Health and Care Bill

Viscount Bridgeman Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I add my congratulations to the noble Lord, Lord Stevens. His matchless experience of healthcare has been communicated to us with a pleasantly light touch.

I rise to speak to the proposed new subsection (2A) outlined in Clause 4(2) of the Bill, to which my noble friend Lord Bethell referred. This was one of three amendments made to the Bill in another place which were accepted by the Government. The mover of this amendment was my honourable friend John Baron who was for nine years the chairman of the APPG on cancer.

The OECD has confirmed that the survival rate for cancer in the United Kingdom ranks near the bottom of the table when compared with other major economies. For some cancer types, only Poland and Ireland were below us. As we have improved our survival rates, so have other countries, and there is very little evidence of our closing the gap with a better performance, despite the considerable increase in health spending in recent decades.

In their research, my honourable friend and his committee discovered that, once a cancer is detected, the NHS performs largely as well as other comparable health services. However, where our NHS falls down is in catching cancers at their crucial early stages. The APPG campaigned, with some success, for a one-year survival rate indicator to be adopted by the NHS at local level. The advantage of adopting this yardstick was that it gave local NHS bodies the opportunity to promote initiatives which boosted early diagnosis. It also gave them the flexibility to devise their own solutions. However, the APPG uncovered the tendency of local clinical commissioning groups to focus on process targets, with funds being released against performance against them.

In recent decades, the NHS has been beset by numerous process targets, of which waiting times is a high-profile example. As a result, these yardsticks have been used at the expense of front-line measuring of the success of the treatment of, among other things, early cancer. The new subsection (2A) proposed in Clause 4(2) addresses the problem by proposing that NHS England should be required to include

“objectives for cancer treatment defined by outcomes for patients with cancer”

and that these are to have

“priority over any other objectives relating to cancer treatment.”

The objective of the proposed new subsection is clear. Process targets may have their place, but it is the simple, clinical procedures of defining outcomes for patients with cancer which will hopefully concentrate resources on early diagnosis, which is currently the Achilles heel of the NHS.

I look forward to scrutinising in Committee this new amendment, which was initiated by John Baron in another place. It is the bedrock of a key change of emphasis in cancer treatment which has, I am happy to say, been adopted in principle by Her Majesty’s Government.

Healthcare (International Arrangements) Bill

Viscount Bridgeman Excerpts

Report stage (Hansard): House of Lords
Tuesday 12th March 2019 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I am privileged to follow my noble friend Lord O’Shaughnessy, and I am sure that Peers from all sides of the House will have been impressed by the thoughtful letter which the Minister has sent to us all. In it, there are a number of concessions, which will be subject to later amendments in this debate. The insertion of a sunset clause is a valuable safeguard, as are the requirements that arrangements are limited to a public authority, and the statutory duty to report to Parliament on an annual basis. All of these are important concessions. Finally, on the Henry VIII clause, the Minister’s letter refers to removing the powers in the Bill to make regulations containing consequential amendments to primary legislation. Individual healthcare waits for nobody.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, I am grateful to the noble Baronesses, Lady Thornton and Lady Jolly, and to the noble and learned Lord, Lord Judge, the noble Lord, Lord Marks, and the noble Earl, Lord Dundee, who I am sorry could not be with us today, for giving me the opportunity to deal with the important matter of the global nature of the Bill. We have already had a good deal of debate about this during our progress on the Bill, but it is a pleasure to return to it today yet again.

It is important that the Government explain why we believe it appropriate to seek powers which are global in nature. As I mentioned in my response in Committee, the EU Home Affairs Sub-Committee of this House, which is very wise, remarked that:

“Reciprocal healthcare oils the wheel of the day-to-day lives of millions of citizens”,


and brings the,

“greatest benefit to some of the most vulnerable members of our society”.

I am grateful to noble Lords from across the House, not only in the debate today but during the progress of this Bill, who have been clear that there is widespread cross-party support for the current EU arrangements, and for providing the people who rely on these arrangements with the assurance that the Government are taking all the necessary steps to support them in these uncertain times.

We clearly all support the arrangements we have with the EU. It therefore does not seem logical to preclude the possibility of seeking new arrangements or strengthening existing ones outside the EU. Where the Government have a good policy in one place, it seems logical that we should want to extend it to others. Reciprocal healthcare agreements promote tourism and facilitate economic exchange and growth by enabling people to study, travel and work abroad without worrying about their ability to access healthcare, or the cost of doing so. As we have discussed in our debates on this issue, reciprocal healthcare arrangements are particularly important for older people, people such as me with chronic conditions, or people with disabilities, for whom access or costs can be a genuine barrier to travelling.

Reciprocal healthcare agreements enable people to travel overseas for planned treatment, which enables patient choice. One of the genuine benefits of the current EU arrangements is to enable mothers to travel to a home country to give birth close to their families and support networks. That is available only to EU citizens at the moment, not to those from other countries who live here. Our existing arrangements with the EU enable around 1,350 UK residents to receive planned treatment or maternity care in another EU member state. We do not want to be forced to limit choices only to EU countries in the future.

Reciprocal healthcare agreements can also help to support international healthcare co-operation through fostering closer working relationships between countries and states. We can be proud that the UK is a prominent voice in the global healthcare community and is a key driver in global attempts to raise standards of patient safety. We could help to further drive that agenda through developing even stronger relationships with our close partners. I have heard the concerns raised by noble Lords about the costs of these arrangements. Reciprocal healthcare agreements enable countries to reimburse one another on a fair and transparent basis. Noble Lords, particularly the noble Lord, Lord Foulkes, have queried why we cannot simply rely on waiver agreements. Fair reimbursement is the key reason why. Without this Bill, we would be restricted to waiver agreements outside the EU without a way to establish fair and transparent payment and cost-recovery mechanisms.

