Healthcare (International Arrangements) Bill

Baroness Blackwood of North Oxford Excerpts

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

Moved by

[Baroness Blackwood of North Oxford]

That the Bill be now read a second time.

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

My Lords, it is a great honour to speak to the Healthcare (International Arrangements) Bill, on behalf of the Government, as my maiden speech—as my noble friend the Leader of the House put it so encouragingly when we first met, “straight in at the deep end”.

Before addressing the Bill in earnest, however, I hope your Lordships will indulge me as I record my profound thanks to noble Lords from across the House for their warm welcome over the past few weeks. I thank particularly my noble friend Lord Younger, Black Rod and the parliamentary staff who have so patiently guided me through the processes and procedures of this place. I offer special thanks to our wonderful doorkeepers, who have on more than one occasion rescued me from complete disorientation. I must also pay tribute to my two distinguished supporters: my noble friend Lord O’Shaughnessy, who is, I am sure we all agree, a formidable act to follow, and my noble friend Lord Young of Cookham, one of our truly great parliamentarians, as well as a former Health Minister himself, of course. I am grateful for their continued advice and support. Last, but certainly not least, I put on record my sincere thanks, and those of my whole department, to my noble friend Lady Manzoor, who has so ably covered departmental business, responding tirelessly on topics ranging from tooth decay to sepsis to breast cancer, not to mention fielding a few lengthy SIs with grace and good humour.

I understand that it is a tradition to treat those of us who have come from the other place to a lesson or two in the nature of truly forensic scrutiny and expert debate. I humbly await my tutorial. However, I am sure the House will also appreciate that I remain very proud to have been elected by the constituents of Oxford West and Abingdon, and the outcome of the 2017 election was a great sadness for me. It was, of course, my home seat. My father was a cardiologist. He met my mother, then a scrub nurse, in an operating theatre in the Radcliffe Infirmary in north Oxford in 1973. On many a doorstep, constituents would tell me how fondly they remembered my father, who had treated or taught them, before proceeding to tell me in no uncertain terms that this did not mean that they would be voting for me.

It was a constant joy to represent such a research-intensive seat, where constituents were always so informed, engaged and unsparingly direct. I used to say that not only was I the only MP to get footnoted letters but I had to spend constituency days constantly at the ready for impromptu tutorials from world experts. Indeed, on one visit to the Rutherford Appleton Laboratory, a particularly keen particle physicist sequestered me in his office for a full 45-minute lecture on the nature of the muon—and, naturally, why STFC funding for his project should be maintained.

It is for this reason that when Garter Principal King of Arms asked me to choose a title, I had no hesitation in selecting north Oxford, the place where I have grown up physically and intellectually all these years. I have a suspicion that—although my previous roles as chair of the Commons Science and Technology Select Committee, Health Minister and chair of the Human Tissue Authority will of course prove valuable—my former constituents, who were so expert and so challenging, will actually have done the most to prepare me to serve your Lordships as a Minister in this Chamber.

I am mindful that the Companion states that maiden speeches should be short and uncontroversial. Short, perhaps, is within my gift, but I fear that my subject matter may diverge from strict convention. EU exit raises the collective blood pressure so notably that I have often wondered whether public health language should be developed for just such occasions. However, during its passage through the other place, the purpose of this Bill attracted cross-party support, and for good reason. However varied our views may be on our future relationship with Europe, we can all agree that access to healthcare is essential both for British nationals living in European countries and for EU citizens living in the UK.

In addition, as we look to a future increasingly defined by global mobility and chronic illness, it is the responsibility of government to consider, with all appropriate care and scrutiny, a more comprehensive approach to reciprocal healthcare. Your Lordships will know that current reciprocal healthcare arrangements give people retiring abroad more security, support tourism and enable essential mobility in our economy. The UK is party to a number of reciprocal healthcare agreements, which range from light-touch arrangements with Australia and New Zealand to the more complex EU reciprocal healthcare system.

