if the mandate shifts too much towards population health outcomes, we will be trying to express it in terms of outcomes which the NHS does not control the means of delivering. That goes back to the point the noble Lord, Lord Patel, made earlier about who is responsible for what. As my noble friend said, in essence, the NHS is responsible for delivering the outcomes in relation to healthcare, but the Government are responsible for delivering outcomes in relation to population health, so we cannot confine this to the NHS. The mandate certainly needs to extend into that territory but, in doing so, it should not lose track of continuous improvement in those things that are measured through the NHS outcomes framework, and its development as we go along.

I also take the point about the timeframe. We have learned that we need the NHS to be planning long term, and it is doing that—not least through its development of the 10-year long-term plan. That extends even beyond the Government’s funding commitment, which has a different timeframe. Neither of those are very easily reconciled directly with the annual funding settlement. The mandate could be developed as a very effective way to enable the NHS and the Government to show, in a way that is accountable to public and Parliament, how the plans of the NHS and the funding commitments from the Government can be reconciled into measurable changes, targets, objectives and outcomes in the lifetime of a Parliament, because that is what Ministers will inevitably be looking for. We want the NHS to feel that it has some degree of certainty for the longer term; we want Ministers to feel that they have some degree of accountability and control in the year ahead, or two or three years ahead. That is what the mandate should be used to enable them to do.

My last word on the mandate is: please could Parliament actually scrutinise it? It was always intended that there would be annual debates in this House and the other place on the mandate. There never were. I thought it was shocking that the Government did not devote a day in each House each year to looking at, understanding and scrutinising the mandate as a mechanism for us to look at our most important public service—you can always argue about that, but I think it is—and know what we are trying to achieve in the year ahead, even if the mandate extends further beyond that.

I thank my noble friend, not least for his point on Amendment 10 and his reassurance that Ministers will always explain their reasons for revisions to the mandate and, indeed, that such revisions, as we all agree, should not be too frequent or too detailed; they need to be strategic in their nature. I am glad for his reassurance on that point. With those thoughts, I beg leave to withdraw the amendment.

Amendment 4 withdrawn.

Health and Care Bill

Lord Lansley Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Lansley (Con)]

My Lords, over the last two years, we have all had cause to be immensely grateful to the National Health Service. NHS staff have responded heroically to the demands of the pandemic, and the service has shown a capacity to innovate, adapt and collaborate. The noble Lord, Lord Stevens of Birmingham, has been at the heart of that, and so we much look forward to his maiden speech today. But we are not out of these woods. There is an immensity of effort yet required, and the Government are right to allocate unprecedented resources to the National Health Service to support the recovery programme.

This Bill enshrines in law an approach that is markedly different from that which has characterised virtually all health legislation in England since the 1980s. That earlier legislation progressively built an NHS based on key principles: autonomous NHS providers held to account by commissioners, who would pay them for the services they actually delivered; patients’ rights to choose a provider; money following the patient; clinical leadership; and, since 2013, an NHS that is operationally independent of politicians but with a series of checks and balances, including a mandated focus on improving clinical outcomes. In some ways, this Bill turns back the clock. Providers’ freedoms are to be limited; the purchaser/provider split is blurred; the NHS is being centralised; payment systems are being delinked from activity; and political direction is being reimposed. We should use debates on this Bill to ask whether this is really the right direction, particularly given the need now for a responsive, productive National Health Service.

One could argue that this Bill reflects a journey that, in truth, started soon after the 2012 Act was passed—and was never truly implemented. We see the Bill establishing integrated care systems, for example, but they have really been around, in one form or another, for six years already, albeit not in statute. Noble Lords considering this legislation should reflect that, much as we labour on the detail of legislation, as the House did a decade ago on my Bill, we should be aware that the NHS may choose simply to ignore it.

The Bill in fact goes beyond the NHS’s own long-term plan. The powers of direction and intervention put in the Bill by the former Secretary of State in Clauses 39 and 40 are not welcome—including to the National Health Service—are a potential political own goal and should be taken out.

Although I see the presentational appeal of repealing Section 75 of the 2012 Act, relating to procurement, virtually the same provisions are contained in Clause 70 of this Bill—highlighting the folly of trying to fix problems in secondary legislation through primary legislation. The slogan is “Collaboration not competition” —ironically, precisely the words that JP Morgan and Rockefeller used when creating vast monopolies.

My legislation was criticised for making the NHS too complex. This Bill takes complexity to a whole new level. We have ICS boards and ICS partnership boards—the latter sitting on top of health and well-being boards. Each ICS is large, so the workaround is to have places within them which map to local authority boundaries. That is just on the commissioner side. On the provider side, we have new provider collaboratives which, in fairness, is where the power in the NHS will lie. The Bill makes no provision for them in terms of transparency, openness or accountability.

The partnership with local government needs to be strengthened. Integration of NHS and social care demands joint planning, so why are the integrated care partnerships and health and well-being boards not made to be the same organisation? We must look also at Clause 54; I do not think hospital foundation trusts should lose their independence.

NHS staff will rightly say that none of this is any good without a clinical workforce, but Health Education England produced the first NHS workforce plan in 2017, and my noble friend referred to the People Plan in 2019. Why, at that time, was Health Education England’s budget cut when the NHS budget was not?

Finally, the Government put Clause 140 in at the last minute, which will mean that if someone has limited assets and must meet heavy care costs, they may end up losing virtually all of their lifetime assets before the cap is applied, but the well-off person would lose only a fraction of their assets. That is not the design of the scheme Andrew Dilnot’s commission recommended to me. I believe many Members in another place want to reconsider this. We should enable them to do so by leaving Clause 140 out of the Bill when we send it back.