Agreements with other countries predate the EU and have never been limited to Europe. This is one reason why the concept of restricting the Bill to the EU does not make sense. We have agreements outside the EU now and will continue to have them in the future. The noble and learned Lord, Lord Judge, and my noble friend Lord Ribeiro raised the matter of scope—the countries which the Bill would apply to. As Clause 4 sets out, data can be shared only in accordance with the GDPR and our data protection regulations. This means that no reciprocal healthcare agreement could be reached with a country that does not meet data adequacy standards. Over and above that, as my noble friend rightly noted, this scope would be further narrowed by the need to agree reciprocal healthcare arrangements only with countries that have a compatible healthcare system. This would mean that countries such as Venezuela, raised by the noble and learned Lord, Lord Judge, would simply be out of scope for an international healthcare agreement. Safeguards built into the Bill would be in place.

I make it clear that I have heard the concerns raised at Second Reading and in Committee about the global scope of the Bill and the breadth of the delegated powers. We have taken considerable steps to address the concerns about the breadth of the powers—the root cause of the concern about the global scope. As has already been referred to, we have tabled a large package of concessions, which I worked hard to try to deliver. The first was to remove the consequential Henry VIII powers; I am taken by the terminology for this now being a “Blackwood amendment”. We have limited the ability to confer functions to public bodies. We have provided greater parliamentary scrutiny over regulations relating to data processing and greater transparency over the financial aspects of future reciprocal healthcare policy in the form of an annual report. I hope that this reassures the noble and learned Lord, Lord Judge. We have placed a statutory duty to consult the devolved Administrations where regulations make provision within devolved competence. Finally, and very significantly, we will sunset two of the three regulation-making powers at Clause 2, so that they can be exercised only for a period of five years after exit day. This final amendment means that it is not possible for the Secretary of State to set up any kind of long-term scheme to unilaterally fund mental health treatment in Arizona or hip replacements in Australia, as the DPRRC proposed. In tabling these amendments, we have limited the delegated powers and therefore the scope of what can be done under the Bill around the world. We have also provided additional parliamentary scrutiny mechanisms and greater transparency.

During the debate on Amendments 1, 2, 11, 12, 13, 27, 28 and 29, from the noble Baronesses, Lady Thornton and Lady Jolly, the noble and learned Lord, Lord Judge, and my noble friend Lord Dundee—who cannot be in his place—I have not heard any concerns raised on the fundamental principle of reciprocal healthcare in countries outside the EU. Rather, I have heard the need for reassurance that in implementing agreements with other countries we seek to appropriately cost such arrangements, protect the NHS, and ensure that those countries which we strengthen or make new agreements with have appropriate healthcare systems and are able to process data appropriately. We are firmly committed to all these principles.

When the Bill was debated in the other place, questions were raised concerning the possibility of a reciprocal agreement with Guernsey, which is something we will need to look into following EU exit. This was seen as a positive possibility of the Bill; it is just one example of how our relationships might evolve and how the Bill can offer people new opportunities which they are currently denied under our legislative framework. If the scope of the Bill is limited to matters relating only to EEA countries and Switzerland, the Government would be unable to implement a reciprocal healthcare agreement with countries such as Guernsey where we are able to reimburse one another fairly. We would also be giving up the opportunity to support people, to bring them confidence and comfort outside the EU.

As the UK considers its relationship with the rest of the world, it is appropriate to take this opportunity to consider strengthening our existing agreements while exploring possible agreements with other countries. The powers under this Bill allow us to fund healthcare overseas to support UK nationals who live in, work in, study in, want to visit or give birth in other countries, while ensuring that we also have appropriate scrutiny powers within this Bill. They also allow us to extend similar opportunities to overseas nationals to use the NHS funded by their own country, making the NHS more sustainable and fit for the future. This is what we would be giving up with these proposed amendments.

There has been much debate in this House and outside it about whether there should, in fact, be two separate Bills: one to provide for implementing agreements with EU, EEA countries and Switzerland, and the other at a later date to provide for countries outside that group. I believe that this is the intent of Amendment 4, in the name of the noble Lord, Lord Marks. That would not be an effective use of parliamentary time; it would prove a barrier to the development and implementation of policy in this area that is clearly in the interests of the people whom I have already discussed. I am also not clear how different a different implementing Bill would look, as it would simply be for the implementation of international healthcare agreements and would be rather similar, whether they are for the EU country or for a country in another part of the globe. It seems to be doing the same work twice.

With the Bill, we seek to ensure that we have an implementing mechanism for reciprocal healthcare now and into the future. While it may be appropriate in other policy areas for the Government to seek new primary powers to implement specific, individual international agreements, it is simply not the case with reciprocal healthcare agreements. These agreements are not far-reaching in nature and are very limited in subject matter: they are about reciprocal healthcare. As has already been discussed, the Government already rely on the royal prerogative to enter into these agreements with other countries. This Bill is simply a smarter implementing mechanism for these agreements.

I also have concerns that Amendment 4 risks our ability to effectively implement a future relationship with the EU. Recognising the broader benefits of reciprocal healthcare, we want a long-term relationship with the EU but, as with any area of policy, we must have flexibility as to how we negotiate with the EU and how we arrange our broader relationship with it. EU law evolves and, as we discussed in Committee, there are proposals currently before the European Parliament that would mean that elements of that model might change in the near future. This amendment would prevent the UK from implementing that evolved arrangement even if that was the desired negotiating position of the UK. If we put this on the face of the Bill, we would have no flexibility on how we would do that, including agreements already concluded with Switzerland and the EEA and EFTA states. The noble Lord himself acknowledges in his amendment that flexibility is needed, but through this amendment that flexibility would be difficult to apply in practice.

