NHS Overseas Charging Regulations Review 2017

Stephen Hammond Excerpts

Wednesday 12th December 2018 Written Statements

[The Minister for Health (Stephen Hammond)]

On 16 November 2017, the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Winchester (Steve Brine) announced to the House that my Department would be conducting a review into the impact of amendments made to the NHS charging regulations in 2017, with particular regard to any impact on vulnerable groups and those with protected characteristics.

The review is now complete, and the evidence received demonstrated that there is no significant evidence that the 2017 amendment regulations have led to overseas visitors being deterred from treatment or that the changes have had an impact on public health.

I am pleased that the review has shown that the 2017 amendment regulations are largely working in the way they were intended. These changes were, amongst other things, made to enshrine in law that overseas visitors not eligible for free care must pay for any non-urgent treatment upfront, to help reduce the need to chase up charges, and to remove the anomaly whereby the healthcare setting or provider type could determine whether services would be charged for or not.

Some case studies presented did reveal that there is more to do to ensure some groups of vulnerable overseas visitors understand their entitlements and treatment options, and that providers of NHS care consider fully when a patient can be reasonably expected to leave the UK before deciding if treatment should be safely withheld if payment is not provided.

We will continue to work to ensure that these issues are addressed, so that the charging regulations are implemented in as fair a way as possible. We will improve information and support for NHS staff and patients and work with stakeholders and interest groups to ensure that key messages and safeguards are understood by all.

To ensure clinicians, NHS and community care staff fully understand our guidance and how it should be implemented in practice, we will revise and relaunch our focused e-learning training programme, and work with NHS Improvement’s support teams to promote it. This will ensure that all relevant aspects of overseas visitors’ personal circumstances are taken into consideration when clinicians decide whether treatment is immediately necessary.

To combat any misconceptions around how the cost recovery regulations affect access to care, the Department and NHS Improvement will continue the close partnership with community groups and stakeholders representing vulnerable individuals to develop user-friendly, culturally-appropriate guidance, and ensure this reaches those who may be impacted by this policy.

Finally, we will continue to work closely with NHS Improvement and frontline staff to keep the impact of the regulations and these further actions under very close review, and to provide additional support and guidance to organisations implementing the regulations in different settings in the best interests of patients.

[HCWS1174]

Clinical Waste: Healthcare Environmental Services

Stephen Hammond Excerpts

Tuesday 11th December 2018 Written Statements

[The Minister for Health (Stephen Hammond)]

I am today taking the opportunity to update the House about a company which provides clinical waste services to NHS Trusts.

This company—Healthcare Environmental Services (HES)—was subject to previous discussions in Parliament. On 9 October, the then Minister of State for Health, set out concerns that a number of waste storage and treatment sites were well over the permitted levels. This included waste collected from hospitals and other public services. Although the waste was stored securely, the Environment Agency was sufficiently concerned at the activities of this company that they took regulatory action, including launching a criminal investigation.

At the start of October, a number of trusts served by HES’ Normanton site, terminated their contracts, and arranged for Mitie to provide waste collection and incineration services instead.

Until last week, a number of other NHS trusts continued to receive services from HES. Those organisations, supported by NHSI and the Department of Health and Social Care, have been monitoring the situation.

However, HES has now failed to collect waste from 24 further trusts. NHSI has sought assurance from HES that it has not ceased trading and is capable of, and will continue to provide services. Such assurance has not been forthcoming. Contingency arrangements are in place for each of the affected trusts. An optional extension in the Mitie contract has been exercised, which will allow all affected trusts to access a replacement clinical waste collection service. This has been communicated to all Trusts and NHSI is working with affected trusts to mobilise and implement contingency plans.

These robust contingency measures mean there is no gap in service provision and no health risk to the public.

[HCWS1168]

NHS: Staffing Levels

Stephen Hammond Excerpts

Tuesday 11th December 2018 Westminster Hall

[The Minister for Health (Stephen Hammond)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I thank the hon. Member for Batley and Spen (Tracy Brabin) for securing this debate. As she and hon. Members who have contributed to other such debates will know, the issues she raises are very similar to those that we discussed on 21 November in the debate that the hon. Member for Ellesmere Port and Neston (Justin Madders) has just referred to. However, it is welcome to have the opportunity to discuss them again, because such debates reflect the importance that we all place on the NHS workforce. The one thing that the hon. Gentleman and I agree on is that it is right to begin by reiterating our thanks to the NHS professional staff for their work treating patients day in, day out.

I also thank other hon. Members for their contributions. I note in particular the comment rightly made by my hon. Friend the Member for Lewes (Maria Caulfield) that we need to upscale nurse degree apprenticeship routes. I will speak about that in more detail if I have time. My hon. Friend the Member for Redditch (Rachel Maclean) spoke about the capital announcement made last week, which I was pleased to see come through. My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) made some points about mental health—may I offer him a meeting at the Department to discuss those matters directly, because today I want to concentrate on other matters? The hon. Member for York Central (Rachael Maskell) made a contribution based on her valuable experience.

I should say right at the outset, as I did in our debate two weeks ago, that the Government greatly value the staff who contribute to and support the NHS. We understand its importance and are committed to ensuring that it is supported and funded appropriately, which is clearly reflected in the extra £20.5 billion a year that the NHS will get by 2023-24.

As the hon. Member for Ellesmere Port and Neston quoted me saying in our last debate, we expect NHS England to set out clearly its commitment to the workforce in the long-term plan. The plan will address how to open up the profession to more people from all backgrounds and ensure that they get the right support throughout their training. To answer his question: yes, when the long-term plan is published, he will see the workforce embedded in it and in our strategy. We also expect NHS England to deliver a clear implementation plan to guarantee the future of the workforce. The NHS employs a record number of staff—more than 1.2 million in 2018, which is more than at any other time in its 70-year history—with significant growth in newly qualified staff since 2010.

Let me repeat what I said two weeks ago:

“the Government, and I as the new Minister for Health, should never be complacent”.—[Official Report, 21 November 2018; Vol. 649, c. 372WH.]

We are not. We are absolutely committed to ensuring that nursing remains an attractive career so that the NHS can build on the record numbers of nurses on our wards. Actions already taken to boost the supply of nurses range from training more nurses and offering new routes into the profession to enhancing rewards and pay packages, and there are now 11,000 more nurses on our wards than in May 2010.

NHS England, NHS Improvement and Health Education England are working with trusts on a range of recruitment, retention and return to practice programmes to ensure that the required workforce is in place to deliver safe and effective services. We should note that NHS Improvement has had some real success with its retention programme. Retention seems to me one of the key issues for the Government to focus on, and that will be reflected in the long-term plan. NHS Improvement’s programme continues its direct work with trusts to support improvements in retention, with a focus on the nursing workforce and the mental health clinical workforce. So far, 35 trusts have been involved and the initial evidence is positive and encouraging, with more flexible working programmes and greater support for older workers. It is therefore right that that programme be expanded further to all remaining NHS trusts in England.

[Maria Caulfield]

Revalidation is a new system for nurses to retain their registration, but it is a very difficult and stressful process for nurses who may be part-time or part of a hospital bank. I was lucky because my NHS trust, the Royal Marsden, is extremely supportive to its bank workers, but will the Minister ensure that bank nurses are supported through the revalidation process to keep them registered?

[Stephen Hammond]

I am listening carefully to my hon. Friend, and I will ensure that that work is undertaken.

As I have said today and on previous occasions, the priority is to get more nurses on our wards. There are currently 52,000 nurses in training, and we have announced a policy change that will result in additional clinical placement funding to make 5,000 more training places available each year. My hon. Friend made the point that nursing bursaries were not always the panacea that everyone suggests; students on the loans system are at least 25% better off than under the previous system. However, we recognise that students incur additional costs as a result of attending clinical placements, so we have introduced a learning support fund with a child dependants allowance, reimbursement of travel costs and an exceptional hardship fund. When I spoke to nurses at Barts last week, I listened carefully to the points they made about the need for help with travel in particular, and I am looking carefully at that issue.

The hon. Member for Batley and Spen raised the RCN proposal. Yesterday, as I had promised I would, I responded to the RCN in a formal letter to Dame Donna, and I look forward to meeting her to discuss her proposals in the near future—hopefully the very near future.

We are increasing the number of midwifery training places by more than 3,000 over the next four years. There continues to be strong demand for nursing places, with more applicants than places, but I am under no illusions, nor am I complacent. We need more people applying and we need to increase that route. A number of routes are open. HEE’s programme covers all fields of nursing; its RePAIR—reducing pre-registration attrition and improving retention—programme explores effective interventions to ensure that people are supported through their whole student journey from pre-enrolment to post-qualification.

The hon. Member for Batley and Spen was right to mention the number of new routes into nursing. In particular, she will have noted the report published last week by the Select Committee on Education on the nurse degree apprenticeship. We are working with the Department for Education to carefully consider the Committee’s recommendations and I will respond in due course.

I want to turn to the story of doctors. In the NHS today, it is true that there are 18,200 more doctors in trusts and CCGs than there were in 2010. My hon. Friend the Member for Central Suffolk and North Ipswich raised the matter of the additional 5,000 doctors. This year, we have recruited 3,473 GP trainees, against the target of 3,250. That is an increase on last year, but we are determined to meet the commitment of 5,000. To ensure that that is possible, we have rolled out an extra 1,500 medical school places. By 2020, as he knows, five new medical schools will be open to deliver that expansion.

In the whole of this discussion, it is only right that I recognise that the Government value the professionals. It is key that we ensure that NHS staff are well remunerated. It is absolutely right that we have given NHS staff a well-deserved pay rise. All staff will receive a 3% pay rise by the end of 2018-19.

There is a lot more I might have said. The hon. Member for Batley and Spen raised a number of local issues, including ambulatory care. If she cares to write to me or to catch me, I would be happy to have a longer discussion with her. I thank her and all hon. Members for the points they have made in the debate. I also stress, as I have done today to staff at North Middlesex, and last week, that making sure that we have an NHS long-term plan that sets out a strategy for the NHS and ensures a sustainable supply of clinical workforce—doctors, workers and others—is key, and it is key to delivering our ambitions for the NHS. I thank the staff for all that they do.

[Tracy Brabin]

I thank colleagues from both sides of the House for their contributions, particularly those with frontline experience, and I thank the Minister for his measured response.

I have a couple of points. First, I am sure the Minister can feel the sense of urgency in this debate. Although I appreciate that long-term discussions are needed, we still do not have a date for when the long-term plan will be published or for the consultation on the Royal College of Nursing proposals. The Minister said it would be soon, but when will we have that?

[Stephen Hammond]

There is a commitment from the Government to produce the long-term plan before the end of the year, as the hon. Lady knows, and I have written to Dame Donna to request a meeting to discuss the RCN’s proposals.

[Tracy Brabin]

That is very reassuring.

We hear from across the House that mental health is receiving such little support. People are hanging by a thread. Nurses are saying to their organisations and their MPs, “I am worried for the health and safety of my patients. I’m doing too many shifts. I’m absolutely shattered. I can’t guarantee that I am going to be doing my job properly. They’re bringing in volunteers to support me on the ward.” It is an absolute crisis. While I understand that the wheels of government work very slowly, I hope that the Minister takes from this debate that Brexit has been a universal issue. We are losing staff members. I welcome the commitment to an extra 5,000 doctors and so on, but that is just plugging the gap of the staff who are draining away from our hospitals and frontline services.

[Stephen Hammond]

I absolutely recognise that Brexit is a pressure on the system, but we should also recognise that there are 4,367 more professionals working in the NHS from the EU than there were at the date of the referendum. It is important to put that on the record.

[Dr Whitford]

Will the Minister give way?

[Stephen Hammond]

I would give way, but I cannot—

[Mr Philip Hollobone (in the Chair)]

Order. I call Tracy Brabin.

Healthcare (International Arrangements) Bill (Third sitting)

Stephen Hammond Excerpts

Committee Debate: 3rd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

Question again proposed.

[The Minister for Health (Stephen Hammond)]

Mr Streeter, it is a pleasure to see you in the Chair this afternoon and to serve under your chairmanship. The hon. Member for Burnley has moved the motion, and in responding, I will take the opportunity to deal with the important issues of financial reporting and facilitating parliamentary scrutiny.

I will say at the outset that there can be no suggestion, nor is it the Government’s intention, that we should have anything other than a commitment to transparency and transparent use of public money. We are also committed to appropriate parliamentary scrutiny: we have taken several significant steps to ensure that central Government data is published in a transparent way, including spending control. However, that needs to be done in an efficient and effective manner, and we need to know what data is available and is not available. I have problems with the hon. Lady’s new clause because such a detailed reporting requirement is premature, and risks the very thing that she seeks to avoid. She seeks to avoid placing an administrative burden on the public bodies, but that is exactly what the new clause might do.

We believe that the frequency and detailed content of a financial report should be determined once the reciprocal healthcare arrangements have been made and the technical and operational details of those agreements are known. At the moment, the collection of administrative data is facilitated by the registration and exchange of e-forms through the processes provided for in the relevant EU regulations. As a result, the UK and other EU member states are able to collect data and report both nationally and at an EU level, based on known processes. Current spending on EEA healthcare is reported as part of the Department of Health and Social Care’s annual report—which the hon. Member for Burnley may wish to look at, or may well already know about—as well as the accounts that are presented to this place. The Department also provides information to the European Commission for its triennial report on cross-border healthcare, as well as providing an annual statement of financial accounts to the Commission.

The Department is currently negotiating with the EU and individual states therein with a view to providing UK citizens with continued access to healthcare in the EEA, either through an agreement or through bilaterals. In that case, we will have to agree how eligibility is evidenced; how, and how often, that information is exchanged; and, of course, the reimbursement mechanisms that will govern the new arrangements. Those agreements will have to take into account the operational possibilities and limitations of each contracting party. That should include how NHS trusts in the UK can evidence eligibility for treatment, and how that can be done in the most efficient and least burdensome manner. I therefore say to the hon. Lady that much of the data she requests is already published. There is no suggestion that the new healthcare reciprocal arrangements will change the administrative burden; in certain cases, it is a simple matter of looking at coding within systems. However, only once the technical details are known will the Government be able to formally commit to any additional reporting, if necessary.

I am bound to say to the hon. Member for Burnley that when I saw that the new clause had been tabled, I remembered that 10 years ago, I was in the place she is in now. It is the traditional role of Oppositions to table these new clauses for almost every Bill; it is also the traditional role of Governments to reject them when they see them, as I remember only too clearly from when I was sat in the hon. Lady’s place. I therefore hope I have gone some way towards making clear to her that we are not trying to avoid any reporting requirement, or to shy away from any parliamentary scrutiny. There are already a number of reporting processes in place, and we want to make sure that any future reporting processes operate in a proportionate and considered manner. I hope that the hon. Lady will accept the spirit of my remarks, and that she will therefore choose not to press the new clause to a Division.