As ever, it is our job to revise constructively. I hope that, in doing so, we shall sustain both the independence and accountability of the NHS.

Covid-19 Update

Lord Lansley Excerpts

Monday 29th November 2021 Lords Chamber

[Lord Kamall (Con)]

As the noble Baroness, Lady Watkins, will be aware, our scientific medical advice and the data are constantly reviewed. We are currently conducting thorough tests to review both LFT and PCR efficacy when it comes to the omicron variant. The advice that I have been given is that we must wait for the data and take a cautious, proportionate approach as scientists work urgently to better understand the variant. In terms of the question on more restrictions in terms of where face masks should be worn, the advice at the moment is still on public transport and in shops, and to continue to encourage people to work either from home or in offices, as appropriate.

[Lord Lansley (Con)]

My Lords, in my noble friend’s repeat of the Statement, he said that

“our strategy is to buy ourselves time and strengthen our defences”.

May I ask him about our border controls? Given our testing capacity, would it not make sense for us, for example, to test everybody who comes into our airports at the airport itself so that we have certainty that, where they are positive, we know who they are and are able to conduct the contact tracing required?

[Lord Kamall (Con)]

I thank my noble friend for giving me notice of the question; I appreciate it. The answer that I have been given in response is that we have built a thriving private diagnostic market to meet the demand of the international travellers and day 2 PCR testing for travellers is provided by these private providers. Based on forecast modelling, we are confident that the market has sufficient capacity to meet the rise in demand that omicron may pose.

Public Health England (Dissolution) (Consequential Amendments) Regulations 2021

Lord Lansley Excerpts

Tuesday 9th November 2021 Lords Chamber

[Lord Lansley (Con)]

My Lords, it was not my intention to speak in this debate—I wanted to come and listen to it—but I am prompted by a number of contributions just to say one or two things in response to the debate and before my noble friend has a chance to reply. I share with my noble friend Lord Cormack his support for my noble friend in taking on these responsibilities, and nothing I have to say reflects on his role in this. Indeed, I think it has been handed on to the Secretary of State as well, so in a sense we have a new team and I hope they will think about things sometimes in new ways.

I want to make a few, very simple points. The noble Lord, Lord Hunt of Kings Heath, is absolutely right: Public Health England was an executive agency. It worked for the department. In so far as it had operational autonomy, that was not in the legislation; it was a choice made by Ministers. At any stage, as was the case during the Covid crisis, Ministers had all the powers they required in relation both to Public Health England and to the NHS under the emergency legislation.

Let us remember that this House went through the 2012 Act in scrupulous—I might almost say excruciating —detail. It arrived at a conclusion that NHS England should be independent and Public Health England an executive agency. Notwithstanding certain measures put into the legislation to make sure that Public Health England would be more transparent and accountable, that balance was struck not least because I and my colleagues on behalf of the Government said, “We want the NHS to be seen to be independent. We want Ministers to take personal responsibility for public health.”

The noble Lord, Lord Howarth of Newport, referred to one or two things that happened afterwards. I want to share in thanking Duncan Selbie for what he achieved. I want to make it absolutely clear that I understand that Ministers subsequent to the establishment of Public Health England did not give to public health the resources, either for PHE itself or for local government with its responsibilities, that were intended back in 2010-12 under the coalition Government. That did not happen.

Let us remember that, at the beginning of 2020, the King’s Fund produced a report saying that it thought that the public health reforms had worked but they had not been sufficiently funded. Internationally, Public Health England was regarded as being as prepared for a pandemic as virtually any other country in the world. That things fell down needs to be thoroughly examined by an inquiry. An inquiry has not even begun, yet we are already at the point where people have made judgments, reached conclusions and found scapegoats. Heads and deputy heads have rolled.

We are not going about this in the right way. I want Ministers in due course to think again in the light of the report of that inquiry about what constitutes the right mechanism for managing their public health responsibilities. They need an organisation that understands public health in its entirety. How many of us think that the pandemic was unrelated to the extent of non-communicable diseases in this country, to the extent of disparities in this country and to extent of the obesity epidemic that we suffered?

We have so many interconnections between inequalities and public health problems, and our resilience against communicable diseases, that we should never think of managing public health in separate, siloed organisations again, but that is exactly what the Government are doing, without, frankly, having thoroughly understood what happened in in 2020 and 2021. I hope that they will go back and say, “Prevention is not the job of the NHS. Prevention is the job of the Government.” Public Health England was the organisation whose job it was to do that. If it was not strong enough in 2020 to do it, Ministers might look at what they did in the preceding years that might have undermined that role and think carefully about how they should take on the responsibility of building an integrated and fully functioning public health organisation for this country in the future, certainly not simply fragment it.

[Baroness Brinton (LD) [V]]

My Lords, I declare my interest as a vice-president of the Local Government Association.

From the Liberal Democrat Benches, we support the Motion of Regret in the name of the noble Baroness, Lady Merron, and the noble Lord, Lord Cormack and the noble Viscount, Lord Stansgate, are absolutely correct that this House does not like the fact that once again the Government have chosen to use secondary legislation to make major changes to the way the Government manage their business—in this case, public health.

The noble Baroness, Lady Merron, has set out the chaos of a series of announcements from August last year, followed by a variety of procedures and changes when the Government kept getting things wrong. I absolutely support her concerns, and, as have many other speakers, I start from the position that major reorganisations during a global pandemic are unsound and unhelpful, not just to dealing with the pandemic but to the performance of any successor bodies, including the UK Health Security Agency and the Office for Health Promotion and Disparities, with disparity work continuing in NHS England. I echo the comments of the noble Lord, Lord Howarth, and others on the work of all the PHE staff, and Duncan Selbie in particular.