In relation to all the amendments in this group I firmly believe that, in pursuing future reciprocal healthcare policy with close partners outside the EEA and Switzerland, the Government are providing hope and opportunity to people. Our colleagues and friends in the other place overwhelmingly supported this endeavour. We have introduced significant restrictions on what this Bill can do globally. However, I regret that these amendments would prevent us from being able to look to the future and embrace an opportunity for EU exit. It would be a great shame to miss that opportunity.

I recognise the valuable contributions from many Members of the House on enhancing and improving many elements of this Bill; I thank them for the time that they have given me, but I am unable to accept these amendments. I hope noble Lords will feel able not to press their amendments on that basis.

European Qualifications (Health and Social Care Professions) (Amendment etc.) (EU Exit) Regulations 2018

Viscount Bridgeman Excerpts

Thursday 7th March 2019 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I apologise for my discourtesy in not being present at the beginning of this debate. A number of years ago, with the very great help of our noble friend Lord Howe, we secured the requirement from the Commission that healthcare professionals coming to this country from the European Union be subject to language tests before registration, and not the other way round, as in the previous arrangement. Can the Minister confirm that this valuable requirement will be kept in place under the new regulations?

[Lord Deben (Con)]

My Lords, I trust that the House heard with great pleasure the Minister’s comments on how major an advantage this whole arrangement in the European Union has been to us. We should not be discussing any of these SIs without reminding people that our membership of the European Union has been a huge advantage to us, and that what we are doing at the moment is picking apart something which is to our advantage, for reasons which are increasingly difficult to understand. We should not allow any of this to go past without constantly reminding the Government that they are leading this country into a position in which it will be poorer and less advantaged than when they came to power. A historic responsibility will lie on their shoulders, and we should remind them of that constantly.

My concern in this whole debate is that we are being asked to discuss this SI under a double falsehood. The first is the argument that we need it because we might crash out of the European Union, but that we need not be too worried because we will not crash out. The second difficulty is that, if we do not crash out of the European Union, we are legislating for a series of things which will be there in the course of further negotiations. Even if what is referred to at the moment as the Prime Minister’s “deal” were to be accepted—and it is manifestly not satisfactory—it is not a deal at all. It is an agreement to go on discussing to get a deal. During that period of time, what we are discussing here will be there in the background. There have been a number of occasions on which Opposition spokesmen have rightly pointed out that the trouble with these things is that if they are in the background while we are negotiating, they have a real effect. We have to take this very seriously.

Nor should we pass over the problem we are presenting ourselves with. We are saying that, to get the best advantage out of this ludicrous foot-shooting activity, we are going to make sure that every European Union national can come to this country to do what we want them to do without there being any difficulty. Of course, we cannot do any of the things that have made that particularly valuable in addition; we are not going to share the information both ways, which is what the European Union enabled us to do. Rather like the noble Baroness, Lady Thornton, I have a real concern that the IMI system will not continue. The idea that you can happily forget about it because it happens to be convenient, and do the things you can do because they happen to be convenient, seems to me an abnegation of responsibility which I find extremely difficult to accept.

The noble Baroness, Lady Jolly, rightly referred to the additional matter of the electronic alert system. We will not be alerted to the very professionals we most want to know about, because we will have decided that, because Britain is so ultimately different from everywhere else, we will not have this association. I know it is not the fault of the Minister, who is having to defend the ridiculous situation in which we find ourselves, but it is for this House to remind people all the time of what this really means.

Then we go on to the fact that these regulations are in conformity with the withdrawal Act, which says that we are not going to use it to create any new legislation, but merely take into national legislation things that would not be in it if we left the European Union without any agreement. The trouble is that this is not actually possible, because we have to have regulators making decisions. They are now going to make decisions under a new regime—in that sense it is a new regime—and I very much want to hear the response to the noble Baroness, Lady Thornton, on how we make sure the regulators make, roughly speaking, the same decisions across the whole range, and how we make sure that those regulators do not make decisions that extend or change the position we are in now. The latter would be contrary to the undertakings given by the Government.

However, the word that I very much worried about when the Minister used it was “flexibility”. She said that no longer being in the European Union would give us a flexibility on the establishment of professional qualifications which we did not have up until now. I do not think that flexibility can possibly be accepted within this SI, because that genuinely changes the position from what it was before. It may be that it is convenient for the Government to talk about flexibility as an advantage. I find it pretty difficult to see what that advantage would be. What would be the point of being flexible in changing our arrangements in such a way that they were out of line with the arrangements of our neighbours, when we rely upon those neighbours for such a high proportion of our professionals? It seems to me that flexibility is one of those convenient words used by the Government and those who believe in Brexit to suggest that there are some advantages hidden here which we have not yet got hold of. I do not think that there are, or that it would be legal for us to use flexibility under this SI, because it is specifically not supposed to introduce into our legislation anything that we have not had up to now.

I am afraid I will move on to something that I constantly say; that there is no impact assessment here. Why is there not? This is the real reason I say to the Minister that this is unacceptable. The reason there is no impact assessment is that the Government want us to believe that there is no impact. It is very inconvenient for the Government to say that the impact is that we will no longer have the advantages we had before leaving the European Union. They ought to be listing those advantages and explaining what the impact on us will be. But they are not doing that, because that would make more and more people aware of the lunacy of the measures we are now taking, and the ridiculous position in which Brexit places us.

