Health and Social Care Bill

Andrew George Excerpts

Tuesday 20th March 2012 Commons Chamber

[Mr Burns]

The aim of this Bill is to secure a national health service that achieves results that are among the best in the world. Through it, the Government reaffirm their commitment to the values and principles of the NHS: a comprehensive service, available to all, free at the point of use and based on need, not ability to pay. However, we have always been prepared to listen and make changes to improve the Bill, and we have continued to do so in another place. The Lords amendments in this group fall within five main areas.

First, we recognised that concerns had been expressed about the Secretary of State’s accountability for the health service. Although it was never our intention in any way to undermine that responsibility, we have worked with Members of another place and the House of Lords Constitution Committee to agree Lords amendments 2 to 5, 17, 18, 24, 39, 40, 74, 246, 287 and 292. Those amendments put beyond doubt ministerial accountability to Parliament for the health service. In addition, they amend the autonomy duties on the Secretary of State and the NHS Commissioning Board, to make it explicit that the interests of the health service must always take priority. They also amend the intervention powers of the Secretary of State and the board, to clarify that they can intervene if they think a body is significantly failing to exercise its functions consistently with the interests of the health service. Finally, a new provision will make it explicit that the Secretary of State must have regard to the NHS constitution in exercising his functions in relation to the health service.

Although clinical commissioning groups will have autonomy in their individual decisions, Lords amendment 9 clarifies that CCGs must commission services consistently with the discharge by the Secretary of State and the board of their duty to promote a comprehensive health service, and with the objectives and requirements in the board’s mandate.

The Government also tabled amendments in response to the recommendations of the House of Lords Select Committee on Delegated Powers and Regulatory Reform, all of which we have accepted. Amendments 15 and 16 ensure that the requirements set out in the mandate, and any revisions to those requirements, must now be given effect by regulations.

Commissioning will be led by GPs, who know patients best. However, with that responsibility must come accountability. Therefore, further to the amendments made in the House requiring CCGs to have governing bodies, the other place has strengthened requirements in relation to CCGs’ management of conflicts of interest. We recognised how important it is to ensure the highest standards of probity in CCGs and accepted amendments 31, 300, 301 and 302, which were tabled by the noble Baroness Barker, and which require CCGs to make arrangements to ensure that members and employees of CCGs, members of the governing body, and members of their committees and sub-committees, declare their interests in publicly accessible registers.

The amendments also require CCGs to make arrangements for managing conflicts of interest and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes. The board must issue statutory guidance on conflicts of interest, to which CCGs must have regard.

Taken together, those amendments provide certainty that there will be clear and transparent lines of accountability in the reformed NHS. However, I cannot support Opposition amendment (a) to Lords amendment 31. The Bill is clear that CCGs must manage conflicts of interest in a way that secures maximum transparency and probity. In most cases, that would mean that a conflicted individual withdraws from the decision-making process, but that might not always be possible, for instance when a CCG is commissioning for local community-based alternatives to hospital services, and determines that the most effective and appropriate way to secure them is to get them from all local GP providers within its geographic area. In that event, it would not be possible for every GP to withdraw from the decision-making process. We cannot, therefore, agree to a blanket ban.

[Andrew George (St Ives) (LD)]

Will the Minister clarify something in view of what he has just said about the conflict that all members of the board and the CCG will have with regard to decisions on the provision of new services? Does he share my fear that the structure of CCGs results in bodies that will continue to be conflicted? Does that continuing conflict not undermine that important structure within the health service?

[Mr Burns]

I appreciate the hon. Gentleman’s intervention, but I am afraid I do not share that view. I hope that what I shall go on to say will help to give him additional reassurance on that.

There will be additional safeguards in the Bill to ensure that those processes are transparent, including the regulations that Monitor will enforce on procurement practices and its accompanying guidance. In addition, the board must publish guidance for CCGs on their duties in relation to the management of conflicts of interest. Of course, the CCGs' commissioning intentions will have been set out in its commissioning plan, which is subject to consultation with both the public and the health and wellbeing boards.