[Julie Cooper (Burnley) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Streeter, and to respond to the Minister’s points. I appreciate some of his arguments, but we are in unprecedented times. As the Bill will facilitate the arrangement of a diverse range of agreements, it must cover every eventuality. It is therefore perfectly reasonable to expect the technical agreements, once they have been reached, to be reported back to Parliament annually. Parliament cannot be expected to grant a blank cheque. I accept that I do not have the Minister’s experience in this place, but large amounts of money will be spent on as yet unknown agreements, so it seems reasonable to request that, when the negotiations result in an agreement, it is reported back to Parliament once a year. That is the first thing that concerns me.

I should have thought that the Government would want to take the opportunity to report on the improved performance and collection of charges due to the UK in respect of all non-UK citizens seeking to access care in the UK.

[Stephen Hammond]

Indeed, and of course we are doing so. We have made that clear. As the hon. Lady knows, over the past four years we have quadrupled the amount of income we are recovering.

[Julie Cooper]

I am grateful to the Minister for that clarification, but my understanding is, as the Public Accounts Committee reported, that the Government have still not met their own targets on improved collection, and there will potentially be greater barriers to protection if several agreements are negotiated. I therefore want Parliament to have the opportunity to scrutinise the Government’s delivery on collection.

I am concerned that the Minister does not think it fitting for Parliament to have sight of an impact assessment of the additional burdens that the collection resulting from the as yet unknown agreements would have on NHS hospital trusts’ general financial wellbeing. I will press this new clause to a Division. I think it is sensible and reasonable, so there can be no cause to object to it.

Question put, That the clause be read a Second time.

--- Later in debate ---

[Stephen Hammond]

The new clause deals with the crucial question of healthcare on the island of Ireland. It focuses on reciprocal access to healthcare between Northern Ireland and Ireland, if there is no UK and EU deal, and would require the Secretary of State to set out plans for an agreement to protect medical access for British and Irish citizens moving between Ireland and Northern Ireland.

We agree that it is absolutely our intention to do two things. First, there should be a deal for reciprocal arrangements between the UK and the EU, and secondly, it is absolutely essential, in the unlikely scenario of no deal, that essential access continues. The UK and Ireland are committed to protecting reciprocal healthcare rights, so that UK and Irish nationals can continue to access healthcare when they live in, work in or visit the other country. We also want to maintain the co-operation between the UK and Ireland on a range of medical issues, including planned treatment, public healthcare and workforce. It is absolutely the intention of the Government that people should be able to live their lives as they do now, and that our healthcare systems support one another.

If there is no deal—in that unlikely scenario—the UK and Ireland will want to set out how we both agree to protect reciprocal healthcare arrangements, but it is also true, and the hon. Gentleman will know, that the UK Government are firmly committed to maintaining the common travel area and to protecting the rights currently enjoyed by UK and Irish nationals when in each other’s states. The hon. Gentleman’s issue about the border is mitigated by the fact that the UK Government are committed to maintaining the common travel arrangements, which allow full protection and maintenance of the status quo for all journeys for individuals between the UK and Ireland. It is currently estimated that there are something like 110 million crossings.

As I said earlier, as with other member states, we would expect to have a healthcare agreement between the two countries in the unlikely situation that there were no deal—an agreement that could be implemented into legislation that would provide the reassurances that the hon. Gentleman seeks. The NHS charging regulations can already exempt individuals that are covered by reciprocal healthcare arrangements. We can also use the powers in the Bill to maintain aspects of our current co-operation, such as reimbursement for healthcare costs and the sharing of data to support entitlements. I therefore say to the hon. Gentleman that I do not think the new clause is necessary, given the clear commitment by both sides. I hope he recognises that commitment and does not feel that he needs to press the new clause to a vote.

[Justin Madders]

I am minded not to press the new clause to a vote if the Minister assures us that he will endeavour to keep us updated on the contingency plans, if it looks like we are approaching a cliff-edge scenario. That is really what we are trying to achieve.

[Stephen Hammond]

Let me make the hon. Gentleman the same offer that I made to the hon. Member for Burnley. In that unlikely scenario, I guarantee that I will make my officials available to give a briefing to the hon. Gentleman and any member of the Committee who wishes to understand what our proposals are.

--- Later in debate ---

[Justin Madders]

I beg to move, That the clause be read a Second time.

On Second Reading, I spoke about the importance of dispute resolution, and asked the then Minister for Health, the right hon. Member for North East Cambridgeshire (Stephen Barclay), to set out how he envisaged it operating in both a deal and a no deal scenario. Despite some prompting from me and my hon. Friend the Member for Weaver Vale (Mike Amesbury), the Minister was not able to set out how dispute resolutions will be handled under the terms of any new agreement or even if the European Court of Justice will continue to represent a red line for the Government. The latter point is particularly interesting, given the new role of the right hon. Member for North East Cambridgeshire. It appears that he did not provide detail on that point because, at that stage, the Government were simply not in a position to confirm what was in the draft withdrawal agreement.

The Prime Minister categorically ruled out any jurisdiction of the European Court of Justice very early in the process, but I have yet to hear any serious suggestion about how disputes can be resolved, if we manage to reach a full reciprocal healthcare agreement with the EU27 beyond the transition period, without some reference back to the ECJ. The same concerns would apply if bilateral agreements were necessary in a no deal scenario.

Given the importance that the Prime Minister and members of her Cabinet have placed on the ECJ following our exit from the European Union, it is curious to say the least that we do not have a clear statement of intent from the Government while we debate this Bill. If their position continues to be that we will not have truly left the European Union if we are not in control of our own laws, as the Prime Minister put it in January 2017, it is vital that we have clarity about the arrangement that will be used in place of the ECJ. If a new arrangement is established, what will the cost be? Who will the judges be? Where will it be based? Will it be an open process?

If, on the other hand, we look to the ECJ for dispute resolution after all, even if only in the limited area of reciprocal healthcare, would that not represent a significant political U-turn? This issue is fundamental to the Government’s approach to Brexit. For example, they decided that we could not continue to host the European Medicines Agency, causing it to go to Amsterdam at the cost of 900 jobs in this country, and potentially hundreds of millions of pounds of investment. The Health Secretary’s sole justification for that was that the Government were not prepared to accept the European Court of Justice’s jurisdiction. Our purpose in tabling this new clause is to get clarity from the Minister about whether the European Court of Justice remains a red line for the Government.

[Stephen Hammond]

The new clause would place a duty on the Secretary of State to lay before Parliament a detailed strategy defining the process for settling disputes concerning healthcare agreements after we leave the European Union. No one in the room would dispute the spirit behind the new clause. As I have stated throughout our examination of the Bill, it is right that there should be transparency regarding the UK’s future relationship with the EU and other countries after exit. It is right that that transparency should apply to the arrangement of future healthcare agreements, and the processes that underpin them, such as dispute resolution, but, although I agree with the spirit of the new clause, I am not entirely sure that it would achieve its intended aim. I will give a number of reasons why.

The new clause would confer a duty on the Secretary of State to lay a strategy on the process for dispute resolution before Parliament. Both in a deal and a no deal scenario, such a strategy would be unlikely to provide information on the process for settling disputes concerning healthcare agreements that is not already available in the public domain. That is not due to a lack of endeavour; it is an issue of timing and consideration of what is already publicly available. In the expected scenario that the UK agrees a deal with the EU, the proposed process for settling disputes has already been confirmed in the White Paper on the future relationship, the draft withdrawal Bill that governs the implementation period and, most recently, the political declaration on the future relationship between the UK and EU. The processes have already been confirmed. They are outlined in those documents and would apply not only to disputes, but clearly therefore to disputes in any reciprocal healthcare agreement.

The hon. Gentleman asks what the dispute mechanism is. I am sure that the Committee will be pleased that I am not going to quote extensively from the withdrawal agreement, but it is worth putting on the record that the mechanism for resolving disputes will be through consultation at the Joint Committee, with the aim of reaching a mutually agreeable resolution. If the parties are not able to resolve the dispute in the Joint Committee, either party can request the establishment of an independent arbitration panel to resolve it. The panel will be made up of five members, with one person being the chairperson. The UK and the EU will nominate two members to sit on the panel and then mutually agree the fifth member, who will be the chairperson. The panel members will act independently and do not represent the party that nominated them. It is binding that the panel members be independent and impartial and they must possess specialised knowledge or experience of EU law and international law.

The hon. Gentleman challenges me on the role of the ECJ. He is right that the ECJ has a role here, but its role is very clear and very limited. The role of the ECJ after the implementation period will be restricted to ensuring the correct interpretation of EU law. There is no suggestion that the ECJ will determine the dispute, or that we would ever agree to the ECJ determining the dispute.

That is the likely scenario and the processes that are already formally set out via the documents that I described earlier. In the unlikely scenario that the UK leaves the European Union without a deal, the United Kingdom will arrange reciprocal healthcare agreements, and in those agreements, there will have to be bilateral dispute resolution. That would clearly have to be determined on a case-by-case basis as part of the negotiations to put those bilateral healthcare agreements in place, and, therefore, there is unlikely to be a single dispute resolution process, which is what the new clause suggests, so while I accept the spirit of it, the wording would restrict the ability for future reciprocal healthcare arrangements.

More importantly, the requirement for such a strategy to be laid before the House one month after the Bill receives Royal Assent does not align with the aim of the Bill to provide future reciprocal healthcare agreements with countries both inside and outside the EU. Clearly, those agreements are likely to be negotiated over a period of time and, as I have just mentioned, the dispute resolution mechanisms within them are likely to be different and may vary. It would therefore be arbitrary and unhelpful to produce a general strategy immediately after Royal Assent.

I understand the intention behind the new clause, but it would place an unnecessary burden and duty on the Secretary of State. In a deal scenario, the procedures are already there. In the unlikely no deal scenario, it would be likely to frustrate the ability to put in place future reciprocal healthcare agreements.

I hope that, having heard that, the hon. Gentleman will accept that, although we understand the spirit of his new clause, its wording would be likely to frustrate the purpose of the Bill. I therefore ask him not to press it to a vote.

[Justin Madders]

I am grateful to the Minister for setting that out in more detail than we were able to elicit on Second Reading. Given that the withdrawal agreement had not been published at the time, I understand why the then Minister was not able to do that. The present Minister has been very helpful in setting out the process for leaving with a deal. He is right that, if we leave without a deal, we are in uncharted territory. I do not think I heard any confirmation that there are red lines, in terms of the European Court of Justice, in that scenario. That is really what the new clause was meant to establish. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 4

Duty to consult with devolved administrations

Before issuing any regulations under this Act, the Secretary of State must consult the Scottish Government, the Welsh Government and the Northern Ireland Government and have regard for their views on the regulations.—(Justin Madders.)

Brought up, and read the First time.

--- Later in debate ---

[Justin Madders]

I beg to move, that the clause be read a Second time.

I hope this is a straightforward and uncontroversial new clause. We have already spoken about the importance of reciprocal healthcare arrangement to citizens in Northern Ireland, and of course there will also be an impact on patients in Wales and Scotland. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements, and why would they not?

The Delegated Powers and Regulatory Reform Committee was clear in its recommendation that there should be active participation of the devolved Administrations in setting out the UK’s position in future arrangements, but I am not aware that there have been any discussions. I would be grateful if the Minister could set out what conversations have taken place, because we did not get clarity on that on Second Reading.

The new clause repeats some of the issues that we raised this morning, which you did not have the pleasure of hearing, Mr Streeter. It is about the scope and power of the Bill and the wide range of duties given to the Secretary of State, which will be subject to the negative procedure. We think it is important that, as part of the Bill, when those wide powers are given to the Secretary of State, there must be a clear duty to consult with the devolved Administrations before those regulations are enacted.

The Fisheries Bill and the Agriculture Bill have dealt extensively with the need to involve the devolved Administrations. I think this is the bare minimum that we need. It would represent a consistent and equitable approach across the devolved nations, in terms of our future relationship with the EU.

[Stephen Hammond]

It is a pleasure to respond to this new clause, which addresses the extraordinarily important issue of engaging and working with the devolved Administrations. We completely agree that regulations made under the Bill may relate to devolved matters, by which I mean domestic healthcare. The Government will engage and meaningfully consult with the devolved Administrations in line with our existing arrangements, as found in the 2012 memorandum of understanding between the UK Government and the devolved Administrations, and the principles that underlie relations between us. That reinforces the positive work that the UK Government continue to do with the devolved Administrations daily for the benefit of the whole of the UK on this matter.

I am forced to reflect that, though the hon. Gentleman’s new clause is not necessary, the sentiment behind it is shared by everyone in Committee, I suspect. The regulation-making powers in the Bill provide us with a legal mechanism to implement international agreements domestically. The Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed with the EU, to the benefit of the residents of England, Wales, Scotland and Northern Ireland. The powers offer flexibility and can be used to implement comprehensive healthcare agreements with third countries in the future for the benefit of all UK nationals.

Healthcare (International Arrangements) Bill (Second sitting)

Stephen Hammond Excerpts

Committee Debate: 2nd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

[The Chair]

I remind the Committee that electronic devices should be turned to silent or turned off. Tea or coffee is not allowed in the Committee Room during sittings.

We now begin the line-by-line consideration of the Bill. The selection list for today is available in the room and on the Bill website. It shows how the selected amendments have been grouped together for debate. Amendments grouped together are generally on the same or similar issues.

A Member who has put their name to the leading amendment in a group is called first. Other Members are then free to catch my eye to speak on all or any of the amendments within the group, and a Member may speak more than once in a single debate. At the end of a debate on an amendment, I shall call the Member who moved the leading amendment again. Before they sit down, they will need to indicate if they wish to withdraw the amendment or seek a decision. I shall work on the assumption that the Minister wishes the Committee to reach a decision on all Government amendments if they are tabled.

Members should note that decisions on amendments do not take place in the order in which they are debated, but in the order in which they appear on the amendment paper. In other words, debate occurs according to the selection and grouping list, but decisions are taken when we come to the clause that the amendment affects. I shall use my discretion to decide whether to allow a separate stand part debate on individual clauses and schedules following the debates on the relevant amendments.

Clause 1

Power to make healthcare payments

Question proposed, That the clause stand part of the Bill.