But then there is another question. If you do not have an impact assessment, you also do not appear to have any idea about how much it will cost. I am afraid that I am a Conservative, and I am always interested in costs—I like to know how much it costs. I know that that is a disadvantage in the whole Brexit discussion, because the one thing we never get is the cost. It is amazing, is it not? We have a Conservative Government who never talk about the costs of Brexit, which is an absolutely ludicrous position for us to be in. Let us ask ourselves—I repeat the words of the noble Baroness, Lady Thornton—“What burden? What resources? What cost?”

One of my difficulties is that I have had the misfortune to have had to sit through a large number of these SIs, and every time you ask about the cost, the Minister concerned explains—charmingly, and with considerable aplomb—that the costs are negligible.

Healthcare (International Arrangements) Bill

Viscount Bridgeman Excerpts

2nd reading (Hansard): House of Lords
Tuesday 5th February 2019 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I have the rare pleasure and privilege of congratulating the Minister on her most impressive introduction of the Bill—on only her second day in the job—and addressing the challenge of a maiden speech in such style. We await her further contributions from the Dispatch Box. I welcome her as a Member of your Lordships’ House.

The Government are to be commended on this Bill. Of course, we await the outcome of the Prime Minister’s dialogue with the European Union, but the Bill has the merit of addressing with flexibility every possible outcome of these negotiations and of the future relationship between the United Kingdom and the European Union. The health of individuals is impatient with political considerations and we can therefore be pleased that the Bill comes before Parliament at an opportune time. Whatever the outcome of negotiations with the EU, the reciprocal healthcare arrangements which currently exist within the EU, the EEA and the European Free Trade Area are an achievement of which all participating countries, and the European Union itself, can be proud. I welcome the flexibility which the Bill introduces, giving the Secretary of State the power to conclude individual agreements with other states, outside and inside the European Union, should they be needed following our exit from the EU.

The noble Lord, Lord Kakkar, who is not in his place, referred to countries on the continent which advocate treatment which would not be available under the NHS in this country. For my own benefit, will the Minister clarify whether the Bill will address that problem? The Minister mentioned the light-touch arrangements that Australia and New Zealand have with this country. I was not party to these negotiations and I just ask whether the Bill is intended to enable our agreements with those two countries to be upgraded to the standard currently available in the EU reciprocal arrangements.

I recently undertook to assist a Hungarian friend of my family, who is registered with the NHS in England and who suffers from breast cancer, to obtain consent under the S1 or S2 procedure to be treated in Budapest, which she wished for personal reasons. I certainly had to go around the block getting advice, which was well-meaning but often contradictory. I eventually located the office in Leicester which handles the S1 and S2 requests and the necessary permission was granted. I ask the Minister to take the opportunity provided by the Bill to ensure that the reciprocal arrangements admirably provided for in it are publicised simply and clearly.

To sum up, this is a timely Bill. Going by the speeches of noble Lords, we can look forward to some very lively later stages, but it was admirably introduced by my noble friend in her new role and I join other noble Lords in wishing her all success with it and all other health matters in your Lordships’ House.

NHS: Healthcare Data

Viscount Bridgeman Excerpts

Thursday 6th September 2018 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I too am grateful to the noble Lord, Lord Freyberg, for the excellent, comprehensive speech with which he opened this debate. After hearing my noble friend Lord Bethell, I am sure that many noble Lords will share my wish to hear much more from him in the future.

I draw your Lordships’ attention to a little-known success story of the initiative of GPs in England—the creation of two databases of notifications of their clinical work. These databases are SystmOne and EMIS. Input is mandatory for all primary practices in England. These databases are widely used across the medical profession, not only in primary care. They have been in operation for some 20 years and provide instant access to statistics on, for instance, cancer, diabetes and heart conditions. I am advised that the secret of their success is that the programmes were written by doctors. They are completely anonymous—this subject has been mentioned by several of your Lordships. Great steps are taken to make sure that the data input is anonymised. There is certainly nothing to match them among the acute hospital trusts and there is no other country in the world to match them in the comprehensiveness of the data which they store and make available for medical research in England and worldwide. My noble friend Lady Neville-Rolfe mentioned the excellent advances made in Australia, Singapore and other places. But I was told that in New Zealand—which prides itself on its primary care—there is no equivalent even there.

Here in the United Kingdom, practitioners act as gatekeepers. In many countries with admirable primary care—and, incidentally, which spend a greater proportion of GDP on it—a patient is referred at an early stage to a specialist in, say, cancer or diabetes. In England, the practice of triage enables the GP to assess the needs of the whole man—or comprehensive gender equivalent—and only then to refer him, or her, to the appropriate specialist.

These databases are a shining example of the contribution of general practitioners to primary care, which was so aptly described by Simon Stevens, chief executive of NHS England, as the jewel in the crown of the NHS.

Time does not permit me to go into greater length on this subject in this debate—except, possibly, to say that much more use should be made of general practices to relieve pressure on A&E departments. But that is for another day. These databases are a fine example of the use of healthcare data in the United Kingdom which, in so many ways, leads the world.

The Long-term Sustainability of the NHS and Adult Social Care

Viscount Bridgeman Excerpts

Thursday 26th April 2018 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I add my thanks to the noble Lord, Lord Patel, for the leadership he has given to produce this excellent committee report. It is a tribute to him and to the quality of the report that only a week ago, the date of this debate had to be changed, but he has still produced more than 50 contributors.

I shall confine my remarks to primary care and the role of general practice in England and, in particular, the primary medical services practices. I go back to 1998. In the revision of contracts at the time for GPs, they were offered two routes: the general medical service, which basically allowed them to continue as before, and the personal medical service. PMS doctors were paid a premium per patient for undertaking additional duties. This was a farsighted development instituted by the Conservative Government and put into action by the Labour Government, and it attracted a number of very forward-looking GPs. The arrangements worked well for 10 years. Patients benefited, and a significant contribution was made by many PMSs to reducing the workload of hospital A&E departments, of which I will speak further.