The second area in which the other place has strengthened the Bill relates to the duties placed on commissioners to ensure a patient-focused NHS. It has always been the Government’s intention to put in place reforms that support the simple principle, “No decision about me without me.” To achieve that, commissioners will for the first time have a duty in relation to patient involvement in decisions. The House strengthened those duties following the listening exercise, and they were further improved by amendments 19, 32 and 33 in the other place, to make it explicit that the duty means promoting the involvement of patients in decisions relating to their own care or treatment.

Another core principle of the White Paper was the need to eliminate discrimination and reduce inequalities in care. The Bill will for the first time in the history of the NHS place specific duties on the Secretary of State and commissioners to have regard to the need to reduce health inequalities.

To reinforce that further, the other place agreed amendments 22, 23, 36, 37, 38 and 60. These ensure that the Secretary of State, the board and CCGs will be better held to account for the exercise of these duties through their annual reports, the board’s business plan and, in the case of CCGs, their commissioning plans and annual performance assessment by the board. However, improvements in quality, outcomes, and reduced inequalities will not happen unless we better integrate services for patients. That is why we placed duties on commissioners, again for the first time, to promote integration in new sections 13M and 14Y, and made clear, following the listening exercise, that competition will not take priority over integration.

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[Liz Kendall]

I am going to finish this point.

The Minister of State, the hon. Member for Sutton and Cheam (Paul Burstow), said that all and any changes to those provisions were “unnecessary”, and denied that there was any lack of effective governance. I would remind Liberal Democrat Members that the Minister argued that putting a board in place or dealing with conflicts of interest would mean that clinical commissioning groups would fail to be “liberated”. Those criticisms were among the many issues that were supposed to be dealt with when the Government embarked on their now infamous “pause” in the Bill’s progress last spring, but they were not. The Government were therefore forced to return to the issue in the other place. However, the amendments before us are still weak, incomplete and ineffective.

The Government say that clinical commissioning groups will have to include in their constitutions how they intend to manage conflicts of interest. However, I am afraid the Government are deluded if they think that the national NHS Commissioning Board will be able adequately to scrutinise whether hundreds of clinical commissioning groups are properly implementing the measures in thousands of contracts, particularly when the board has already taken on so many other huge responsibilities for managing the Government’s new system. Giving Monitor powers to scrutinise clinical commissioning groups is inadequate for the same reason. Saying that Monitor can deem a clinical commissioning group’s contract to be ineffective, if it thinks that conflicts of interest have not been dealt with, will in effect mean closing the stable door once the horse has bolted. Indeed, there could be huge problems on the ground, as a provider may have already started delivering services to NHS patients by the time Monitor takes its decision.

Labour’s Front-Bench team in the other place tabled a comprehensive amendment to deal with conflicts of interest in clinical commissioning groups. It would have ensured a code of conduct for how clinical commissioning groups register, manage and report on conflicts of interests among its members and employees, and imposed a duty on CCG members to abide by the code. The amendment would have ensured that no member of a clinical commissioning group could take part in discussion or decisions concerning any provider of services with which that person had a registrable interest, and allowed the Secretary of State to appoint an adjudicator to investigate complaints about any breaches of the code, with a range of financial and other sanctions available, including the ability to suspend or remove a person from the clinical commissioning group. However, the Government rejected that comprehensive amendment, saying that such sanctions were unnecessary.

The Government have agreed to Lords amendment 31, which at least says that there must be a register of interests for a group, along with its governing body, sub-committee and employees, and that the register must be kept up to date, with information updated within 28 days. That change is welcome, but it does not go anywhere near far enough in ensuring that conflicts of interest are robustly dealt with. That is why our amendment (a) to Lords amendment 31 would ensure that members of a clinical commissioning group would not be able to take part in discussions or decisions about services in which they had declared a registered interest, which is the same format as in local government.

[Andrew George]

Although we welcome Lords amendment 31, which was tabled by my noble Friend Baroness Barker in another place, the hon. Lady’s amendment (a) proposes to go a stage further. I personally welcome that, but did she notice that the Minister, in justifying the Government’s position that it would not practically be applicable, gave the example of a CCG commissioning from all its membership? Does that not fundamentally undermine the argument that clinical commissioning groups cannot be conflicted per se?

[Liz Kendall]

I am simply arguing in amendment (a) that the same robust mechanisms that exist in local government should apply in this case. The hon. Gentleman will have to have a conversation with his own Ministers about what they have said in response.