[The Minister for Health (Stephen Hammond)]

It is a pleasure to serve under your chairmanship, Mr Stringer. This is a short, sensible Bill to ensure that we are prepared, whatever the outcome of leaving the European Union. The Bill confers powers on the Secretary of State to make and to arrange for payments to be made in respect of the cost of healthcare provided outside the United Kingdom. It will allow for the funding of reciprocal healthcare arrangements for UK nationals living in the EU, the European Economic Area and Switzerland.

The Bill is part of the Government’s preparation for EU exit and will allow us to take the necessary steps to broadly continue reciprocal healthcare arrangements or to otherwise support UK residents to obtain healthcare when they move to or visit the EU. It is an important and necessary piece of legislation, so that the British public can look forward to the future with the confidence that they will get the healthcare they need when they need it.

Clause 1 introduces a new power for the Secretary of State to make payments and to arrange for those payments to be made to fund healthcare abroad. I will start by setting out for the Committee why it is necessary for the Government to seek that power.

Currently, there are limited domestic powers in relation to the funding of healthcare abroad. The existing reciprocal healthcare arrangements with the EU are based on EU law. Reciprocal arrangements with other third countries at this time do not involve making payments, as they are based on waiver agreements. In line with the Public Accounts Committee concordat, the clause provides statutory authorisation for the expenditure in relation to future funding of healthcare abroad. It enables the funding of any reciprocal healthcare arrangements that the UK may enter into with EU member states, non-EU states and international organisations, such as the EU, as well as unilateral funding of treatment abroad if needed. It is a vital power to ensure a smooth transition post EU exit.

As a number of colleagues set out on Second Reading, including the Chair of the Select Committee on Health and Social Care, it is essential that the Government take appropriate measures to support a reciprocal healthcare arrangement and agreement with the EU. The Bill and the clause are crucial to that endeavour. Our arrangements with the EU are by their nature reciprocal and require a mutual understanding, and continuation of the arrangements are therefore a matter for negotiations between ourselves and the EU. It is incumbent upon any responsible Government to take forward responsible measures, and the Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed, with the EU. It is the Government’s ambition to ensure that we have the powers and the legal basis to implement comprehensive reciprocal healthcare agreements with other countries around the world, where that would be cost-effective and support wider health and foreign policy objectives after the EU exit.

Clause 1 means that we are ready to respond to any scenario concerning future reciprocal healthcare arrangements with the EU on exit day. In a deal scenario, we would use the power to fund a future reciprocal healthcare arrangement with the EU following the implementation period. In the unlikely no deal scenario, our offer to all EU member states would be to maintain reciprocal healthcare arrangements on a bilateral basis for at least a transitional period. We would use the power to fund those arrangements.

On 2016-17 estimates, the United Kingdom spends about £630 million per year on the EU system of reciprocal healthcare. That is an accrued liability where payments are made to individual member states on a monthly basis in arrears. Once we leave the EU, the clause will allow the Government to continue to fund such a system of reciprocal healthcare, subject to any agreement with the EU and/or EU member states.

The payment system for funding reciprocal healthcare arrangements is set out in EU law. In the future, detailed provisions could be given effect domestically by the regulations under clause 2(1), which we will discuss later, and the payments could be made by exercising clause 1.

Of course, the spending of any public money is and should be closely monitored. The money spent under clause 1 would be no exception to that rule—the usual safeguards apply. As with all departmental expenditure, it would need to be authorised by the Treasury supply process and will be included in the Department’s annual estimates, as well as being included in the annual resource accounts that are audited by the Comptroller and Auditor General. The exact arrangements will be provided for under the future reciprocal arrangements, which are obviously a matter for negotiation. It is envisaged that the current arrangements will be used as a basis for future arrangements with the EU.

It may be helpful to the Committee to look briefly at how the current process of payments works. At the moment, if a UK national were to injure themselves on a holiday in France, they would present their European health insurance card, commonly known as EHIC, at the hospital and receive the necessary treatment. The hospital would then raise an invoice for the treatment with its liaison body. In the case of the United Kingdom, that liaison body is the NHS Business Services Authority. The French liaison body would then submit a claim for the cost of the treatment to the NHS Business Services Authority based on receipt of the invoice from the hospital.

Once the NHS Business Services Authority is satisfied that the claim is accurate and valid, the UK would then release the payment to France, alongside any other claims received for that month. Our intention is to provide for those administrative and operational facets through the regulation-making powers in clause 2(1), which I referred to a moment ago and which we will discuss later. Clause 1 will provide for the payment element.

As is clear to all Committee members, the UK Government’s ambition is to have a reciprocal healthcare agreement with the EU, which should include reciprocal healthcare for state pensioners, UK participation in the EHIC scheme, and co-operation on planned treatment. We expect that that will continue to involve our making payments—for example, on the hundreds of thousands of British citizens who require treatment each year during their holidays in Europe. It also reflects current arrangements, whereby we receive money from EU member states when healthcare has been provided in the United Kingdom—for example, when a tourist to the United Kingdom has presented their EHIC.

It is, of course, our ambition to secure a future deal with the EU on the matter. Should that not be possible, we would seek to agree a broad continuation of the current system with EU member states on a bilateral basis for at least a transitional period. The Bill also provides flexibility to fund healthcare even where there is no bilateral agreement, which we might explore using in exceptional circumstances to secure healthcare for certain groups of people.

At the outset of the Committee’s line-by-line scrutiny, I put on the record my thanks to all hon. Members who spoke on Second Reading and who were supportive of the Bill in principle, and I thank hon. Members for their attendance today. I am also grateful, as I am sure everybody is, to the witnesses who attended on Tuesday. I put on the record my thanks to them, not only for giving us their valuable insight but for supporting the Bill.

Hundreds of thousands of people rely on reciprocal arrangements to access healthcare every year. Ensuring that the Government have a clear legal basis on which to fund these arrangements in the future is an essential component of allowing us to meet our shared goals in this area. I therefore recommend that the clause stand part of the Bill.

Question put and agreed to.

Clause 1 accordingly ordered to stand part of the Bill.

Clause 2

Healthcare and healthcare agreements

Question proposed, That the clause stand part of the Bill.

[Stephen Hammond]

This clause goes to the heart of the purpose of the Bill. It will ensure that the Government have the discretionary powers they need to respond flexibly to all possible outcomes of EU exit; to make regulations in relation to making or arranging payments in respect of healthcare provided abroad; to make regulations to support the provision of healthcare outside the United Kingdom; and to make regulations to give effect to complex international healthcare agreements. The Government can use such regulations to confer or delegate functions. The clause also provides that the Government can issue directions to a person about exercising functions as circumstances require. The powers in the clause are needed to provide the Government with both the flexibility and capability to implement detailed and complex arrangements concerning healthcare abroad. These powers ensure that we are taking the appropriate measures to be able to respond to the multiple EU exit scenarios.

As I remarked earlier regarding the powers in clause 1, as a responsible Government we believe that it is important to take forward appropriate measures. The Bill, and the clause, will ensure that we can broadly continue reciprocal arrangements with the EU where agreed, or, if necessary, with individual EU states on a bilateral basis. The Bill will support the potential strengthening of existing reciprocal healthcare agreements with countries abroad and around the world, and will potentially add to their number as part of future health and trade policy. I am grateful to my hon. Friend the Member for East Renfrewshire, who supported this facet of the Bill on Second Reading.

Facilitating the provision of healthcare for UK nationals abroad can be incredibly complex, and the scope of these powers necessarily reflects that. For example, the EHIC system is a broad and generous scheme for all UK and EU nationals. It covers a variety of different types of care, including emergency care, ongoing routine maternity care or a trip to a GP while abroad for someone with a chronic condition.

As I mentioned, it is our intention to negotiate a future arrangement with the EU that provides broad continuation of the current reciprocal healthcare system, including our participation in the EHIC scheme. That is a complex arrangement to provide for, and requires suitable domestic implementation to ensure that it operates effectively. It is therefore necessary and appropriate for the Government to seek suitably flexible powers to make regulations and directions that will allow us to implement such a scheme. It is also appropriate that these powers should afford us the capacity to implement and make provision for similar arrangements with other countries all over the world where this would be cost-effective and would support wider health and foreign policy objectives. The powers in the clause ensure that we are taking the appropriate measures to be able to respond to multiple EU exit scenarios, including the making of regulations for, or in connection with, the funding of provision for healthcare abroad and for implementing healthcare agreements.

--- Later in debate ---

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Stringer. First of all, I join the Minister in thanking those witnesses who came and gave evidence on Tuesday. There were certainly some helpful comments that we will no doubt return to in Committee.

As was made clear on Second Reading, this is a very important piece of legislation. More than 190,000 UK expats live in the EU and of course there are 50 million British visits within the EEA countries each year: all those people want clarity about what the arrangements are in the event that they will need healthcare. So we do not oppose the principle of the Bill. We absolutely agree that it is important that there are arrangements in place after 29 March 2019 and into the future. However, we are concerned about a number of issues, some of which I referred to on Second Reading and some of which we will discuss today.

It is fair to say that there are concerns about the breadth of powers that the Secretary of State is requesting in clause 2; I do not believe they would be countenanced at all under normal circumstances. I appreciate that we are not in normal circumstances and I am grateful to the Minister for setting out how he envisages those powers will be used in practice. We are not here to judge things just on what the situation is at the moment, but on how the powers could be used at some point in the future. With regard to that, the Minister referred to this Bill being used possibly to further foreign policy and trade objectives. When he responds, I would be grateful if he expanded on what he has in mind.

To compound our issues about the scope of the regulations, we are also concerned about our lack of opportunity to scrutinise them; we will return to those concerns when I move amendment 2 to clause 5 later on. Of course, we are not alone in having concerns about the scope of this clause and the lack of clarity about how the powers might be used. In the evidence session, Raj Jethwa, Director of Policy at the British Medical Association, said:

“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6.]

We will certainly push for that today.

The Delegated Powers and Regulatory Reform Committee in the other place went further than that, describing the scope of clause 2 as “breath-taking”. As that Committee correctly pointed out, there is no limit to the amount of any payments, to who can be funded or to the types of healthcare being funded. The regulations can confer or delegate functions to anyone, anywhere, and primary legislation can be amended for these purposes.

It is also worth noting that although this legislation has been presented as a Bill to enable us, as far as possible, to retain the arrangements that we already have—who would disagree with that?—the powers conferred by the clause, as I think has been conceded by the Minister, can go far beyond the current EU and EEA countries that we are primarily concerned about.

We consider the powers in the clause to be inappropriately wide, if they are not going to be subject to the correct levels of scrutiny. At this eleventh hour, we understand why a certain level of flexibility is being sought by the Government, but with that request comes a responsibility to ensure that proper parliamentary scrutiny is exercised.

Rather than oppose the clause in its entirety, we believe that the appropriate remedy would be to ensure that any regulations introduced under the Bill will be subject to the affirmative procedure. We will return to that point when we consider amendment 2 to clause 5.

[Stephen Hammond]

The hon. Gentleman is right to say that these powers are flexible. Part of the reason for that is that there may well be a need to anticipate the sort of bilateral arrangements that we put in place in the future—notwithstanding our hopes that we will secure a continuation of the current reciprocal healthcare arrangements, which is our ambition. When we come to debate not only the hon. Gentleman’s amendment, but clause 5—when the discussion on scrutiny of these arrangements should take place—I will seek to reassure him that the procedures in place will allow for the usual and appropriate parliamentary scrutiny of the Bill.

The hon. Gentleman talked about the powers being too broad. The Bill has a very focused purpose: to ensure that the reciprocal healthcare arrangements, which benefit UK nationals abroad and also EU and non-EU nationals in the UK, are continued. He also challenged me on the issue of potential future trade or foreign policy objectives. As he will know, we already have arrangements with a number of countries outside the EU, and the Bill must have the flexibility for the continuation and updating of those arrangements. The matter will clearly be of operational importance—potentially, it will be a policy decision after exiting the EU. Were a UK holidaymaker going abroad to a non-EU country, they would clearly expect the Government to have in place—or to have the potential to put in place—the reciprocal healthcare arrangements that would allow them to be treated should that be necessary.

I hope those words will satisfy the hon. Gentleman that the clause needs to stand part of the Bill. We can have the appropriate discussion about scrutiny in somewhat more depth when we debate clause 5.

Question put and agreed to.

Clause 2 accordingly ordered to stand part of the Bill.

Clause 3

Meaning of “healthcare” and “healthcare agreement”

Question proposed, That the clause stand part of the Bill.

[Stephen Hammond]

Mr Speaker—sorry, Mr Stringer: although who knows what may happen later next year?

[The Chair]

A serious promotion!

[Stephen Hammond]

One that I am sure would be welcomed by Members on both sides of the Committee.

Clause 3 is very simple and sets out the definition of “healthcare” and “healthcare agreement” used within the Bill. The definition of healthcare is modelled on the definition provided in the Health and Social Care Act 2012, which we have adapted to include the additional element of ancillary care. That is to reflect where current arrangements provide for ancillary costs, such as travel, which do not fit strictly within the definition of healthcare. As in France, this is for use in circumstances where residents are reimbursed a contribution of their travel costs when attending healthcare appointments.

I would like to clarify that access to social care in England would not be provided for through any reciprocal healthcare agreement. It is up to each individual country to determine what is available through the public healthcare system, just as we do with the NHS. The clause would enable individuals to access healthcare on those terms.

A healthcare agreement could be made either bilaterally or multilaterally, or it could be an agreement between states, countries or multilateral organisations. Such agreements provide access to agreed forms of healthcare when individuals from one country seek healthcare in the other, and vice versa. They also provide for how the funding will be shared between parties. Funding could mean a direct payment, arrangements to waive or set off costs, or other arrangements to cover costs. Clause 3 is short but important.

Question put and agreed to.

Clause 3 accordingly ordered to stand part of the Bill.

Clause 4

Data processing

[Julie Cooper (Burnley) (Lab)]

I beg to move amendment 1, in clause 4, page 3, line 17, leave out paragraph (d).

It is a pleasure to serve under your chairmanship, Mr Stringer, and I am pleased to have the opportunity to speak to clause 4. At this time of great uncertainty, when the nature of our future relationship with the European Union is still unknown, we welcome the intention outlined in the Bill to give some confidence to those who currently rely on the reciprocal health arrangements between the UK and the nations of the EU and EEA. We are only surprised that the Bill has taken so long to come before us.

The scope of the Bill is designed to cater for all possible outcomes of the UK and EU negotiations. The intention is that, deal or no deal, the Bill will empower the Secretary of State to negotiate future reciprocal healthcare arrangements between the nations of the UK and the EU, and any other such nation as is desired. Providing for pensioners, visitors, students and workers to live, work, study and travel in EU member states with complete peace of mind regarding the provision of healthcare is a priority for Labour. We therefore recognise the need for the Bill.