In 2014, NHS England reviewed the operation of PMSs, and concluded that the premium could not demonstrate value for money. As a result, it was to be withdrawn by the CCGs over four years and redistributed to all practices in the relevant health districts. Among the conditions handed down by NHS England were three significant ones to these other practices: to help reduce health inequalities; equality of opportunity to all GP practices; and support for fairer distribution of funding at a local level. Those are laudable intentions indeed, and I am sure that they will have the effect of bringing the standard of practices up, but I fear that that will be at the expense of the go-ahead PMS practices, which stand to lose a lot of money in resources.

Among the PMS practices, there is predicted an average fall in income in year four of 35%. How will those practices address this shortfall? Inevitably, it will involve a reduction of support staff, practice nurses, nurse practitioners, healthcare assistants and administrative staff. Perhaps some doctors will be unable to bring themselves to curtail some services, walk-in surgeries being an example. The shortfall will have to be made good out of partners’ profits.

One of the main points I want to make, and have made, is the effect that this is likely to have on A&E and emergency admissions. In one practice, in central London, with which I am familiar, the emergency admissions are down by 60% from the national average. A&E attendances are reduced by 35%, and ambulatory care conditions, which I think is outpatients, by 73%. The key figure, by which a GP practice is measured, is the 65% reduction of antibiotic prescribed per 1,000 patients against the average practice.

I am lucky enough to be a patient of a central London PMS practice that has walk-in surgeries for two hours five days a week in the mornings, and for four days a week in the afternoon. I am assured by the senior partner in the practice that this was made possible by PMS premium funding and would not be possible without it. Let me mention briefly the financial aspects of practices against hospital admissions. A few years back, a PMS surgery was paid an annual fee per patient for an unlimited number of attendances at the surgery. As it happens, this was broadly equivalent to the cost to the NHS of just one basic admission to A&E before adding the cost of extra services, such as radiology. That is a clear reminder of the savings to the health service that the more go-ahead PMS practices have up to now been able to offer. I suggest that this move by NHS England, admittedly four years ago, was certainly unintended and unforeseen, but it has been adverse for patients, for the viability of the practices and an additional workload for the hospitals’ A&E departments.

The British primary healthcare system has been described as the jewel in the crown of the NHS—I believe by Simon Stevens who is the head of NHS England. Both France and Germany, to take two examples, have fine healthcare structures, but I understand that primary care through general practice arrangements that we have in the United Kingdom are indeed the envy of both. The jewel in the crown the primary care sector may be, but it does not have the clout of the larger acute care trusts.

This debate coincides three days ago with my right honourable friend the Secretary of State’s letter to fellow Peers in which he outlined plans for health and now, newly under his jurisdiction, social care. This was to mark the 70th birthday of the NHS. Outlined in the letter are some quite radical plans for the reorganisation of the National Health Service, and I hope that he will bear in mind the fact that the PMS has been a huge success, contrary to the view of NHS England, and deserves further funding.

National Health Service (Mandate Requirements) Regulations 2017

Viscount Bridgeman Excerpts

Wednesday 6th September 2017 Lords Chamber

[Lord Beecham (Lab)]

My Lords, the impact of the cuts which are being debated tonight—and here I congratulate my noble friend on bringing forward his Motion—are not confined to the health service. They also stretch to social services departments and social care. The most rewarding period of my fairly lengthy political life was as the chairman of social services in Newcastle from 1973 to 1977 when we transformed social care in that city. Much of what we did in those days is now being undone as the result of pressures on the social care budget and a lack of adequate funding for the problems which many of us are becoming increasingly familiar with. What are the Government going to do about that impact of the decision, as it would appear to be, not to adhere to the 18-week period? What estimate have they made, if any, of the impact on social services and social care in a climate where local government budgets are extremely hard pressed? The two things are inseparable. It was a Health and Social Care Bill, now an Act, and we need to look at the social care implications of this extended period because, undoubtedly, it will put increasingly impossible pressure on local authority social services departments and other organisations involved in supporting people in the community.

[Viscount Bridgeman (Con)]

My Lords, we have a health service which is endeavouring to meet an ever-present and probably ever-growing demographic challenge. I was interested to hear the remarks of the noble Baroness, Lady Finlay, on the effect of the number of older people accessing the service, but there are many more people growing old and it is surely self-evident that there is bound to be an increase in waiting lists.

Perhaps I may leave your Lordships with two statistics. It is remarkable that last year the NHS carried out 11.6 million operations, some 1.9 million more than in 2009-10, and 61 million out-patients were seen, again 1.9 million more than in 2009-10. The health service is not perfect and there is certainly no room for complacency, but perhaps I may remind noble Lords that the 2016 GP patient survey showed that 84.6% of respondents rated their overall experience as good, while the 2016 British Social Attitudes survey showed a historical high level of satisfaction. This is a service which is endeavouring under very strict budgetary pressures to improve the lot of the nation.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, perhaps I may first thank all noble Lords for their contributions and indeed thank the noble Lord, Lord Hunt, for bringing about this debate and giving me a chance to defend the Government’s record on the NHS. We are very proud of our record on the NHS at a time when it is treating more people than ever before. We have protected and increased health funding, with real-terms increases every year since 2010, with more doctors, nurses, midwives and GPs working in the NHS, so people can get the care they need when they need it. This is the first Government to have got a grip on NHS spending and really prioritised those areas of the service in need of investment. We are investing in general practice, an issue that has been raised in the debate, allowing GPs to open for longer so that more people can access the services that they offer. Some 17 million patients have already benefited from evening and weekend appointments through our seven-day NHS, which is a considerable achievement. Investment in general practice will increase from £9.5 billion in 2015-16 to more than £12 billion in 2021, a 14% real -terms increase. By 2020 there will be an extra 5,000 doctors working in general practice, as well as 5,000 extra staff.