The potential for conflicts of interest under the Bill is so great, and the amount of public money being spent by clinical commissioning groups so substantial, that the Government should have put in place far tougher provisions to deal with conflicts of interest. The Deputy Prime Minister has failed to guarantee the integrity of clinical commissioning groups, as he claimed in his joint letter with the noble Baroness Williams to Liberal Democrat Members. The integrity of clinical commissioning groups cannot be guaranteed by having only two lay members who will not even be independently appointed, nor can it be guaranteed through guidance for GPs, which the General Medical Council is currently developing. Indeed, I would argue that the GMC’s role should be to ensure professional integrity in the treatment of individual patients, not with regard to organisational misconduct, which would be a complete change in its current role. Nor can the integrity of clinical commissioning groups be guaranteed by national bodies such as the NHS Commissioning Board and Monitor, which will be too distant, too remote and too busy dealing with the fallout from other aspects of the Government’s Bill to be able effectively to address the potential conflicts of interest that clinical commissioning groups will face every day.

This issue might not have received as much public or media attention as other aspects of the Bill, but it will become significant in future, as patients and taxpayers struggle to determine whether their best interests—not the financial interests of GPs—are at the heart of the NHS. Examples of that have already come to light. In October last year, the Haxby practice in York wrote to its patients to say that a range of minor treatments would no longer be available on the NHS, but that they could be carried out privately at a number of clinics, including one owned by the practice itself. Those treatments included the removal of skin tags, at a cost of £56.30, and the treatment of benign tumours at a charge of £243.20.

Dr Richard Vautrey, of the British Medical Association’s GP committee, has rightly said that

“the direction of travel in NHS policy, particularly combined with the financial situation, does increase the risk of conflicts of interest for GPs which is one of the reasons the BMA is so concerned about the Health and Social Care Bill.”

Similarly, the NHS Confederation and the Royal College of General Practitioners have felt forced to issue guidance to GPs on how they should manage conflicts of interest, because they believe that the arrangements will become more complex under the Government’s plans. The Lords amendments before us are not robust enough to deal with this. It is a real concern for GPs that they will be unable to deal with conflicts of interest. That is what they are saying, and they need to be protected. The Government should support our amendment, because that would enable that to happen.

[Andrew George]

I congratulate my noble Friends Baroness Jolly, Baroness Barker, Lord Marks, Baroness Williams, Baroness Tyler and Baroness Northover on putting in a tremendous amount of work during the Bill’s various stages to negotiate and table amendments to advance the arguments that my Liberal Democrat Friends and I have expressed concern about. I have already put on record the fact that, although some of those amendments represent important strides towards making the Bill less bad, the changes still do not satisfy me to the extent that I feel that the Bill should be entitled to go forward from this, the elected House, as a piece of legislation. Unfortunately, that is not an argument that I am going to win, but I wanted to put the point on record.

Lords amendment 31 represents an important step forward, but it will merely provide a sticking plaster in what will be a fundamentally challenging scenario. The clinical commissioning groups represent a crumbling pillar in the edifice of the legislation. The big weakness at the centre of the CCGs is the fact that their members will, collectively and individually, be conflicted in almost all circumstances, and they will be unable to escape from that.

The Minister emphasised that point further when he told the House why he could not accept the amendment tabled by those on the Labour Front Bench. He told us that members of a CCG should not take part in certain discussions and decisions, even though they had declared an interest, because the groups would, on occasion, be commissioning for all their members. In those circumstances, a CCG would be incapable of making a decision because none of its board members or general members could be brought in to help because they would all be conflicted. That demonstrates a fundamental weakness in the legislation. My noble Friend Baroness Barker tabled an excellently drafted amendment to deal with that problem, but she was working within very limited parameters. The amendment would simply provide a sticking plaster for a crumbling edifice that will be unable to hold up this policy. I have a fundamental concern about the way in which the legislation will work in this regard.

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[Dr Poulter]

I rise to speak in support of the Government, and of what the previous Government did for the NHS. When the shadow Secretary of State was Secretary of State for Health—the same was the case with many of his predecessors—there was a consistent policy whereby the private sector should be used where it could add value to patient care in the NHS. That was done very effectively by the previous Government to bring down waiting times for operations, but it was not effective when it was not done in an integrated way. Very often, it was done without regard to post-discharge planning for patients but, as we heard earlier, the renewed focus on integration should help to deal with those problems.