While understanding that any future agreement must allow for the smooth transference of data for the achievement of the best possible outcomes for patients, we believe it is also crucial that the Bill provides robust powers to protect personal data. Health records contain both personal and sensitive data, and access to such information must be allowed sparingly and only for medical purposes. Access to personal data should be available to health professionals who are bound by a duty of confidentiality on the basis of need to know. The Data Protection Act 2018 outlines the key principles relating to the protection of data; compliance with the spirit of those principles is fundamental to good data protection practice, and embodies the spirit of lawful, fair and transparent use of data.

Currently, the General Data Protection Regulation places restrictions on the transfer of personal data to countries outside the EU and EEA. As the UK leaves the EU, we will not automatically enjoy existing protections; indeed, this Bill provides powers for negotiations to take place with nation states across the world, to reach agreement on a bilateral basis. That makes it imperative, in our view, that the Bill protects against potential misuse of personal data.

Clause 4 outlines the detail of how data will be processed for the purposes of the Bill. We have noted the wide-ranging powers to be given to authorised persons, who may

“process personal data held by the person in connection with any of the person’s functions where that person considers it necessary for the purposes of implementing, operating or facilitating the doing of anything under or by virtue of this Act.”

We are not satisfied that sufficient safeguards are in place when defining an authorised person for the purposes of the Bill. We have listened carefully to the concerns of the British Medical Association, and share that organisation’s concerns about the lack of detail in the definition of “authorised person” in subsection (6). Mr Jethwa, representing the BMA, said in his evidence to this Committee that data

“has to be accessed on a need-to-know basis, and only when it is in line with patients’ expectations. Data sharing has to be transparent. We would be absolutely concerned that any safeguards meet those criteria and principles. I do not think the details in the Bill make that clear at the moment. We would like to see more clarity and detail about that in future.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 5, Q14.]

Mr Henderson, from the Academy of Medical Royal Colleges, said that although he recognises that there must be a “free flow” of data,

“individual patients’ data must be protected”,

and that

“it is slightly hard to say whether there is sufficient protection there or not”.––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 5, Q13.]

He is correct: it is hard to see that there are sufficient protections in the Bill. This is a hugely important issue that needs to be fully addressed.

With that in mind, we are of the view that subsection (6)(d) should be deleted, principally because it gives the Secretary of State a power—to authorise private health companies to access patient data—that is far too wide ranging. We believe that removing that paragraph protects personal data and achieves a balance, giving more confidence to patients while allowing the smooth transfer of data to designated qualified personnel.

The right to privacy and access to healthcare are rights that we value, and the one should not be conditional on the other. We wish to ensure that the Bill gives UK patients, and patients from the EU, full confidence that their personal information will not be shared inappropriately. That remains the case whether healthcare is received in the UK or overseas as part of a reciprocal healthcare agreement. As we leave the European Union, citizens accessing medical care as part of a reciprocal health agreement need to be sure that their personal data will not be shared inappropriately. Without that assurance, citizens may be discouraged from seeking medical assistance.

[Stephen Hammond]

I thank the hon. Member for Burnley for moving this amendment, because it gives me the opportunity to set out clearly and in some depth why we have chosen to include clause 4(6)(d) in the Bill. I want to lay out the reasoning for our concerns about this amendment. I hope that I will be able to reassure her of the vital importance of paragraph (d), and that it is necessary and appropriate, because we will be unable to accept the amendment.

Reciprocal healthcare agreements are made possible by close, consensual co-operation of different parties and bodies, such as the Department of Health and Social Care, the Commissioners for Her Majesty’s Revenue and Customs, Ministers of devolved Administrations, healthcare providers and all their opposite numbers in EU and EEA countries. Since the Bill is about the provision of healthcare, it would be remiss of Her Majesty’s Government to exclude healthcare providers, either those in the United Kingdom or those in other countries, from the list with authority and sanction to process and share data. Given that it is the Government’s position that in the agreement with the EU, future arrangements for the provision of healthcare abroad will reflect existing ones, it is worth reflecting on the place of healthcare providers in these processes, to illustrate the role they play in the commission and delivery of healthcare abroad.

Under the S2 route, a UK resident may decide to seek planned treatment abroad. As part of the ordinary procedure, the UK resident must visit a healthcare provider in the UK. The clinician would then provide written evidence that the person has had a full clinical assessment, which must clearly state why the treatment is needed in their circumstances and what the clinician considers to be a medically justifiable time period within which they should be treated again, based on their circumstances. As is clear under existing arrangements, this function can only be served by a medically trained healthcare provider. This paperwork is then passed on to NHS England or the comparable authority in the devolved Administrations for further processing. Many of those organisations are provided for by subsection (6)(c). Members will, I hope, understand that the lack of qualification around the term “provider of healthcare” is appropriate and necessary at this stage, given that future arrangements are not yet clear.

If the Government are adequately to fulfil the purposes outlined in clause 1, they need to be able to facilitate and fund healthcare for UK persons, for whom they feel responsible, whether the provider is based in the UK or overseas. In that connection, I think it is worth pointing out that the current reciprocal healthcare arrangements allow UK persons to access treatment from providers of healthcare in another country that are not NHS bodies or comparable state providers in another country, as defined by UK healthcare legislation. That might include an optometrist or a dentist, many of whom fall outside the state healthcare system.

Subsection 6(d) proposes to ensure that other types of healthcare providers are authorised to process personal data under the Bill, but most importantly that NHS bodies are able, where necessary, to share personal data for the purposes of the Bill with healthcare providers based outside the UK. Simply, if such providers were not also considered authorised, it would be impossible for healthcare commissioned, implemented, facilitated or funded by the UK to be authorised to be rendered abroad.

The hon. Lady is concerned that the clause will allow private providers access to patient data and the powers to process it. She should be reassured that that is already legal and proper under existing arrangements governed by EU regulations. Under existing reciprocal healthcare arrangements, UK persons are able to receive treatment in another country on the same basis as a local resident of that country. That includes healthcare or other treatments given by healthcare providers other than those that fall within the scope of domestic UK healthcare legislation.

After the fact and on return to the UK, the person would be able to seek reimbursement, where appropriate, from the relevant UK authorities. It is worth noting that the person who sought treatment abroad would typically only be reimbursed up to the amount it would have cost under the NHS. It would be for the person, not the Department of Health and Social Care, to bear the financial risk of any additional cost.

Since our desire to continue existing arrangements is shared by those on both sides of the House, I do not feel that the clause has inappropriate powers. To further allay any other fears, I remind members of the Committee that the clause contains safeguards to guard against any misuse of data. The Bill gives powers to providers, either in state healthcare systems or private ones, to process solely where it is necessary for the limited purpose of funding or arranging healthcare abroad—nothing more.

All processing of the data by all parties must also comply with existing data protection legislation. That is a crucial safeguard under UK data legislation. Data concerning healthcare is personal or specific category data. That can only be processed where specific conditions are met, namely that processing is necessary for the purpose of healthcare and in the public interest. Members will recognise that clause 4(6)(d) does not represent a deviation or new departure from existing arrangements and simply allows for the Government to maintain or improve those arrangements in whatever circumstances we find ourselves in after exit.

In closing, were the amendment agreed, it could risk patient outcomes by excluding providers of healthcare from the list of authorised persons. The hon. Lady expressed some concerns, and I hope that my response has allayed them. I offer to make my officials available to provide a briefing on this matter to her and any other member of the Committee who should so wish, so that they can be completely reassured that the normal data protection legislation will apply to the Bill. The exchange of data may happen only for a limited and focused purpose. The hon. Lady was right to express her concerns, and I hope she will be reassured by my words and that she will not feel the need to press her amendment to a Division.

[Julie Cooper]

I am grateful to the Minister for those explanations, and I welcome him saying it is a very limited and focused use of the data. I would be happy to take a briefing from his officials, but further to that, to give assurance to our side, I would be grateful if he will undertake to go further on Report and outline the scope of the subsection. If he will do that, we will not press the amendment to a Division.

[Stephen Hammond]

We will carefully consider what the hon. Lady has said and her request for further details on Report. I have listened and have offered that briefing, and I hope that is sufficient for her to decide not to press the amendment to a Division now.

[Julie Cooper]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

[Stephen Hammond]

I will try to limit my comments, given that we have already had discussions on the amendment. I am sure that will be welcome on this cold November day in a rather warm room.

Clause 4 provides a clear legal basis for processing personal data under the Bill for the purposes of UK data protection legislation. At present, the EU regulations provide a lawful basis for processing data for the purposes of reciprocal healthcare. Personal data is integral for providing healthcare abroad. It is vital that authorised persons in the UK can process data for that purpose. The clause ensures that, after exit day, there is a clear and transparent basis for processing personal data for the purposes of providing healthcare abroad, as required by UK data protection legislation. Clause 4 will ensure that safeguards are in place for that processing.

Subsection (1) limits processing to that which is necessary for the purposes of the Bill. Subsections (2) and (3) ensure that any such processing must remain in compliance with UK data protection legislation and the Investigatory Powers Act 2016, and any other relevant restrictions. Finally, the persons who can process data under the Bill are limited to those authorised in subsection (6), which we have just discussed.

The safeguards limit the scope of clause 4 to what is necessary and proportionate to provide healthcare abroad. For reciprocal healthcare, personal data is required to process reimbursements to and from other countries, and where reimbursement is made to a person as well. It is also sometimes necessary for healthcare providers to share medical information to facilitate treatment. The clause ensures that the Government can continue to process personal data as necessary, after exit day, in an effective and lawful way. Personal data transferred from outside the UK will remain subject to the need for safeguards to be put in place before it is transferred. Those safeguards will not be able to be contracted out as part of any healthcare agreement with the EU or member states or third countries.

As I said a moment ago, subsection (1) provides for an authorised person to process data related to the provision of healthcare abroad. Personal data is defined in the GDPR as data that relates to a living person who can be directly or indirectly identified from the data. Specific category data is personal data containing health and genetic data. At present, there are different routes for providing healthcare abroad, such as the S1, S2 or EHIC routes, and each route requires different forms of personal data.

Subsection (2) disapplies the duty of confidence and any restriction on the processing that would otherwise apply. The exemption ensures that data can be disclosed where it is necessary for the limited purposes of the Bill. The measure is necessary and appropriate. For example, authorised persons may need to share data if a person is unconscious and therefore not in a state to provide it themselves. Importantly, as expressed in subsection (3), data processing must continue to comply with the UK data protection legislation, which ensures there are further safeguards around data processing. The GDPR also governs data transfers between the UK and other countries. All EU and EEA countries are bound by the GDPR, which means the relevant national data protection safeguards in each country are adequate, allowing the free transfer of data between countries.

Subsection (3)(a) expressly requires that the processing of data does not contravene existing data protection legislation, and subsection (3)(b) requires that the processing of data must comply with parts 1 to 7 or chapter 1 of part 9 of the Investigatory Powers Act 2016. The only purposes for which investigatory powers may be required are to investigate and tackle suspected cases of fraud and error relating to healthcare abroad.

As set out in subsection (1), the processing of data under the Bill is limited to authorised persons who, as we have discussed, are defined in subsection (6). The list reflects those persons and bodies currently involved in processing data, including personal data under existing reciprocal healthcare arrangements.

I mentioned that, for clarity’s sake, subsection (6)(a) lists

“the Secretary of State, the Treasury, the Commissioners for Her Majesty’s Revenue and Customs, the Scottish Ministers, the Welsh Ministers and a Northern Ireland department”.

Healthcare abroad is entirely managed and operated by the Department of Health and Social Care in co-operation with the Executives in the devolved Administrations and their local healthcare systems. Although the Bill is about the provision of healthcare abroad, it is vital that the Executives of the devolved Administrations are considered authorised persons, since healthcare abroad is often facilitated in co-operation with them. Under subsections (6)(b), (c) and (d), healthcare bodies and providers are considered authorised persons as they are directly involved in the provision of healthcare.

Finally, subsection (6)(e) gives the Secretary of State the power to add to the list of authorised persons, which will ensure that the Government can respond appropriately, whatever the outcome of EU exit. It is also deemed necessary to allow the Secretary of State to respond to the changing demands of systems and operations. In future, duties may change and adding to the list will be difficult, so it is necessary to have the power in place.

Clause 4 is an important component of the Bill. It provides the Government with the necessary power to process and share data that relates to healthcare provided abroad. Therefore, I recommend that the clause stand part of the Bill.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Regulations and directions

[Justin Madders]

I beg to move amendment 2, in clause 5, page 3, line 44, leave out subsection (5) and subsection (6) and insert—

“(5) Any statutory instrument which contains regulations issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a resolution of each House.”

This amendment would make all regulations issued under this Act subject to the affirmative procedure and require approval from Parliament before they become law.

This amendment is probably one of the most important items that we will discuss in Committee. As I made clear when we discussed clause 2, there are widely held concerns about the scope of the regulations, which are exacerbated by the fact that these extraordinarily wide powers, necessary as they may be in the circumstances, are subject only to the negative procedure.

As I referred to earlier, the Delegated Powers and Regulatory Reform Committee in the other place clearly set out the potential impact of my amendment not being accepted when it said:

“If, without such amendment, the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure. Of course, these examples will not be priorities for any Secretary of State in this country.”

I hope that is the case, but we are here to look at how the powers could be used over, possibly, the next 100 years, and not just how we would expect them to be used in the foreseeable future.

Nobody knows where this process will take us, and when examining legislation there is always merit in considering the unlikely as well as the stated intentions of the Government at the time. The Minister’s comments about wider objectives reaffirms the importance of our scrutinising the regulations as much as possible. We find ourselves in an unprecedented situation in Parliament, and it is therefore important that we consider all eventualities.

If Committee members need further persuasion that the amendment should be carried, that Lords Committee set out a devastating list of reasons why the negative procedure is inappropriate. It said:

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere. The regulations can delegate functions to anyone anywhere.”

The Committee concluded:

“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”

The most significant reason why we do not object to the legislation is that the biggest risk at this stage is that arrangements are made that do not safeguard the ability of our constituents, when they travel abroad, or of UK citizens who currently live overseas to access healthcare, as they do now. However, because of the way the Bill is drafted, we will find that we are unable to debate whether those safeguards are in place as a matter of course. We have heard many references to the 190,000 UK expats living abroad and the 50 million or so nationals who travel to EEA countries every year. These are huge numbers of people, and the impact of the legislation on them is potentially huge. We owe it to all those people to ensure that any future arrangements are properly scrutinised.