This is also a Government who have given parity of esteem to the treatment of mental health in the National Health Service. The Five Year Forward View for mental health sets out our ambitious programme for further system reform: more skilled staff, the first ever waiting time standards, and an ambitious plan for children and young people’s mental health provision is in development. We have increased mental health funding significantly since 2010 so that we can deliver the services that people deserve.

I am proud that the NHS has been found by the Commonwealth Fund for the second time in a row to be the best, safest and most affordable healthcare system of 11 countries including the US, Canada, Australia, France and Germany. This is a tremendous achievement and I join with all noble Lords in congratulating our dedicated NHS staff on the excellent service that they continue to provide for patients.

Spending is of course important. According to the OECD, in 2014, UK spending on the NHS was 9.9% of GDP, which is above the average for both the OECD and the 15 countries which were members of the EU prior to May 2004. I would also gently remind Members of the previous Labour Government that this is a higher level of spending than at any time during that Government. Of course, we are not complacent and we understand that the NHS needs to change, develop and improve in order to meet the needs of the future. The mandate to NHS England that the Secretary of State is required to publish and lay in Parliament for each financial year therefore sets out the steps that the Government expect NHS England to take to ensure that the NHS offers the safest, most compassionate and highest quality healthcare in the world. The mandate for 2017 sets ambitious objectives for the coming year with the aim of delivering real improvements in patient care and outcomes. They include improving outcomes for maternity and diabetes, reducing health inequalities, improving patient safety and quality, moving more care out of hospitals, and supporting people to live healthier lives—all while delivering a balanced budget.

In his Motion, the noble Lord, Lord Hunt, has questioned our commitment to ensuring timely access to elective NHS services by arguing that the National Health Service (Mandate Requirements) Regulations 2017 and the associated mandate to NHS England make no reference to NHS England’s obligation to deliver the 18-week standard. I do not accept that and I see no grounds for making such a claim. On the contrary, we remain committed to a waiting time standard for non-urgent referrals whereby NHS commissioners must make arrangements to ensure that not less than 92% of patients have been waiting to start treatment for fewer than 18 weeks. That standard, the standard we are discussing tonight, remains a patient right that is embedded in the NHS constitution and underpinned by legislation passed, as the noble Lord pointed out, by a Conservative and Liberal Democrat Government. We have no plans to change it. Alongside the other priorities that the Government have set out for the NHS, maintaining and improving performance against core standards continues to be a commitment.

I turn now to the legislation itself. The Health and Social Care Act 2012, which we have discussed tonight, introduced a requirement for the Secretary of State for Health to publish and lay before Parliament a mandate in each financial year. It sets out the Government’s objectives for NHS England and may specify requirements that the Government consider essential for the objectives to be met. Any requirements must also be set out in regulations. The mandate for 2017-18 has been published in full accordance with the Act, including with the requirement in the Act to consult both NHS England and Healthwatch England on it. There is no question as to its legality. The mandate for 2017-18 sets a clear expectation that NHS England will maintain and improve performance against core patient access standards, and the annual deliverable in the mandate reads as follows:

“With NHS Improvement, to meet agreed standards on A&E, ambulances, diagnostics and referral to treatment”.


I now turn to the key facts on NHS waiting times performance, as indeed the noble Baroness, Lady Walmsley, said I would. As noble Lords know, the NHS faces increasing demand for health services as a consequence of the ageing and growing population, together with the costs of new drugs and treatments. Let me give noble Lords some figures on how many more people are receiving care from the NHS. Some 23.4 million people went to A&E in 2016-17, 2.8 million more than in 2010. Some 1.87 million people were seen by a specialist for suspected cancer, 973,000 more than in 2010. My noble friends Lady Redfern and Lord Bridgeman have given other facts and I could go on, but I will not. However, the NHS is doing more and better for more people than ever before.

Despite the record numbers of people being seen by the NHS, the vast majority are being seen within the waiting time standards, whether for A&E, cancer treatment or non-urgent treatment. If we consider the 18-week standard, which is the subject of our debate today, the referral to treatment standard for non-urgent care is that at least 92% of people are seen by a consultant-led team within 18 weeks of referral, most commonly by a GP. I am very well aware that the NHS is not currently meeting the standard for 92% of patients to wait a maximum of 18 weeks from referral to treatment. The standard was last met in February 2016. The Secretary of State reflected this in his annual statement on NHS England for 2016-17. It has been laid before Parliament —we do not hide or resile from it. In the latest published monthly figures national performance was 90.3%, which is clearly lower than we would like.

Queen’s Speech

Viscount Bridgeman Excerpts

Thursday 29th June 2017 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, at this late hour in the debate I briefly bring to your notice a specific issue which has arisen in the GP sector of the NHS in England. The GP settlement of 2006, a far-reaching measure by the party opposite, introduced two categories of general practice: the General Medical Service, GMS, where practices continued broadly with their existing level of funding; and the Personal Medical Service, PMS, whereby practices could opt for extra responsibilities in return for which they received extra remuneration—typically £15 to £30 per patient per annum. I must be careful not to generalise, but the PMS has attracted the more far-reaching entrepreneurial GPs, while those who are happy with the status quo tended to remain with the GMS. However, the PMS unlocked a whole spectrum of entrepreneurial initiatives on the part of many PMS practices. In particular, one PMS practice that I know of used the premium funding to introduce: counselling for sexual health, alcohol misuse and depression; the management of common mental health problems and enduring mental illness; providing facilities for rough sleepers and homeless people; specialist care for the vulnerable elderly; and, last but not least, walk-in surgeries. In this practice, these have led to high levels of patient satisfaction and, with its improved facilities, it and others like it have encouraged patients to avoid the use of overstretched A&E units, in turn reducing costly but avoidable emergency admissions. All in all, it is fair to say that the vast majority of PMS practices have put the extra funding they received to good use.