We have some of the very best hospitals not only in this country but in the world, including the Royal Marsden and Moorfields eye hospital, where a relatively high proportion of activity is carried out by the private sector. No one doubts those hospitals’ commitment to their NHS patients or that they still provide those patients with the very high standards of care of which health care systems in other countries are very envious. We are very proud of what those hospitals do, and the Government would like to give other hospitals the same opportunity and freedom to follow their example. The Government believe that it is absolutely appropriate that we should use the private sector where it can enhance value to NHS patients. That is absolutely consistent with the previous Government’s policies, for which many Labour Members campaigned at the last general election. This Government are also committed to those policies.

[Andrew George]

I understand and respect the sincerity of the principle that my hon. Friend is describing, but can he reassure me, particularly given his understanding of the NHS and health systems, that under these proposals it would not be possible for a foundation trust to drive some NHS patients towards the private arm of the activities that they undertake, particularly in the case of procedures that are exactly the same in the private and the public sector?

[Dr Poulter]

My hon. Friend makes a valid point, and he is right to raise it. That happened in the past when, under the previous Government, private sector providers were paid 11% more for the provision of services than NHS providers, which created an incentive for the private sector to be used ahead of NHS services. This Government are committed to ensuring that that does not happen. My hon. Friend the Minister and my right hon. Friend the Minister and Member for Cheltenham—[Interruption.] I mean Chelmsford; I apologise, particularly as I get the train through his constituency on the way home every Thursday night. They have clearly stated that the Bill is about making sure that we use the private sector when it adds value for money. The hospital that uses the private sector the most—the Royal Marsden—does not have a two-tier service for NHS patients and private patients. The involvement of the private sector at that hospital greatly enhances the work of the NHS and the quality of service and care available to its NHS patients because of the increased research that is performed, the high quality of care, and the high standard of clinicians who are attracted to work there. That works well for the private sector and for the NHS.

I agree with the right hon. Member for Bermondsey and Old Southwark (Simon Hughes) that, where possible, we should be using NHS providers. The Royal Marsden, where there is a high potential cap on private sector involvement, does not use the full capacity of that cap, and there is less private sector activity than it could undertake. That is because the Royal Marsden says, in effect, “Yes, the private sector is good, but it is not only about maximising our cap and maximising our profits but taking into account the best interests of our local patients and striking a balance.” That works very well.

[Andrew George]

As I understand it, the majority of the private work at the Royal Marsden is in areas such as research and development that are not in any way similar to the services it provides to NHS patients. I asked my hon. Friend whether he agreed that where the private sector and public sector were providing the self-same services for NHS patients, there was a risk that patients might be driven from the NHS towards the private sector.

[Dr Poulter]

I hope I reassured my hon. Friend with my earlier answer. Yes, he is right that that has happened in the past. However, there is a presumption in the Bill—particularly for rural areas such as Cornwall and in Suffolk, which I represent—that the renewed focus on integrated care that we heard about earlier is the primary focus and purpose of commissioning, over and above the use of any willing provider or private sector providers. That has given me great reassurance regarding our ability to take on and deal with the big demographic challenges of looking after older people better.

I am reassured by what the Minister has said, and I urge Government Members to support the Government.

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[Paul Burstow]

My right hon. Friend is absolutely right. Hard-wired throughout the Bill are requirements on patient and public involvement in clinical commissioning groups and health and wellbeing boards. Local healthwatch will provide a vehicle for delivering much wider engagement. One criticism that has often been levelled at past attempts at public and patient engagement has been the absence of hard-to-reach groups, which are seldom heard from in our health system. As a result, their voices have not helped to shape commissioning decisions. We need to ensure that they do, so that CCGs commission effectively for their whole population. That is a key part of what the Bill provides for.

As the Bill makes its way on to the statute book, Members of all parties will need to look closely at the opportunities for far wider public involvement that will result from how it has been improved. We have listened closely to groups such as the Richmond group, which has been a powerful advocate on behalf of a wide range of patients’ groups. It has talked about the importance of involving patients far more in co-production and commissioning decisions. That is an essential component of how we intend the Bill to be given effect in the months to come.