We also need to consider the impact of any new arrangements on the NHS. As Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, set out in evidence on Tuesday:

“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]

He went on:

“In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q9.]

If we do not agree to the amendment, Parliament could end up in that scenario without any voice.

While there is scope for the affirmative procedure to be used in cases where Henry VIII powers are invoked to amend primary legislation, I think it is pretty clear that potentially the most significant changes to reciprocal agreements that could be enacted under the legislation are those that are subject only to the negative procedure. As we know, the negative procedure means that an instrument is laid in draft and cannot be made if that draft is disapproved within 40 days, normally via a prayer against, which is usually by way of an early-day motion. If that does not happen, the legislation is then passed. That is a 40-day process in the best-case scenario.

If I am correct, and if we leave without a deal, the Secretary of State will have to reach agreement with each of the 30-plus countries no later than Friday 15 February, assuming that Parliament does not sit on the following Sunday. At this stage, who knows where we might end up, but we will assume for now that the sitting days are as set out, so Friday 15 February will be the last day that an instrument can be laid that will pass before 29 March, assuming that it is not prayed against. Hopefully the Minister will be able to advise whether my understanding of the timetable is correct.

Will the Minister concede that, on a practical level, it would be better for regulations moved under the Bill to be moved using the affirmative procedure? We could then get them through scrutiny in both Houses much quicker than the 40-day procedure currently allows.

[Stephen Hammond]

The hon. Gentleman raises some important issues, including the issue at the heart of the clause—the appropriate, necessary and correct scrutiny arrangements for Parliament. Let me be clear at the start: the Government absolutely recognise the importance of appropriate levels of scrutiny of the Bill and its subsequent secondary legislation. It is clearly the hallmark of any effective parliamentary system that there are processes in place by which we draft, consider and test legislation. After all, that is what we are doing today.

The appropriate parliamentary procedure for the scrutiny of regulations made under the Bill that do not amend, repeal or revoke primary legislation is the negative procedure. If I am not able to reassure the hon. Member for Ellesmere Port and Neston and he chooses to press the amendment to a Division, I am afraid the Government will resist it.

--- Later in debate ---

[Justin Madders]

I am afraid the Minister has not managed to reassure me, despite his best efforts. When a Bill would confer power on the Executive, we have to be very careful about giving that power away. It cannot be done without good reason, even in these extraordinary times. I have not heard any justification for giving such sweeping powers to the Secretary of State without adequate scrutiny. No matter how well-intentioned the Minister is in his responses—I acknowledge his sincerity —we do not know who will be doing what in 12 months’ time. As we said earlier, we could be handing a future Secretary of State the ability to enter into arrangements for hip replacements in Australia or such like.

As the Minister said, the regulations will enable the Government to enter into detailed and complex arrangements on future healthcare. That is precisely why we need them to be subject to the affirmative procedure. I appreciate the point about the treaties possibly containing more detail, but this is about how Parliament will be able to scrutinise and challenge those arrangements.

[Stephen Hammond]

The hon. Gentleman will have heard that the treaty arrangements will be subject to parliamentary scrutiny in the normal way. We are discussing the regulations as to how we enact those treaties. I was hoping that he might be reassured by that.

--- Later in debate ---

Question proposed, That the clause stand part of the Bill.

[Stephen Hammond]

Having failed to reassure the hon. Member for Ellesmere Port and Neston, I will have another attempt in this stand part debate. Clause 5 supplements the substantive regulation-making powers in clause 2. It provides detail on the parliamentary procedure, as we have already discussed, that will apply to regulations made under the Bill. Subsections (1) and (2) introduce standard provisions, and are consistent with regulation and direction-making powers in many other Acts of Parliament, such as the Health and Social Care Act 2012 and the National Health Service Act 2006.

The clause is required to ensure that regulations and directions made under the Bill will be fit for purpose. As I have said, the powers in the Bill provide the Government with the flexibility and capability to ensure and implement detailed and complex arrangements concerning healthcare abroad. For example, the Government may use regulations to confer different functions on different bodies, in order that they may implement and operate effectively what may be provided for in an agreed reciprocal healthcare agreement. We do that now in relation to the EHIC scheme, which, as I said earlier, the NHS Business Services Authority administers on behalf of the Department. That administration includes the registering and issuing of EHICs and the processing of EHIC claims.

Future administrative arrangements to implement reciprocal healthcare agreements may reflect the current situation, or may involve conferring different functions on other bodies, as appropriate. Once the arrangements are negotiated, we will be in the best position to decide what the appropriate bodies to administer those arrangements are. We will be able to provide for the practical processes and implementation arrangements through the regulations. Clause 5 provides the Government with the flexibility to ensure that any healthcare arrangements can be implemented effectively and efficiently.

Subsection (3) provides that regulations made under clause 2

“may amend, repeal or revoke primary legislation…for the purpose of conferring functions”,

or

“to give effect to a healthcare agreement.”

I want to try again to reassure the Committee about that. The Government are conscious that Parliament rightly takes an interest in this area and, of course, we share the view about the importance of scrutiny.

This is a consequential power to make amendments to primary legislation, which is limited to three restricted uses: for the purpose of conferring functions, to give effect to a healthcare agreement and to make modifications to retained EU law. It is not a free-standing power; it is a focused power to ensure that we can implement healthcare arrangements effectively. That may involve conferring functions on healthcare bodies, which could involve amending primary legislation.

Subsection (4) provides that:

“Regulations under this Act may amend, repeal or revoke retained EU law”,

which is the body of existing EU law that the European Union (Withdrawal) Act 2018 will convert into domestic law, together with the laws we have already made in the UK to implement our EU obligations. It is vital that the regulation-making powers extend to amending, repealing and revoking retained EU law, because the bulk of the existing provisions that relate to current reciprocal healthcare arrangements with the EU will be EU retained law.

Subsection (4) will ensure that domestic legislation in that area is clear and accessible. It will allow us to amend EU retained law, where appropriate, to give effect to new reciprocal healthcare arrangements. It would be an oversight if the Bill did not provide for such amendment, given that current reciprocal healthcare arrangements with the EU are entirely bound up in EU law.

I stress again that, of course, Parliament will be given the opportunity for the appropriate scrutiny of regulations made under the Bill that amend, repeal or revoke primary legislation. As such, subsection (6) makes it clear that regulations that contain provisions that make modifications to primary legislation will be subject to the affirmative resolution procedure and, therefore, Parliament will have the opportunity to debate them. That is the parliamentary scrutiny procedure befitting Henry VIII powers, and one that allows for proper scrutiny.

Regulations made under the Bill that do not contain provisions that amend, repeal or revoke primary legislation will be subject to the negative resolution procedure. It is our job—and I think it is only right—to ensure that legislation is afforded the appropriate level of scrutiny. Therefore, regulations that are made under the Bill that do not amend, repeal or revoke primary legislation should be subject to the negative procedure, as is normal.

The remit of our regulating powers is focused. They can be used only to give effect to healthcare agreements or to arrange, provide for or fund healthcare abroad, as is clear in the enabling powers found in clause 2(1). Where the UK negotiates a comprehensive international healthcare agreement, whether multilaterally with the EU or bilaterally with EU members, the most important element that sets out the terms of that agreement would be included in the agreement itself, as hon. Members would expect. Regulations that give effect to such an agreement would likely focus on procedural, administrative and technical details, such as the types of documents or forms that could be used to administer those reciprocal healthcare arrangements, which is a point I made earlier.

In a scenario where a comprehensive healthcare agreement is being implemented through regulations made under clause 2(1)(c), that agreement would be subject to parliamentary scrutiny under the ratification procedure contained in section 20 of the Constitutional Reform and Governance Act 2010. That ratification procedure provides an opportunity for parliamentary scrutiny of the substance of the healthcare agreements being given effect to in the regulations made under the Bill. It is for those reasons that I rejected amendment 2, which the hon. Member for Ellesmere Port and Neston moved a moment ago.

The final provision of the clause, subsection (7), sets out the definition of “primary legislation”. To reassure the hon. Gentleman, and the Committee, the Government absolutely understand and appreciate the necessity for appropriate parliamentary scrutiny. The level of scrutiny must reflect the substance of the piece of legislation. That is what I believe the clause does, and I therefore recommend that it stand part of the Bill.

[Justin Madders]

The Minister and I will not agree on that, unfortunately. I will not repeat the arguments that we have already gone through, but I will remind hon. Members that the Lords Delegated Powers and Regulatory Reform Committee described the powers and regulation as “breath-taking”, and said that

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere.”

The scope of the clause is breath-taking. Although the Minister is trying to reassure us, as parliamentarians, we need the security of the affirmative procedure.

--- Later in debate ---

Question proposed, That the clause stand part of the Bill.

[Stephen Hammond]

I wish to introduce this short clause, which I suspect will be somewhat less contentious than the previous one. Subsection (1) provides that the Bill extends to England and Wales, Scotland and Northern Ireland. Subsection (2) provides that the Bill will come into force on Royal Assent, which reflects the need to respond to the range of possible EU exit scenarios in a timely manner. Subsection (3) establishes that the short title of the Act will be Healthcare (International Arrangements) Act 2018. With that short explanation, I recommend that the clause stand part of the Bill.

Clause 6 accordingly ordered to stand part of the Bill.

New Clause 1

Annual report on the cost of healthcare arrangements

‘(1) The Secretary of State must lay before Parliament an annual report setting out all expenditure and income arising from each healthcare arrangement made under this Act.

(2) The annual report laid under subsection 1 must include, but is not limited to—

(a) all payments made by the government of the United Kingdom in respect of healthcare arrangements for healthcare provided outside the United Kingdom to British citizens;

(b) all payments received by the government of the United Kingdom in reimbursement of healthcare provided by the United Kingdom to all non-British citizens;

(c) the number of British citizens treated under healthcare arrangements outside the United Kingdom;

(d) the number of non-British citizens treated under healthcare arrangements within the United Kingdom;

(e) any and all outstanding payments owed to or by the government of the United Kingdom in respect of healthcare arrangements made before this Act receives Royal Assent; and

(f) any and all administrative costs faced by NHS Trusts in respect of healthcare arrangements.

(3) The information required under section 2(a) and 2(b) above must be listed by individual country in every annual report.’—(Julie Cooper.)

Brought up, and read the First time.

[Julie Cooper]

I beg to move, That the clause be read a Second time.

I should stress that we support the intention of the Bill. Providing that UK citizens can live, work, study and travel in EU member states with complete peace of mind with regard to the provision of healthcare is a priority for us. We are aware that, under existing arrangements, the healthcare of 190,000 UK state pensioners living abroad, principally in Ireland, Spain, France and Cyprus, and of their dependent relatives, is protected.

In addition, we seek to ensure that the health benefits currently enjoyed by UK residents who visit the EU on holiday or to study continue, so that they may use the European health insurance card to access healthcare and emergency treatment for healthcare needs that arise during their stay. We also seek to continue the arrangement under which EU nationals receive reciprocal provision when they visit the UK post Brexit.

We note, however, that the Bill is intended to provide for all reciprocal healthcare arrangements in the future, even though we still do not know—even at this late stage, two and a half years after the referendum—whether a satisfactory Brexit deal will be approved by the UK Parliament. Given the possibility of a no deal scenario, where the UK crashes out of the EU and potentially enters a period of unprecedented uncertainty, we are extremely concerned.

We understand and support the Government’s preferred policy position with regard to future reciprocal healthcare agreements, where the intention is to seek a wider agreement with the EU that covers state pensioners retiring to the EU or UK and allows for continued participation in the European health insurance card scheme, together with planned medical treatment. We want to ensure, however, that appropriate safeguards are in place with regard to costs, not least because the Bill provides the authority for the Secretary of State not only to facilitate a continuation of existing arrangements, but to enter into any number of bilateral agreements with individual member states, with no provision for parliamentary scrutiny.

We also note that the Bill provides the authority to strengthen existing reciprocal healthcare agreements with countries outside the EU, or to implement new ones with countries across the globe, in line with the Government’s aspiration to develop trading arrangements with countries beyond the EU. There is, therefore, the potential for the establishment of multiple complex agreements.

As it is not possible to know the detail of those agreements in advance, we cannot assess their likely cost implications. We therefore believe that the Government’s impact assessment is woefully inadequate in that regard. The assessment suggests that the cost of establishing a future reciprocal healthcare arrangement would be £630 million per year, which is the same as the current agreement and takes no account of inflation or future medical developments. The impact assessment’s suggestion that costs might actually be less than those we already incur is not credible.

We will be in uncharted waters, facing the prospect of the necessity to negotiate multiple agreements, some of which may be complex. As the former Secretary of State said,

“It is perfectly possible to agree the continuation of reciprocal healthcare rights as they currently exist, but it is not possible to predict the outcome of the negotiations.”

We agree that it is impossible to provide reliable estimations of likely costs in advance. We are therefore not prepared to give the Government carte blanche.

New clause 1 would provide a sensible requirement for the Government to report back to Parliament on an annual basis. Subsection 2(a) would require the Government to provide details of all payments made by the UK Government for healthcare provided outside the UK to British citizens. Subsection 2(b) would stipulate a requirement to provide details of all payments received by the UK Government in reimbursement of healthcare provided by the UK to all non-British citizens. Subsections (c) and (d) are straightforward and would require details of the numbers of citizens treated under reciprocal arrangements. Subsection 2(e) would write into law a requirement to report on all outstanding payments owed to or by the UK Government.

The Bill provides an opportunity to monitor efficiency in this area and may provide an incentive to address the concerns raised by the Public Accounts Committee in its 2017 report, “NHS treatment for overseas patients”. It stated,

“the NHS has been recovering much less than it should”,

and,

“The systems for cost recovery appear chaotic.”

That is not good enough and we would not want to see that poor level of performance replicated as a result of any new reciprocal agreements.

Currently, the Public Accounts Committee reports that there is no evidence that EU reciprocal health arrangements are being abused. However, there is an increased risk of poor performance on collection targets if there are multiple future arrangements with differential terms. Subsection 2(e) will enable ongoing parliamentary scrutiny of performance levels. While respecting that urgent medical care is provided to any patient who needs it, the NHS and the Department of Health and Social Care must always ensure that money due to the NHS is recovered. We need a system that is fair to taxpayers and to patients who are entitled to free care either by virtue of being a British citizen or under a reciprocal agreement.