For the first 10 years or so, this arrangement has worked very well for PMS practices. However, in the 2013-14 GP contract imposition, NHS England decided that the premium paid to PMS practices was to be withdrawn and redistributed via the local CCGs—significantly, to all practices in their areas. Particularly hard hit have been practices in authorities with a small number of PMSs relative to GMSs, and where they receive back only a tiny fraction of the premium surrendered. The arithmetic is simple: in a not atypical split, an authority may have one PMS practice and 19 GMS practices. The PMS practice will therefore receive only 5% of the funds which it has surrendered.

I agree that this redistribution of funds is for the benefit of general practice as a whole, and that the proposals as they stand will have the effect of providing resources for many GMS practices which need them. Where I take issue is that this redistribution is at the expense of the PMS practices, which as a group embrace many practices that have shown initiative over the past 12 years in expanding their services, for which they have received the extra funding I referred to. I know of one central London practice which will lose £400,000 in funding per year that, after a partial clawback from the CCG, will result in a net loss of £200,000. This is an annual, ongoing figure and clearly cannot be sustained. This, by the way, is a total NHS practice with no private patients and therefore no income from rich private clients. There can only be one outcome from this haemorrhage of funding: inevitably, some of the services built up since the inception of the 2006 agreement will have to go.

However this policy is viewed, it means that many GP practices will be subsidised by the star performers in their sector, at a huge cost to the latter. It is simply wrong that these PMS practices, which simply by the way they were constituted have attracted many entrepreneurial and far-sighted GP doctors, should see a significant proportion of their funding withdrawn. Several GPs I have spoken with who took advantage of the PMS funding are quite simply perplexed that, at this time when the NHS is faced with a massive black hole, NHS England should apparently be pursuing a course of what is effectively the disincentivisation of many leading practices within the sector that are dedicated to taking the strain off the hard-pressed and expensive A&E departments. They also show, as a group, much initiative and enterprise in helping to keep GP practice—what has been described as the jewel in the crown within the NHS—as healthcare providers of excellence.

I wholeheartedly agree that our aim must be to ensure that all patients get a minimum standard of treatment. However, I urge the Minister and his colleagues in the Department of Health and NHS England to look elsewhere for funding and not penalise so many high-achieving practices in the GP sector. I understand that the redistribution is to be rolled out over four years, so I hope it is not too late for NHS England to accept my submission that this imposition on the PMS practices is a basically short-sighted process, and to reconsider the department’s policy on it.

NHS and Social Care: Impact of Brexit

Viscount Bridgeman Excerpts

Thursday 21st July 2016 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I thank the noble Baroness, Lady Watkins, for securing the debate.

I draw your Lordships’ attention to a very interesting and concise blog from Miss Clare Marx, the president of the Royal College of Surgeons. She makes three important points. The first, already voiced in many quarters, is that losing non-UK staff would, in her words, be “cataclysmic”. I totally echo the words of the noble Baroness. Toughened migration rules often affect technicians, porters and cleaners. A clear message must be sent to the Government that the NHS needs to retain these vital staff.

Miss Marx’s second point is the opportunity that will be presented to the NHS to improve patient safety. Up till now, the UK has been required to accept the lowest common denominator of standards across Europe. An example is that some devices have found their way into the UK having been approved in European countries with lower safety standards. In many cases, these standards need to be toughened up, but at the same time the baby must not be thrown out with the bathwater. Care must be taken. The stricter regulations could make it harder to attract international innovators in healthcare. In other words, a sensible mean must be struck.

Ms Marx’s third point is a vital aspect of the changed climate in which healthcare in the UK will find itself post-Brexit—language testing. This is a subject not infrequently aired in your Lordships’ House. The law as it stood until 2012 was governed by directive 2005/36, which concerned mutual recognition of professional qualifications by all member states. Under this directive, healthcare was lumped in with professions such as engineering, surveying and so forth. It meant that English language testing could be made only following registration by the appropriate body, such as the General Medical Council and the Nursing and Midwifery Council.

The effect of this, particularly in the case of nurses, was that there were cases where a candidate could obtain registration and disappear, as far as the regulator was concerned, never to be seen again, with, of course, their English language ability untested. There were cases where the only evidence of English proficiency was a certificate obtained for a fee at a street corner in an eastern European capital. Representations were made, particularly from the UK, that healthcare differed from other professions, in that there was the additional consideration of patient safety and that it accordingly required special treatment. Thanks to the persistence of the Department of Health—I particularly mention my noble friend Lord Howe and my honourable friend Dan Poulter in another place, both at that time Ministers in the Department of Health—the Commission accepted the case for language testing of health professionals prior to registration. This can now be required not as a routine, but when the relevant regulator has reasonable grounds to believe that a candidate’s English language skills are not adequate.

This has been a step in the right direction, but it is not enough. At present the EU, within the constraints I have just mentioned, permits testing only on broad English language skills—effectively, conversational English—while to take the case of the GMC, candidates from outside the EU are required to show English language proficiency in, and I emphasise this, a clinical context. There is a huge difference between these levels. Note-taking is a particularly strong tradition in British medical practice. As one facetious journalist has written, the difference between a microgram and a milligram can be a coffin.