In tabling our amendments in the House of Lords, we wanted to ensure that local authorities had greater flexibility in the organisational form that local healthwatch takes. Local authorities are best placed to make decisions about the right way to commission a local healthwatch service for their area, but they cannot decide not to have a local healthwatch organisation, and we would not allow them to do that. It is essential that the voice of patients and carers is heard loud and clear in the decision-making processes of our NHS and social care services.

[Andrew George]

I am grateful to my hon. Friend, particularly for his last remark. I know that he will come on to Lords amendment 181, but I could not find anything in the debate in the House of Lords justifying the rationale behind the provisions relating to the establishment of local healthwatch organisations as statutory bodies corporate. I am sure that he is just about to provide that rationale.

[Paul Burstow]

I am grateful to my hon. Friend for the opportunity to do just that. First and foremost, I want to be absolutely clear that local authorities are under a statutory duty to ensure that local healthwatch arrangements are put in place. The Lords amendments do not change that one iota, and they do not in any way weaken the statutory functions conferred upon local healthwatch organisations. Nor do they enable local authorities in some way to limit, restrict or censor what local healthwatch organisations can do. Indeed, we tabled amendments to ensure there are better safeguards in relation to how local authorities carry out their role. The Secretary of State will be able to publish guidance relating to potential conflicts of interest between a local authority and its local healthwatch organisation, to which both sides must have regard. We have provided for HealthWatch England to make recommendations in that respect, but to be absolutely clear, local healthwatch has a statutory basis. All that has changed is that we want to enable local decisions about whether it is a social enterprise, a voluntary organisation or another format.

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“reform fatigue among local activists.”

[Andrew George]

I am listening carefully to the hon. Lady’s arguments about the structure and funding of local healthwatch bodies and HealthWatch England. I ask this question not to be deliberately mischievous, but in view of her comments and criticisms: what is the preferred option of the Labour party for those scrutiny bodies?

[Liz Kendall]

I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords, which set out how we could have a separate independent, body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.

National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK, Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.

Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.

The risk register says that there is a high risk that

“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities

“will not invest in establishing effective relationships with existing LINks and other community organisations”

because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch

“doesn’t work effectively with providers and commissioners. HW is not fully representative.”

It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:

“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”

The cause is identified:

“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”

Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.

Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[Interruption.] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified

“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”

The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.

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[Simon Hughes]

I understand that. I was not pretending that everything could be dealt with in regulations. I said to the hon. Lady, I hope fairly—I am trying to be fair—that I thought she made a good point that the proposal has come late in the day and does not have the support of the people leading the community involvement at the moment, one of whom she cited and whom I have known for many years. I do not think that the Government have yet given a full explanation of why the new proposals are better than the old ones. I understand why they have suggested that there should not be a one-size-fits-all approach, but I hope that in his winding-up speech the Minister will explain, because I think that Ministers have a case to answer.

[Andrew George]

My right hon. Friend will have heard me intervene on my hon. Friend the Minister of State on that issue, seeking the rationale behind the decision to remove the statutory basis for HealthWatch. As I understand it, his response was that there would be a statutory measure to achieve this—healthwatch organisations would be tied in with local authorities. Does my right hon. Friend agree that there is a potential weakness there? If we are seeking to integrate health and social care, a conflict of interest may arise if a body is tied in with the local authority but is also supposed to be scrutinising the activities of that authority.

[Simon Hughes]

I understand that point and share some of those concerns. I hope that the Minister will explain before the end of the debate why the more variegated model will not carry the risks that were alluded to by the hon. Lady when she read from the document earlier and by my hon. Friend.

I want to flag up two other things in relation to accountability, one of which is to do with the decisions made by the commissioning groups. Like many colleagues, I met a group of my local doctors again the other day. They had two areas of concern. First, they had concerns about the Bill. There is a lot of work to be done by Ministers and by all of us to allay concerns about the Bill when it becomes an Act—that is, on the basis of the facts, not the fiction. There is a huge amount of work to do. I do not think that we should underestimate that. Secondly, they have concerns about the system as it is now, before any measures have become law. I hope that Ministers have heard those concerns, some of which are not of this Government’s making but derive from previous legislation.