It is clear that, even under current arrangements, the collection of moneys owed for healthcare provided to foreign nationals, together with the administration of existing reciprocal healthcare agreements, is an onerous task for hospital trusts. As we leave the EU, it might be necessary for the UK to enter into multiple complex arrangements on a bilateral basis. Indeed, the Bill gives powers to the Secretary of State to enter into any number of agreements, which would introduce additional considerable financial burdens on hospital trusts whose duty it will be to administer the collection of charges for NHS services provided to foreign nationals who retire to the UK or who visit the UK under future reciprocal arrangements. It is likely to be a more onerous process as a series of differential arrangements might be required. The BMA and the Royal College of Paediatrics both agree that, should it be necessary to establish bilateral reciprocal arrangements with EU nations, significant additional costs would fall on the NHS.

Subsection 2(f) would introduce a requirement for the Government to report the detail of all costs incurred by hospital trusts in the pursuance of that duty. Cuts to real-terms NHS funding since 2010, together with increased demand, have pushed many NHS hospital trusts into deficit positions. The NHS is underfunded and understaffed, and hospitals face all-year-round crises. It is therefore imperative that hospital trusts are not required to shoulder additional financial burdens because of the costs of administering the collection of charges. It is absolutely essential that all agreements reached within the remit of the Bill do not direct funds for the treatment of patients to administration.

Ordered, That the debate be now adjourned.—(Wendy Morton.)

Healthcare (International Arrangements) Bill (First sitting)

Stephen Hammond Excerpts

Committee Debate: 1st sitting: House of Commons
Tuesday 27th November 2018 Public Bill Committees

[The Chair]

Q We will now hear evidence from the Academy of Medical Royal Colleges and the British Medical Association.

I remind hon. Members that questions should be limited to matters within the scope of the Bill, and that we must stick to the timings in the programme motion that the Committee agreed for this session. We have until 10.25 am. I hope, because the Minister has to be on his feet on the Floor of the House immediately after this, to cut a couple of minutes off the session to enable him to carry out his duties.

Are there any relevant interests to declare? No. Will the witnesses introduce themselves?

Mr Henderson: Thank you. I am Alastair Henderson, the chief executive of the Academy of Medical Royal Colleges, which is the umbrella body for all the different medical royal colleges and faculties in the UK and Ireland. We represent the range of specialties, particularly on training, education and standards matters.

Raj Jethwa: I am Raj Jethwa, director of policy at the British Medical Association, which is the trade union and professional association for doctors in the UK.

[The Minister for Health (Stephen Hammond)]

Q Good morning, gentlemen. Thank you for coming to give evidence to us this morning. Mr Henderson, in your evidence to the House of Lords European Union Committee, you noted that you want to see the current arrangements preserved. Could you just say how you think the current regulations for reciprocal healthcare work and why they are so satisfactory?

Mr Henderson: Yes, certainly. I think that the feeling of clinicians and health organisations, and also of patients, is that the current regulations work well because they are simple, well understood, easy to operate and pretty well universal in their coverage. We have a good system at the moment that is effective and easy to operate, and going forward we are looking for something that repeats or replicates that as closely as possible.

[Stephen Hammond]

Q In your evidence to the Lords Select Committee, you stated that pretty clearly as well. The Bill obviously aims to replicate and continue the current arrangements. I assume that, given your support for the regulatory system, you think that this is a sensible way for the Government to proceed.

Mr Henderson: Yes, I do; we are pleased to see that. I suppose our position is that, overall, the best and easiest thing would probably be for reciprocal healthcare agreements to be covered in an overall agreement. That seems to me to be the best thing. If we are not in the position of having an overall agreement, the Bill, which puts in these complementary arrangements, seems to be exactly the right thing. We are very supportive of it and are pleased to see that there.

[Stephen Hammond]

Q This is my final question to you, Mr Henderson. In your evidence to the Lords Select Committee, you also made the point about costs and administrative burdens. As I understand it, if a new system were needed or if a no-deal scenario unfortunately arose—that is not the Government’s intention—the costs or administrative burden would be a change in coding, rather than any other major administrative burden. Is that your understanding as well, in terms of cost recovery?

Mr Henderson: In terms of the overall cost, that may well be the position. It is not known what the arrangements for cost recovery would be. Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive. If all people in this country from the European Union or European economic area have to be charged, what would be the implications for NHS organisations and clinicians?

It is important to say that doctors have had a consistent anxiety about becoming involved in being responsible for either immigration rules or charging rules, which would potentially have a quite adverse effect on the doctor-patient relationship. I think it is really important that whatever arrangements come in are as seamless and as simple as possible, so that they do not take people away from clinical duties or get in the way of delivering care.

[Stephen Hammond]

Q Thank you.

Mr Jethwa, good morning. I noticed in your written brief that the BMA stated that the Government should undertake every effort to retain the current model of reciprocal healthcare. My first question is the same as that to Mr Henderson: can you state why you think the current system works so well?

Raj Jethwa: For exactly the same reasons my colleague sets out: the arrangements are wide-ranging, secure and simple. They give security and clarity and are well established. Our view is that the best possible arrangement is for those arrangements to continue. If they cannot, the arrangements that come in their place should mirror them as far as possible.

[Stephen Hammond]

Q Given that, and given that that is the intention of the Bill, do you think that the Government are taking the right approach to ensuring that they put those arrangements in place and that the legislation has the flexibility to cover both what we hope for, which is an achievable deal, and a no-deal situation?

Raj Jethwa: We largely welcome the Bill for exactly the intention behind it, but because the detail in it is limited we have some concerns about exactly the clarity going forward that the Bill allows for. We support the broad intentions behind the Bill, but we would like to see more detail about exactly how the arrangements will operate in practice, particularly the scrutiny arrangements to ensure there is clarity and transparency in what the arrangements negotiated and facilitated through the Bill would look like.

[Stephen Hammond]

Q In terms of the security arrangements, do you mean security of data?

Raj Jethwa: No, I beg your pardon. We do have concerns about security, but I meant clarity, from the perspective of patients understanding and being secure in themselves about what the arrangements would mean.

[Stephen Hammond]

Thank you.

--- Later in debate ---

[Justin Madders]

Q I have one more question to both of you—I am not sure if either of you will know the answer. Some of the reciprocal arrangements we have at the moment are based on the actual cost expended and some are based on an average—Estonia, Denmark, Finland, Hungary, Malta and Norway. I am not clear why that is the case. Is there some sort of historical issue? If either of you can shed any light on that, that would be extremely helpful. One of you is shaking your head.

Raj Jethwa: I do not know that, but again we are happy to look into that and to come back to you if we find out that somebody back home does know the answer. I am not sure that I know.

Mr Henderson: It is probably lost in the mists of various previous agreements.

[Stephen Hammond]

Q Can I come back on the data point that you both commented on? Clause 4 deals directly with that and provides the usual protections in terms of data. I heard Mr Henderson’s point, and it is important that there needs to be a flow of data, although that needs to be secure. Are you happy that the protections in the Bill at the moment are the normal and adequate protections?

Raj Jethwa: One of the concerns we have is the reference to the authorised person and who could fit into that category. Without seeing more detail about what the arrangements will look like in the future, we do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly what process will be used to, for example, recoup the money or make payments, it is hard to know exactly what those arrangements would look like and on what basis information would be shared. We do have concerns about the authorised person aspect of the Bill, and we need to ensure that we have greater understanding about exactly who would be an authorised person, beyond that list of specific bodies and individuals who are named in the Bill at the moment.

[The Chair]

Does the Committee have any more questions? No. I thank the witnesses for helping the Committee with its deliberations, and call the next witness.

Examination of Witness

Alisa Dolgova gave evidence.

[The Chair]

Q The next evidence is from the Association of British Insurers. Good morning. Would you please introduce yourself?

Alisa Dolgova: Hi. I am Alisa Dolgova. I am the manager looking after Brexit at the Association of British Insurers. We are a membership organisation representing more than 250 insurance and long-term savings firms in the UK, ranging across general, life and reinsurance companies.

[Stephen Hammond]

Q Good morning, and thank you for coming to give evidence this morning. Could you set out the advantages of the EHIC scheme as the ABI sees them?

Alisa Dolgova: I agree with those who gave evidence before me, in that the advantage of the EHIC is that it is a simple, easy-to-understand system. From an insurance perspective, the EHIC covers the medical treatment of UK nationals travelling through one of the covered countries, in the same way as local nationals would be covered in terms of state provision of healthcare. The insurance then covers anything that is not covered by EHIC, meaning things that are not covered by the state healthcare system—some countries have a greater tradition of state healthcare than others—but also things such as repatriation. The advantage of the current system continuing for customers is mainly that it is a system that is well understood, and there is a minimum that is covered for everybody, irrespective of whether they have travel insurance.

[Stephen Hammond]

Q Specifically on travel insurance, if reciprocal arrangements were not in place, what would be the implications in terms of cost, and are there any other potential implications that we should understand?

Alisa Dolgova: If EHIC were not in place, those costs would be covered by the person’s travel insurance, if they have insurance in place. That means that costs that are currently covered by EHIC would be borne by the insurer. I think £156 million is currently covered by EHIC, so part of that would be covered by the insurer, and that would have an impact on the claims costs for insurance companies—costs that currently are not there. That might have an impact on the premiums that insurers charge their customers.

[Stephen Hammond]

Q Have you made any estimate of what the increase in premiums would be if reciprocal arrangements were not in place?

Alisa Dolgova: That is difficult. Insurers do not know what the impact is going to be, because currently they do not have the data on where the policyholders travel to. By far the most common type of travel policy that is bought in the market is a multi-year insurance policy, which covers an individual who can travel anywhere in the EU—or the rest of the world, for that matter. Currently, because part of that is covered by EHIC, insurers do not have the breakdown, and it is therefore difficult to give a number for what might happen.

[Stephen Hammond]

Q Do you have some indication of what the typical current premiums are for people with complex and acute conditions who travel to Europe, and what the premium increase would be if reciprocal arrangements were not in place?

Alisa Dolgova: Generally speaking, premiums will be higher for two reasons: first, if the chance of the person claiming is higher, and secondly, if the volume of payout is likely to be higher—so, if someone has a condition that is particularly expensive to treat. That is why health is one of the risk factors that may increase premiums. Again, it is quite difficult to say what the difference in the potential increase would be between those who have existing conditions and those who are in good health, because it basically depends on where that group of people is likely to travel to, in terms of how expensive healthcare is in that country. For example, if someone travels to the US, that is a lot more expensive than if they were to travel to some other destinations. I would just say that if you look at countries where you do not have EHIC or reciprocal arrangements, insurance policies are available but it may require a bit more effort to locate the right product for the right individual. We are working with the Financial Conduct Authority, Macmillan and other organisations on that.

[Stephen Hammond]

Q I want to ask you broadly the same set of questions, but specifically with regard to health insurance and what the implications would be if reciprocal arrangements were not in place for UK citizens travelling to the EU.

Alisa Dolgova: Most private medical insurance policies in the UK are generally designed to cover treatment within the UK. It is relatively rare for the policies to also cover healthcare while you are travelling.

[Stephen Hammond]

Q If reciprocal arrangements were not in place, you would have to have extra healthcare insurance to cover eventualities abroad and in the EU.

Alisa Dolgova: Yes. It may vary depending on the type of policy, but generally speaking that is the most common situation.

[Stephen Hammond]

Q Have you given any thought as to what the cost implications would be if you had to put those arrangements in place?

Alisa Dolgova: For health insurance?

[Stephen Hammond]

Yes, for health specifically.

Alisa Dolgova: The implications for health insurance are a lot less than for travel insurance. Apart from that, health insurance would primarily be affected in the same way as any other insurance in terms of transferring data across borders. I am not sure there is likely to be a significant impact on health insurance if the reciprocal healthcare arrangements are not in place.

[Stephen Hammond]

Q Given what we have just said and some of the implications for not having reciprocal arrangements in place, can I assume that in principle the ABI thinks that the Government are acting in the correct way to put in place reciprocal arrangements, or arrangements to make reciprocal arrangements?

Alisa Dolgova: We are supportive of the Bill and giving the Government the powers they need to implement reciprocal healthcare arrangements. From the insurers’ perspective, the most important thing for us is to know as early as possible, whatever the outcome, so that insurers can plan for any changes and so that we can let our customers know what the impact is likely to be.

[Stephen Hammond]

So, the sooner the Bill gets Royal Assent, the happier you will be.

[Justin Madders]

Q On the cost point, I think some evidence was given to the House of Lords Committee that in a no deal you expected premiums to increase by between 5% and 10%. Does that sound like a familiar figure?

Alisa Dolgova: My colleague Hugh Savill gave evidence to the House of Lords, where he stated that there is likely to be an increase of between 10% and 20%. To be honest, we do not really know, because it very much depends on the particular insurer, who it insures and where that specific group of people travels to.

--- Later in debate ---

[The Chair]

Q We will now hear oral evidence from Kidney Care UK. Could you introduce yourself, please?

Fiona Loud: My name is Fiona Loud, and I am the policy director for Kidney Care UK. We have been around for over 40 years and were formerly known as the British Kidney Patient Association. We are the national kidney patient support charity, so we give emotional, financial and practical help to patients and their families who are affected by kidney disease, but particularly kidney failure.

[Stephen Hammond]

Q Good morning and thank you for coming. I am particularly keen to hear evidence from you about how the current reciprocal arrangements work for patients with high needs and complex arrangements. It would be very helpful to hear how you think the current arrangements work.

Fiona Loud: At the moment, 29,000 people in the UK are dependent on dialysis. That is three times a week, about five hours at a time, and those people cannot miss a session, because those sessions maintain their life. If a person is on dialysis and wishes to travel—anywhere in the world, but let us talk about the EU here—whether to meet family, to have a holiday, or to work, they need to be able to pre-book a slot or slots at a dialysis unit that is convenient to the place they are travelling to. At the moment, the EHIC card either covers it completely or, in countries where there is a co-payment because local residents make a co-payment, it covers the bulk of your care. Many patients tend to go to places such as Spain and France, and some go to Italy, because they are holiday-type destinations. It works for them because they get the EHIC, are able to get their life-maintaining treatment and have the opportunity, for themselves and their families, for a much-needed break. That is an example of one of the main reasons people might use that.

So it works well at the moment. It is not completely perfect because sometimes units that were public become private and it may occasionally happen that someone has booked a holiday a long way in advance. But, in general terms, it means that people are able to go away with the confidence that they will be able to be supported and receive the treatment they need.

[Stephen Hammond]

Q You will have heard the evidence we have just taken from ABI. I was particularly keen to understand the variations in insurance and exclusions that might currently exist where there are high needs and complex conditions. Could you set out for the Committee the experience of Kidney Care UK?