I urge the Minister to give priority to completing this mission, which is to require that all healthcare professionals coming to this country, from within and without the European Union, are subject to meaningful English medical language tests prior to registration. There is an urgency about this—patient safety is involved—and I hope this can be put in hand straightaway in the time remaining while the UK is still within the European Union, if not in the hopefully constructive environment post-Brexit, freed from any constraints imposed by Brussels.

The other matter that needs urgent review is the working time directive. Surgeons in particular have had long-standing concerns about the impact of the working time directive on time for training. In 2014 the task force on the EWTD concluded that we need greater flexibility for training hours while ensuring we never go back to a culture of excessive working hours that can only harm patient care. I understand the task force is due to report shortly. We await this with interest.

Finally, a brief word about research. It is essential that arising out of the Brexit negotiations there is sustained funding and continuing mobility of researchers and clinicians to ensure that the UK research industry can thrive and advance patient care.

I declare my record as a remainer at the referendum, but, as has been widely quoted, we are all Brexiteers now. I am confident that Brexit will provide a not-to-be-missed opportunity to rectify some of the anomalies and deficiencies in clinical practice that continuing membership of the European Union has involved.

General Practitioners: Appointments

Viscount Bridgeman Excerpts

Thursday 17th March 2016 Grand Committee

[Viscount Bridgeman (Con)]

My Lords, I, too, thank my noble friend Lord Attlee for initiating this debate. We heard from him that in his view the conduct of the practice of which he is now a patient leaves something to be desired. He has also been good enough to indicate that I might be able to sketch out for your Lordships a somewhat contrasting view. These two interventions, from my noble friend and myself, have not been co-ordinated; we only exchanged views two days ago.

I and my family are fortunate to be patients of a practice in central London which tells a different story. This practice has a walk-in surgery open for an hour and a quarter in the morning and two and a half hours in the evening Monday to Friday, with the exception of Wednesday evenings. I have never had to wait more than 20 minutes to see a GP. The practice has first-class support in practice nurses and receptionists. Repeat prescriptions can be requested online—this is now fairly common among GP practices. Significantly, and in many ways this is the acid test, the practice has some of the lowest referral rates to A&E in central London. In other words, more patients can be treated for minor ailments in the surgery without going to A&E. The cost of an A&E admission is approximately £80. Your GP is paid that same sum to have you for one year, so if you go to A&E for a runny nose that is the same money paid out again.

In 2006, under the GP settlement, practices could opt for PMS premium status where for extra work undertaken they received extra pay. On the whole the more enterprising practices—including the one where I am a patient—took advantage of this offer. Now I understand that the latest proposal from NHS England is for this premium to be substantially reduced or eliminated over a period of four years to bring the funding of PMS practices in line with the GMS practices that did not take advantage of the 2006 premium. It would be interesting to know if my noble friend Lord Attlee’s practice is one of the latter. It is policy to recycle the resultant savings thus made back to CCGs and through them to the practices within their groups. Where PMS practices are in a group with a substantial number of other PMS practices, the clawback available to CCGs will be considerable and as I understand it there will be significant funding available for improved services and financial support. However, PMS practices that stand virtually alone within their groups will not enjoy the same level of support. Note also that all funding deriving from the cutback to PMSs will be available to both PMS and GMS practices—a further subtle discrimination against the former.

Let me attempt to be constructive with three examples of welcome initiatives instituted by NHS England. The first is integrated care: a structuring for the patient to formulate with his GP a health plan. In my case, this involved an hour-plus session with the doctor—just think of that length of time being made available in an NHS practice. As I understand it, that model draws on experience in the US and elsewhere where patients with planned maintenance prove to be much less of a demand on healthcare services. This is being funded by CCGs, which are investing very considerably in it. It is a nation-wide initiative and much to be welcomed.

Another development in our part of London is the rapid response teams under the control of local health trusts but funded by CCGs. These consist of doctors, nurses and paramedics and I understand they are extremely effective in saving GPs in practice from having to leave their surgeries to answer emergency calls. The noble Lord, Lord Turnberg, suggested the damage caused by such calls in terms of the time of doctors in small practices.

Thirdly, I draw attention to the development of GP federations, where GPs join together in a unique and largely unprecedented way. These are set up as limited companies and their mission is to bid for services that hospitals may wish to contract out. Examples I know about are smoking cessation clinics, cardiograms, testing patients on warfarin for anti-coagulation and looking after airways disease—in short, widely disparate procedures. I think we can assume that in all cases there will be cost savings for NHS England and any profits made by the federations will be available to their GP shareholders.

I revert to the subject of my noble friend’s debate. My question for the Minister is how NHS England is to reconcile the very different standards that are emerging from this short debate. The challenge for NHS England is how to bring the less adventurous practices up to an acceptable standard without effectively dumbing down the forward-looking practices which, as I have tried to illustrate, have the potential to introduce new, co-operative practices with a substantial contribution to cost savings.

My own NHS practice reckons it will lose around £400,000, resulting in a cutback to the PMS premium over four years. From the resulting benefits that are to be made available by the CCGs to the practice, and I have given three examples, it is estimated that the practice will reduce the loss to about £200,000. Why should any loss be acceptable in this of all branches of healthcare? This is one branch of healthcare which is showing real initiative, particularly in regard to enterprise and its financial viability. Surely the NHS is in danger of killing the goose that lays the golden egg. I shall very much welcome my noble friend the Minister’s comments on that. I am in danger of mixing my metaphors, but general practice is one of the jewels in the NHS, which has been made clear by all the speakers today. Let the entrepreneurial practices not only be an example to their less-motivated colleagues but also lead the way in taking advantage of the imaginative developments that NHS England has initiated—but free from the financial penalisation that many practices are now facing.