There is a concern that there is an excessive interest in some places in looking for private work and private contracts. There is a concern that the middle class and well heeled will speak more loudly and influence the commissioners in their interests, rather than in the interests of the poor and the vulnerable. That is a real issue in a constituency such as mine, where a lot of people are on low incomes and in need of a good public health system.

I want to put on the record that, although I understand the argument about getting rid of tiers of management and giving GPs the power to commission, and that is a good thing, it will not be a good thing if the decisions end up being taken not by GPs and the commissioning groups and the people who are meant to be taking them, but by the people they appoint to do the work for them. They may be private sector companies or somebody else. We have to make sure that it is health service professionals who make the decisions, in an open, accountable and transparent way, not people they employ, who may have a big vested interest in capturing more work for their own commercial gain.

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[Mr Deputy Speaker (Mr Nigel Evans)]

I thank the hon. Lady for her point of order. It is in order for the Minister not to be here at this moment in time, and it is up to each Member’s judgment as to what to make of that.

[Andrew George]

It is a pleasure to follow the right hon. Member for Wentworth and Dearne (John Healey), who has taken us round a number of issues, particularly in relation to the public’s ability to scrutinise, through the proposed healthwatch organisations, the effective delivery of commissioning in their areas.

As my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) suggested, there is a desperate need for provision within our procedures whereby important Bills such as this, which have been significantly altered in another place, can be reviewed on Third Reading. Our earlier debate about the still unpublished transitional risk register was, in a sense, a proxy for that lack of a Third Reading debate.

This debate has placed public health and the role of HealthWatch, particularly local healthwatch, in the context of local health services being placed at risk. We have already discussed how clinical commissioning groups may be fundamentally conflicted. In my contribution to that debate, I posed questions about the conflicts that intrinsically exist within those organisations. I believe that HealthWatch should be there to provide scrutiny of those conflicts. Throughout the debates on the Bill, fundamental concerns have been expressed about the fragmentation of local health services. We need a strong and independent-minded local healthwatch in all our areas to be watching for that and looking out for opportunities to maintain the integration of local services.

I fear that one of the effects of such a major reorganisation of the health service nationally and locally will be to make it more difficult to deliver the £20 billion efficiency gain that the previous Government proposed and that the coalition Government intend should be delivered. That issue needs to be considered at national level, with HealthWatch, and at local level. I believe that we need an independent body that is capable of ensuring that efficiency gains are being achieved at local level and that keeps an eye on the commissioning and delivery of local health services.

The Royal College of Nursing has said today that there is a need to look carefully at staffing levels in front-line health services, including in acute hospitals. There is a debate about whether that should be mandatory. That has long been a concern of mine when looking at the delivery of local health services and it is identified by people when they visit hospitals. There are staff-to-patient ratios that, in my view, are barely tenable and barely safe. Qualified nurses are struggling to provide the support and care that patients require, simply because the staffing ratios are inadequate. The same ratios may have been adequate in the past when the throughput of patients and the acute status of patients were lower, but with the current turnaround of patients and their acute status, it is no surprise that the RCN’s survey has identified the need to review staffing levels in our wards.

[The Secretary of State for Health (Mr Andrew Lansley)]

In commenting on the level of nursing staff, will the hon. Gentleman observe that since the election, there has been a 5% improvement in the ratio of nurses to occupied beds in general and acute wards?

[Andrew George]

I am not in a position to doubt that figure. The question is whether the ratio is sufficient to ensure that there is safe staffing in our hospitals now, as the RCN identified after a recent survey. I understand the argument advanced by Ministers that it comes down to the management and the management of paperwork within hospitals, and is not just about staff-to-patient ratios. I do not want to have a debate just about staff -to-patient ratios, but that issue has been raised today and I believe that it resonates with people out there in the country, who can see that nurses in particular are struggling to provide adequate services within their hospitals. Those ratios have an effect on the level of care that nurses can provide, as has been found by a variety of reports. The problem is not down to the callousness of the nurses or untrained care assistants who provide the services—where that exists, it should clearly be rooted out of the service—but to whether staff resources are sufficient to maintain safe services on our hospital wards. I think the RCN is right to raise that issue.