Fiona Loud: For people with a pre-existing condition, such as kidney failure, we always advise that they take out insurance in addition to having a current EHIC card, because there will be situations in which they may need to cancel their travel at very short notice due to illness. What we regularly hear from patients—this is probably one of the most common questions asked on our closed social media forums, especially at holiday time—is, “Where do I book? Where do I get insurance from? Where do I get the best deal?” My understanding is that some people go to specialist insurers to get their cover—they will be those that we tend to recommend to people because they are much more likely to understand and to be able to support these complex conditions. Whether everyone gets insurance, I honestly do not know. Some people will say that it is so expensive that they cannot afford it, and that could put them off travelling. Other people will say that they have incredibly cheap deals, and I do wonder whether those would actually cover the situation of someone really needing care.

Let me give you a recent example of someone who booked a holiday a year in advance, not in the EU but further away. They took out specialist travel insurance and during that time their transplant failed, which meant that they became dependent on dialysis, were particular ill and had to cancel the holiday for them and all their family. They were able to get all their money back because they had given a clear declaration and that had been accepted. That is how it should work, and it was some comfort to them in what was not a very good situation.

We have people who are taking the option to travel now because they have no idea what will happen after 29 March. For them, the ability to travel with confidence—I think there is something in the Bill about people being able to travel with confidence—is something they can do now, and they are not confident yet that they will be able to do that after 29 March.

[Stephen Hammond]

Q The intention of the Bill is to provide that confidence, so may I ask whether you support that intention in principle?

Fiona Loud: We understand the reason for it and we support its intentions. You may have seen some of our comments: we want more assurance, some more detail and some things about contingency as well but, yes, we have been hoping for some time that something could be put in place to set this process in motion.

[Stephen Hammond]

Q I know that you and my colleague, the noble Lord O’Shaughnessy, have had a discussion. Could you tell this Committee what the contingency issues you refer to are?

Fiona Loud: The contingency issues would be for people who have holidays already booked for after 29 March. There are people who have already done that and, because their EHIC card has a date of after 29 March—the cards will go on for many years afterwards, as we all know; they are issued for five or 10-year chunks—they imagine that they can go away and receive their dialysis. What happens in the case of no deal, where holidays are booked on that presumption? Will there be cover?

The second question will be about emergency cover. I have just given an example of somebody who was fine when they booked the holiday but who now may not be fine, because people’s health state can change. Generally speaking, holidays are booked in advance. It is basically about looking at what the immediate arrangements would be and to make sure that no citizens are caught in the gap of assuming they have cover and somehow not realising that things have changed. There is an awful lot about Brexit at the moment and this is a very specific detail in a much noisier environment. Those are the people who might be caught out and whom we are concerned about.

[Stephen Hammond]

Q Finally, without putting reciprocal arrangements in place, as this Bill intends to give the Government the powers to do, presumably it would make it more or less impossible for your sufferers to travel.

Fiona Loud: Yes, it is our conclusion that it would be very hard. It is worth mentioning that at the moment it is generally easier to obtain dialysis at a unit away from your home in Europe than it is in the UK, because we have a heavily pressed NHS. Trying to get capacity in other units is possible with a lot of planning, but if you want to travel for a funeral or for something at short notice, it becomes very difficult to go away for more than one or two days in between dialysis sessions. NHS staff will help and do their very best, but it is easier to go away for two weeks in Europe and take a break in that way than it is to get two weeks in a UK unit, unfortunately.

[Justin Madders]

Q It is alarming to hear about some of your members seeing the expiry date on their EHIC card and assuming that carries—

Fiona Loud: I have heard it as a comment.

Oral Answers to Questions

Stephen Hammond Excerpts

Tuesday 27th November 2018 Commons Chamber

[Gill Furniss (Sheffield, Brightside and Hillsborough) (Lab)]

11. What the timetable is for the NHS to meet its target of seeing 95 per cent. of A&E patients within four hours.

[The Minister for Health (Stephen Hammond)]

rose—

[Hon. Members]

Hear, hear.

[Stephen Hammond]

Thank you very much.

The Government’s mandate to NHS England for 2018-19 clearly sets out A&E performance, and it will see performance improve. So far this year 18 million more attendances have been seen within the standard, and the NHS is introducing more options for urgent patient care. Of course, as the hon. Lady will know, the extra £20 billion a year that is going into the health service will ensure that more patients are seen in A&E.

[Gill Furniss]

According to a recent poll of doctors by the Royal College of Physicians, almost six in 10 doctors report feeling very worried or worried about the ability of their hospital to deliver safe patient care over the winter period. What is the Secretary of State or the Minister doing to help our hard-working NHS staff provide the best possible care for patients?

[Stephen Hammond]

The NHS faces a challenging winter, but it has been planning throughout the year for this winter. It has been supported by an extra £420 million to redevelop A&Es, improve emergency care and help patients get home quicker. Those plans, more directly, include reducing the extended hospital stays we saw last year, increasing access to GP appointments and increasing the volume of cases that can be treated by emergency dentists.

[Jeremy Lefroy (Stafford) (Con)]

Last week I visited the A&E at County Hospital, Stafford, which achieved 95.8% on the four-hour target in the week beginning 22 October and has consistently achieved over 95% for the past few months. Will the Minister come to Stafford to see what a great job it is doing, and to see how we can use County Hospital more and bring more services into it?

[Stephen Hammond]

My hon. Friend has always been an assiduous advocate for his constituents and their concerns. He is right to make that case today. He is also right that, thanks to the hard-working staff in his hospital and across the country, the four-hour target continues to be met for nearly nine out of 10 patients. I will be delighted to come to Stafford.

[Mr Gregory Campbell (East Londonderry) (DUP)]

Does the Minister agree that what considerably exacerbates A&E waiting times at the weekend is when, on occasion, our highly valued NHS staff come under attack? We should have a zero-tolerance approach to any attacks on those highly valued members of staff.

[Stephen Hammond]

The hon. Gentleman is absolutely right. There can be no statement other than complete condemnation of attacks. We have changed the law, and it came into force earlier this month.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I welcome the Minister to his place. Although he is new, he will know that the A&E waiting target is not a recent initiative. It is a key part of the NHS constitution, but it has not been met for over three years. If he cannot make a commitment today on when the target will be met, will he accept that, at least for this winter under this Government, the NHS will once again be underfunded?

[Stephen Hammond]

As I said in my earlier answer, we recognise that this winter will be challenging. We recognise that the A&E performance standard is not currently being met, but, as the hon. Gentleman knows, we are investing an extra £20 billion in the NHS to ensure that the standards are met. The NHS will use that investment to treat 250,000 more patients and to improve A&E performance across the country.

[Mr Laurence Robertson (Tewkesbury) (Con)]

12. What recent estimate he has made of the number of people entering nursing higher education; and if he will make a statement.

[The Minister for Health (Stephen Hammond)]

The latest UCAS data from October 2018 show that demand for nursing courses remains strong, with applications exceeding the number of places available this year. The number of acceptances to nursing and midwifery courses in 2018 is consistent with earlier years at approximately 22,000. The final data will be published in December 2018.

[Mr Robertson]

Does the Minister accept that student nurses face pressures from the long hours they have to study and the long hours they spend on placements, which makes it very difficult for them also to carry out paid work? Is there any more the Government can do to support student nurses financially as they go through college?

[Stephen Hammond]

As my right hon. Friend the Secretary of State said earlier, we recognise the vital role that nurses play, and we are determined to support them. We are determined to have more nurses in training and more nurses treating patients. At the moment, a student on the loan system typically achieves 25% more in their pocket than they would have had on the bursary, but the Government recognise that there are still pressures, which is why we have the learning support fund, the exceptional hardship fund and support for mature students.

[Karin Smyth (Bristol South) (Lab)]

I talk to local employers who desperately want to support nursing apprenticeships as an alternative to the higher education route, but the uptake of apprenticeships is very disappointing. The levy can be used only for training costs, and trusts have been asked to plug the shortfall in funding for wider capacity building and to cover the 20% of time for which apprentices have to go to off-the-job training. Does the Department recognise this problem? What is being done to address it?

[Stephen Hammond]

The hon. Lady is right that the number of trusts that currently use the levy is not as high as it should be. We hope that all will do so. It continues to be a priority for us to broaden the routes into nursing. We will address in the long-term plan the specific matter about which the hon. Lady talks.

[Sandy Martin (Ipswich) (Lab)]

13. What estimate he has made of the level of workforce vacancies in the NHS.

[The Minister for Health (Stephen Hammond)]

The NHS employs more staff now than at any other time in its 70-year history. It has recruited 18,200 more doctors and 11,000 more nurses are in our wards since 2010. NHS Improvement publishes vacancy rates using provider information. As the hon. Gentleman will know, the record investment that the Government are providing will ensure that the number of vacancies reduces.

[Sandy Martin]

With Suffolk’s only psychiatric intensive care unit having been closed down from April to October this year because of lack of staff, and with a two-to-three-month waiting list for counselling, does the Minister not understand that his reassurances do not bear much relationship to people’s lived experience?

[Stephen Hammond]

I am aware that the local trust has had a number of problems and that there were a number of bed closures—both temporary and permanent —earlier this year. The trust is closely monitoring how those closures are affecting services and patients. The hon. Gentleman will know that beds are being reopened—five beds have been reopened recently—and that there is a plan to put in place the staffing so that the whole ward can reopen in the near future.

[Jeff Smith (Manchester, Withington) (Lab)]

19. The Department’s own statistics show that more than 23,000 mental health staff left the workforce last year. That is an eighth of the total mental health workforce. How can we possibly get parity for mental health when more than one in 10 posts are vacant and staff are leaving?

[Stephen Hammond]

The hon. Gentleman will know that the Government are committed to having more nurses and more staff in training, that we are putting in place extra measures to ensure that specialities are supported through that training process and that the extra £20 billion in the long-term plan will ensure that there are the staff and nurses needed to fill those vacancies.

[Mr Speaker]

We are running over time, so very briefly, please, Dr Philippa Whitford.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Last week, the Secretary of State claimed that the number of GPs in England had increased by more than 1,000 from June to September, when the data actually showed a drop of 10 full-time equivalent doctors. In 2015, his predecessor promised an extra 5,000 GPs by 2020, but so far there are 1,000 fewer, so how does the Secretary of State plan to meet that target in just the next year?

[Stephen Hammond]

As the hon. Lady knows from a previous answer, we are committed to making sure that 5,000 extra GP places are available. There are more GPs in training than before, and 52,000 nurses are now in training. We will ensure that the number of GPs in training meets the target.

[Dr Whitford]

I find that hard to believe when there is only a year left of the five-year promise.

Scotland has 30% more GPs per head of population, but last year we lost 14% of our EU doctors, and England lost 19%. Does the Secretary of State recognise that the hostile language of the Brexit debate is making the UK seem unwelcoming and making it harder for all four UK health services to recruit?

[Stephen Hammond]

There are currently more doctors from the EU treating patients in the national health service than on referendum day. We are committed to the 5,000 target.

--- Later in debate ---

[Mr Philip Dunne (Ludlow) (Con)]

T5. Does the Minister agree that last week’s success by Shrewsbury and Telford Hospital NHS Trust management in securing sufficient qualified clinicians to keep the A&E and Telford’s Princess Royal Hospital open 24/7, rather than closing it overnight, is a positive first step on the journey out of special measures?

[The Minister for Health (Stephen Hammond)]

My hon. Friend is right. I welcome the trust’s recent announcement that it now has enough middle-grade doctors and nurses to keep the Prince Royal Hospital’s A&E open 24/7. It has been receiving some excellent support from NHS Improvement, and I hope that it will achieve similar success in improving the quality of care as that support continues.

[Lisa Nandy (Wigan) (Lab)]

T3. It has been eight months since the child abuse inquiry that the Prime Minister set up recommended urgently that compensation be paid to the survivors of the child migration programmes. The Prime Minister said that she would act; she did not. The Minister said that she would respond; she has not. Twenty-two people have died since that report was published. How can we believe a single word said by the Government today, when so many promises to people who deserve better have been broken? Where is the response to this report?

--- Later in debate ---

[John Woodcock (Barrow and Furness) (Ind)]

Is not the Secretary of State alarmed that fake psychiatrist Zholia Alemi was revalidated in 2013 under the supposedly strengthened revalidation process? Why did the Government not act on the findings of the Sir Keith Pearson report in January last year, which pointed out this exact weakness in the system?

[Stephen Hammond]

The hon. Gentleman raised that matter with me last week. He knows that the Government take it very seriously and that we are asking the General Medical Council for an immediate review of that case, but I am happy to meet him to discuss it further.

[Robert Courts (Witney) (Con)]

I welcome the new early diagnosis ambition for cancer, but does the Minister agree that for the people of West Oxfordshire, this is about delivery and having the people available to implement the strategy that he has worked so hard to produce?

--- Later in debate ---

[Kevin Foster (Torbay) (Con)]

My constituent Alice Sloman died during what should have been a routine MRI scan, following complications with the general anaesthetic that had been administered to her. Will the Minister agree to meet me and Alice’s parents to discuss the possibility of people, particularly those with existing conditions, having routine heart checks before such procedures?

[Stephen Hammond]

The Government express sincere condolences to my hon. Friend’s constituents. I would of course be happy to meet him and his constituents.

Blood Cancer

Stephen Hammond Excerpts

Friday 23rd November 2018 Commons Chamber

[The Minister for Health (Stephen Hammond)]

It is a great pleasure to be here.

Blood cancer is the third biggest cancer killer in the UK and nearly 250,000 people are living with it today. Although cancer is relatively rare in younger people, blood cancers are the most common cancer in under-30s, so this is an important debate, despite the fact that the Chamber is not packed.

I congratulate my hon. Friend the Member for Crawley (Henry Smith) on securing the debate and thank him for his contribution as chair of the all-party parliamentary group. As he rightly said, this is cross-party, so I also congratulate the hon. Member for Alyn and Deeside (Mark Tami), who I understand is the deputy chairman and had an Adjournment debate yesterday.

Cancer is a Government priority. Survival rates have improved since 2010. About 7,000 people are today alive who would not be if mortality rates had remained at those levels. This must continue. We are transforming cancer services across England and taking an “all cancer” approach to improvements. We want our cancer services to be the best in the world. We want all cancer patients to have access to the treatment and the care that will allow for the best possible chance of a successful clinical outcome.

This is really important. That is why the Prime Minister last month announced a package of measures that would see 75% of all cancers detected at an early stage by 2028. Currently, just half of all cases are detected at an early stage. The new 75% target applies to all cancers, not just the 10 currently in the public health outcomes framework early diagnosis metric. We are keen to work with charities representing sufferers of cancers not currently included in that metric on how best to measure progress towards the 75% target.