That concern is relevant to ensuring that we have adequate local healthwatch services because it shows that we need independent scrutiny of the health service by a body that is not in the pocket of anyone, including the local authority, but that is able to scrutinise hospitals and speak out about staffing levels in its area. We cannot be dependent on the RCN reporting such matters to the Department and on there being top-down diktats that impose mandatory staffing levels that apply in all circumstances. Rather, there should be a local healthwatch that looks at the guidance and recommendations of the professional bodies and ensures that the services in its local hospitals are adequate to provide safe nursing and hospital care. That is why it is important to ensure that the local healthwatch bodies are, as far as is possible, independent of any external influences, whether from the Department, the NHS Commissioning Board, clinical commissioning groups or the local authority. That is where I shall take my arguments.

[Fiona O'Donnell]

I feel as if I have been here before, in that I agree with some of what Government Members are saying. Will the hon. Gentleman therefore vote with us tonight?

[Andrew George]

I shall sidestep that question at present and return to it later, because I first want to listen to the Minister’s winding-up speech. As I want to ensure that he has adequate time, I shall conclude my remarks as swiftly as possible.

I could, however, initiate a brief yah-boo interlude, such as by saying that the previous Government got rid of community health councils. Many people look back at the era of CHCs as the halcyon days of independent scrutiny of local provision. In creating local healthwatch, we should as far as possible mirror, and learn from, the excellent services provided by the CHCs.

[Liz Kendall]

On 26 October 2006, when the Secretary of State was the shadow Secretary of State, he set out his policies on HealthWatch. He said:

“I envisage it as an independent body with a separate funding stream and the right to decide its own agenda of work.”

Does the hon. Gentleman agree that that has been completely changed under this Bill?

[Andrew George]

Earlier, I asked a question about the rationale behind the last-minute change from having independent bodies to the situation now, under which, as a result of both a proposal we are debating this evening and an amendment tabled in the Lords, we are allowing local authorities to commission community interest companies or others to provide the healthwatch function in their areas. That ties the local healthwatch into the local authority. I believe we should devolve and localise, and empower local communities as far as possible, but this change does not achieve that. Instead, it empowers the local authority. If there is a genuine intention to ensure that we have integrated health and social care, then there is a problem here. If the local authority provides both the social care and the local scrutiny, I fear we may not have effective scrutiny of the work of the local authority in this regard.

Liberal Democrats in the Lords have done excellent work in advancing a large number of amendments to improve the Bill, and I am perplexed that the proposal before us tonight appears, in effect, to backpedal from that progress made in other areas. That is why I hope the Minister will reassure us on the rationale for this proposal, and assure us that the new body will be genuinely independent and genuinely effective. I shall therefore reserve judgment on the question of which way to vote tonight.

[Grahame M. Morris]

Although the HealthWatch issue is important, in the brief time available to me I want to talk about Lords amendments 249 to 283, dealing with the health and social care information centre and patient confidentiality. The amendments raise several issues about who would have access on a mandatory basis to the information provided by the centre as well as changes in the terminology used to refer to the persons who would be able to make such requests. There are important issues here about patient confidentiality and protections to ensure that the right checks and balances are in place. I am sure Ministers will be well aware of the arguments made in Committee about the issue, and I wish to seek some assurances and express some concerns. Perhaps the Minister may be able to address some of them.

One issue that was raised in Committee was the power of the Secretary of State to direct the information centre as he wishes. The Opposition think it is a good thing that the Secretary of State should discharge certain powers, particularly when failures happen, and be held to account for them by the House. Naturally, we support the view that people should have greater access to, and control over, their health and social care needs and the care that they receive. I am sure the whole House can subscribe to that idea. However, the opportunity to access health and social care records has to be tempered by protections for patient confidentiality and, equally importantly, protections to prevent the misuse of information by private bodies.

The Opposition have raised the issues of access to patient information and privatisation, and expressed concerns that sensitive information may find its way to organisations that will use it for commercial reasons. In Committee, my right hon. Friend the Member for Rother Valley (Mr Barron) spoke about the value to patients of anonymised data, which enable them to make relevant choices. It is not a huge leap of faith to imagine that those same data would be commercially valuable to pharmaceutical companies and commercial interests. I am concerned to hear from the Minister that adequate safeguards are in place in the Lords amendments.