We are reforming screening, and investing in technology and research to improve diagnosis and care. That will form part of the long-term plan for the NHS and forms part of how we will achieve our ambition of seeing 55,000 more people surviving cancer for five years in England after 2028.

In December 2016, the Government invested £200 million to encourage earlier diagnosis, improve the care for those living with cancer and ensure that cancer patients get the right care for them. Early diagnosis of blood cancers can sometimes be difficult, as my hon. Friend said. Symptoms can be vague and often misdiagnosed, delaying treatment.

[Mark Tami]

That is a particular problem with children. Sometimes these things are dismissed as growing pains or bruising—just kids being kids.

[Stephen Hammond]

The hon. Gentleman makes an important point. That is essentially why the Government put that money in—to ensure that earlier diagnosis could be enabled. He makes a valid point. It is clear that sometimes patients see GPs multiple times before getting that referral. The money put in to ensure that earlier diagnosis will hopefully ensure that that referral happens more quickly.

In addition to helpful earlier National Institute for Health and Care Excellence guidelines, NHS England has been testing innovative ways of diagnosing cancer earlier, with sites piloting multidisciplinary diagnostic centres for patients with vague or non-specific symptoms, such as those common in blood cancers. In her announcement, the Prime Minister pledged to roll out these rapid diagnosis centres nationally to offer all patients a range of tests on the same day with rapid access to results.

My hon. Friend the Member for Crawley mentioned CAR-T cell therapy. He will know that earlier diagnosis must mean earlier treatment and there have been some exciting developments in that area for people under 25 with leukaemia. Last week, NICE recommended the pioneering cancer treatment CAR-T cell therapy for young people with relapsed or refractory B-cell acute lymphoblastic leukaemia.

My hon. Friend asked about what is happening and timescales. Through the Cancer Drugs Fund, Kymriah will now be offered to people under the age of 25 who have not responded to current treatment or who have relapsed from stem cell transplants. That marks a new generation of personalised medicine with the potential to transform cancer patient care worldwide. As he knows, the work is in its early stages. We know that more personalised treatments will be game changers in cancer treatment.

My hon. Friend also talked about people who have to live with and beyond cancer. More than 300,000 people are diagnosed every year. Innovations in treatment mean that more people look forward to a life after cancer and, as survival improves, we must ensure that patients enjoy as good a quality of life as possible after treatment. We are rolling out the recovery package to every cancer patient by 2020, including of course those with blood cancer. This is a set of interventions designed to help patients and clinicians to assess a patient’s physical and emotional needs at appropriate points on the journey of recovery. It goes from diagnosis at the beginning to recovery at the end. For blood cancer patients, the recovery plan will be personalised to take account of the unique characteristics of blood cancer, which can be very different from those caused by a solid tumour, as my hon. Friend, the chair of the all-party parliamentary group, rightly recognised.

My hon. Friend asked for some comments on psychological support, which was the basis of the Adjournment debate yesterday. Many patients with a chronic blood cancer diagnosis will sadly never be cured. They will be on a regime of watch and wait, often over many years, to see if the cancer has progressed to a point where treatment needs to take place. This takes a huge psychological toll on the patient and their family. The recovery package therefore takes a holistic approach and also considers mental health needs. When patients require additional psychological support, they must have access to appropriate mental health services. Mental health is a priority for the Government, and last year we announced an additional £1.3 billion to expand the NHS mental health workforce, which will allow an extra 1 million patients to be treated by 2020-21. That will help to ensure that cancer patients can be referred promptly to any psychological support they need as part of their recovery package.

My hon. Friend mentioned including blood cancer in the cancer dashboard. Public Health England is working with NHS England on the next phase of the dashboard development, and this will be informed by the needs of key stakeholders and cancer charities. I know that the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Winchester (Steve Brine), has expressed his frustration that the dashboard is limited to the top four cancers and wants to see it expanded. NHS England and Public Health England have had clear direction from him on this, and he and the Department will be watching this with interest. I know that he will want to speak to my hon. Friend and to the all-party parliamentary group on that matter.

I hope that my hon. Friend the Member for Crawley will be reassured to hear that the Government are absolutely committed to transforming services for all cancer patients, including blood cancer patients. More people are being referred and diagnosed than ever before, and thanks to innovative treatments, more of them will survive their cancers. The cancer strategy and the progress that the Government have made in implementing its 96 recommendations provide the ideal launch pad for the long-term plan. With cancer as one of its key components over the next decade, it will enable the NHS to ensure that every cancer patient gets the emotional, psychological and physical support that they need to live well with, and beyond, cancer.

Question put and agreed to.

Nursing: Higher Education Investment

Stephen Hammond Excerpts

Wednesday 21st November 2018 Westminster Hall

[The Minister for Health (Stephen Hammond)]

It is a great pleasure to serve under your chairmanship, Mr Davies, as I make my first speech in what I regard as one of the most important ministerial roles in the Government. I thank the hon. Member for Wolverhampton South West (Eleanor Smith) for securing the debate. It has been a passionate debate that has reflected the importance that so many people—including, clearly, everybody in this Chamber—place on NHS professionals. It has recognised that high-quality education and training for nurses is fundamental to ensuring that the highest level of nursing care is given to patients. I obviously recognise that the hon. Lady, having served in the NHS for more than 40 years, has first-hand knowledge of the difference that nurses can make to individuals and families.

The hon. Lady raised several points in her speech, many of which I will address. However, she quite rightly opened by saying that we need and must have staffing that is safe for effective care. No one in the House would move from that. She asked several questions, including on bursaries, mature students and the number of people in training, which I will come to, but also made several points about the long-term plan, which it is important to talk about at the beginning.

The long-term plan will contain a chapter on NHS professionals and workforce planning, which I recognise will be the most important chapter. The hon. Lady will know that Health Education England undertook a consultation on the strategy for the workforce, which was published in draft last year. HEE also undertook a full consultation on the priorities for the health and care workforce, which concluded in the summer. The “Talk Health and Care” platform has been introduced, which the Government particularly expect to inform the work that NHS England is leading on the long-term plan.

It is also particularly important—it is potentially by accident—that the debate takes place on the day that the RCN produced a document, to which the Secretary of State and I have committed to respond. The shadow Minister is right: I deliberately took the time before the debate to meet a number of the students. I heard at first hand a number of their concerns, and I said to them—the hon. Gentleman will perhaps understand this, given his remarks about retention at the start of his speech—how important I think retention is, not only of nurses but of Ministers as well.

[Vicky Ford]

I am delighted that the Minister met the RCN and nursing students this morning. Will he confirm that hearing the voices of students themselves is absolutely vital in making decisions on the future?

[Stephen Hammond]

Of course it is important. As my hon. Friend will know, as Members, and particularly as Ministers, we get all sorts of briefings, which are very helpful and contain lots of numbers, but not real-life experience.

My hon. Friend the Member for Henley (John Howell) talked about the experience of nurses at his hospital. He made the point quite powerfully that there are several common issues that we need to address, but several other issues that are not necessarily common to every experience. It is right that we consider the issues they raise.

[Janet Daby]

One of my constituents who is a student nurse has been to see me. She is struggling with her student nursing loans. She has two children, and she was literally in tears while telling me her stories about how difficult it is for her—the Student Loans Company is demanding the money back. She is working and has children, and cannot afford to pay back those loans. Does the Minister think that situation is tenable?

[Stephen Hammond]

I will talk about that issue in more depth later, but if the hon. Lady wishes to write to me, I will look at her constituent’s case. I will point out that the learning support fund already offers a number of opportunities, including child dependants allowance, travel costs and an exceptional hardship allowance. I hope her constituent knows about and is taking advantage of those opportunities.

The hon. Member for Ellesmere Port and Neston (Justin Madders) asked whether the Government will publish an update on the impact of the reforms. That is currently being worked on with education and health organisations and stakeholders. We will look at the most appropriate way of making sure that, following receipt of the proposals by the RCN, and in the context of the long-term plan and the chapter on workforce planning, the higher education funding review takes place and feeds into that update. We will set that position out in due course—I dare say that the hon. Gentleman and I will debate it in due course as well.

My hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) described what an excellent training scheme should look like, which was very helpful and powerful. My hon. Friend’s experience as a clinician is invaluable, and hopefully my speech will address a number of the points that she raised. I listened carefully to the asks of my hon. Friend the Member for Chelmsford (Vicky Ford). Some are in my power and some are not, but she made a point about mature students, and the Government recognise that the number of mature student applications has dropped across the wider higher education sector as well as in nursing. We are working with organisations in the sector to see how we can attract more mature students and whether specific funding can be targeted more effectively towards those students via the learning support fund.

It does not really need saying that, at the national level, the Government understand how important nurses are. We are committed to making sure that the nursing workforce are properly supported and funded. In her contribution, the hon. Member for Wolverhampton South West made the point that funding to the NHS is increasing: by 2023-24, it will receive £20.5 billion a year more than it currently does, and the Government expect the long-term plan to set out a strategy for the NHS to ensure a sustainable supply of nurses, rolling that supply across the whole range of pathways. We expect NHS England to clearly set out its commitment to the nursing workforce in the long-term plan, and ensure that there is a clear way for that plan to be implemented. A number of significant interventions are already in place to boost the supply of nurses, including training more nurses, offering new routes and enhancing reward packages. As my hon. Friend the Member for Sleaford and North Hykeham pointed out, there are over 11,900 more nurses on our wards than there were in May 2010.

However, the Government, and I as the new Minister for Health, should never be complacent, so I will set out a few other things that I regard as priorities. Our priority is to get more nurses on to our wards. As has been referred to, the education funding reforms, which moved student nurse funding into the student loans system, were introduced to unlock the cap that constrained the number of pre-registration nursing training places. Those reforms allow more students to gain access to nurse degree training courses. We have announced funding for 5,000 more clinical training places to make sure that those placements can be put in place. We have also increased midwifery training places by more than 3,000 over the next four years, and in 2017, there were 22,575 acceptances—the second-largest number since nursing became a degree-only profession.

It is also important to note that the loans system gives more cash when compared with the bursary system—effectively, up to 25% more. A mature student with two children will receive up to an extra £7,500 a year. I recognise that a number of other things need to be, and should be, put in place and known about more widely. The Government have also targeted support for healthcare students on courses through the learning support fund, which provides additional non-repayable grants. Up to £1,000 is available for eligible students in childcare allowances and hardship funding provisions. None of that, of course, was available under the bursary scheme. More nurses are in training, and the Government are working with Health Education England and the university sector to ensure that students continue to apply for nursing courses up to the end of clearing this year. I am pleased to say that, this year, we have seen a 6% increase in the number of 18-year-olds applying for courses and being accepted.

As an hon. Friend pointed out, there continues to be strong demand, specifically for younger people. I have made the point that we need to address the issues faced by more mature students who wish to enter, or re-enter, the profession. That should be a key priority in the long-term plan. The Government, and I as the new Minister, recognise that we need to do much more to continue to encourage people to apply for nursing courses, particularly more mature students. Therefore, my officials are actively engaging with the Royal College of Nursing, the Council of Deans of Health, and Universities UK—all of those organisations have a role to play. The Government will be consulting on the detailed proposals on future funding for higher education that the RCN has put forward today. I said this earlier, but I want to recommit and make it clear that we regard those as serious proposals, and will be writing to the RCN to engage on those proposals. We will start that work straightaway.

[Paul Blomfield]

I appreciate that the Minister is new to his post, and that it may be more appropriate for him to write to me in response to this point. I wonder whether he will address the attrition rates question asked by my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders). There is a relationship between the falling number of applications, the funding regime, and the higher attrition rates. Does the Minister have numbers on that, and what consideration are the Government giving to it?

[Stephen Hammond]

Inspiration has just reached me. As the hon. Gentleman will know, Health Education England recently published a report on attrition rates on nursing courses—I made the point earlier that the rate of attrition among all people applying for university places has gone down. However, I will write to the hon. Gentleman. The report published by Health Education England describes how attrition rates on those courses have fallen considerably over the past few years, but I will write to him to be absolutely clear. He may then choose to make that letter available.

[Dr Caroline Johnson]

“The nursing workforce” report, which was published by the Select Committee on Health in January, identified that 30% of students due to complete in 2015-16 or 2016-17 did not complete within that period. Significant variability between different training institutions was also identified. Will the Minister commit to looking at why some institutions have such high attrition rates compared with others?

[Stephen Hammond]

That is an extremely important point. There is not necessarily a universal reason why particular institutions have worse attrition rates than others, and that may well be key to retaining people who wish to stay in the profession.

In my last minute, I will finish on this point: NHS England, NHS Improvement and Health Education England are all working with trusts on a range of recruitment, retention and return-to-practice programmes. Some of those have met with some success: NHS Improvement’s retention programme works directly with trusts to support improvements in retention. However, I want to make clear that, as the newest member of the Government and of the Department, I regard the retention of our NHS professionals as a priority, and I am looking forward to making a contribution not only to things like the “Talk Health and Care” platform, through which there has already been positive engagement, but on this matter more generally. Retention is key, and we want to make sure nurses understand that we recognise how important they are. The long-term plan will set out a strategy to ensure a more sustainable future supply of nurses. They work incredibly hard, and it is absolutely right that this Government will commit to ensure that funding is dedicated to the supply—

Motion lapsed (Standing Order No. 10(6)).

King’s College Hospital Foundation Trust

Stephen Hammond Excerpts

Tuesday 12th December 2017 Commons Chamber

[Mr Dunne]

I think the hon. Gentleman’s critique would have a shade more credibility if he acknowledged that, before the 2015 election, the then shadow Health Secretary indicated that he wanted £5.5 billion less for the NHS than my party was offering. If we had followed that prescription, the financial position of the NHS would be far worse.

The hon. Gentleman asked about delayed transfers of care. In March, the Chancellor gave an additional £2 billion to the adult social care system, precisely targeted on reducing DTOC, and significant progress is being made in freeing up beds across the system. He also asked about NHS funding in the most recent Budget. The Chancellor awarded an additional £2.8 billion in revenue support for this year, next year and the following year, and a further £3.5 billion of capital to support programmes.

[Stephen Hammond (Wimbledon) (Con)]

As a London MP, I know that other hospitals that have faced challenging situations have put in place improvement plans and met the targets set by NHSI. If the regulator had not acted yesterday, would it not have been letting down other London hospitals and my constituents?

[Mr Dunne]

My hon. Friend is quite right. There has to be a sense of responsibility and accountability for delivering on budget deficits—if they are deficits—that have been agreed between the regulator and the trust. That is happening up and down the country, and it would be unfair on other trusts and other areas of the country if one trust was allowed to get away with its performance unchecked.