I will briefly outline the latter: the UK funds healthcare for 180,000 pensioners and their dependants in the EU, living principally in Spain, France, Cyprus and Ireland. We fund needs-arising healthcare in the EU for UK tourists and students. The scheme is hugely popular. There are 27 million EHIC cards in circulation in the UK, resulting in around 250,000 claims each year. We directly fund healthcare for 10,000 posted workers and their dependants in the EU, EEA and Switzerland, and we fund around 1,350 UK residents to travel overseas to receive planned treatment in the EU, primarily maternity care.

The cost of EU reciprocal healthcare is £630 million a year, and at present we recover £66 million each year. This amount is increasing as the NHS gets better at identifying EU visitors and ensuring that the UK is reimbursed for care provided, but it is likely to remain a net spend because many more British pensioners go to Europe than the other way round. Unless there is a dramatic change in the weather across the continent, our models do not forecast that changing much in the near future.

It is clearly in the interests of the British public to ensure that reciprocal healthcare arrangements similar to those currently in place continue when we leave the EU, whether that happens through an agreement with the EU itself, as we very much want, or through bilateral agreements with individual member states in the unlikely event of no deal. For this reason, although this is a short Bill of just six clauses, it is vital. The powers in it are designed to ensure that, no matter the outcome of the exit negotiations, British nationals living in European countries and EU citizens living in the UK, not to mention tourists and posted workers, can have certainty and continuity of care. Should we wish to, the Bill would also allow us to strengthen existing reciprocal healthcare agreements with non-EU countries and to explore new agreements in future.

The Government are determined that we will reach a deal with the EU. With a deal, the withdrawal agreement will enable the continuation of existing reciprocal healthcare rules during the implementation period, and afterwards for people covered by that withdrawal agreement. But it is not a long-term arrangement and does not provide for the unlikely event that the withdrawal agreement is not concluded. In the event of no deal, the powers in the Bill would enable the UK to act swiftly to protect existing healthcare cover for British nationals in the EU, EEA and Switzerland, whether deals are made with the EU or with individual member states. This is clearly undesirable but it is the job of a responsible Government to prepare for all scenarios.

In preliminary discussions with a number of your Lordships, I have been asked about the scope of the powers contained in the Bill. In this regard, I record my thanks to my noble friend Lord Blencathra and the DPRRC for the work that it has already done on this matter and for its characteristically robust report. I wrote last week to the committee in response to its report and have placed a copy of that letter in the Library.

So what, in detail, does the Bill do? There are three key elements. First, it seeks payment powers so that the Secretary of State can make payments for healthcare abroad. Expenditure by the Department of Health and Social Care relating to EU and other reciprocal healthcare arrangements is currently published in this place in the form of annual resource accounts in line with government reporting rules, and will continue to be so to ensure transparency. Secondly, it seeks discretionary powers to make regulations to give effect to healthcare agreements that are entered into. It is important to note at this point that any secondary legislation under this clause that amends primary legislation—Henry VIII powers—would be brought forward under the affirmative procedure, while other regulations that are expected to be technical and administrative in nature, such as replacing or updating the administrative forms, would take the negative procedure. Thirdly, the Bill seeks powers for authorised persons to lawfully share data to facilitate payments or treatments in a safe and effective way. Data would be shared in accordance with UK data protection legislation, including the Data Protection Act 2018.

It is important to note that the Bill does not affect the UK’s ability to negotiate or enter into international agreements; the power to negotiate and sign treaties is a prerogative power and always has been. It simply empowers the Secretary of State to implement agreements once they have been negotiated. The details of new reciprocal healthcare agreements will of course remain subject to negotiation and parliamentary scrutiny. I am aware that there has been some debate about whether CRaG powers are sufficient and that the Constitution Committee, so ably led by the noble Baroness, Lady Taylor, is currently conducting an inquiry into this very matter. I shall be interested to hear its conclusions.

I reassure the House that there can be no cause for concern that the Bill represents an attempt by the UK Executive to seize power from the devolved Administrations. The Department of Health and Social Care currently funds and arranges EU reciprocal healthcare for people from England, Scotland, Wales and Northern Ireland. We have been working with the devolved Administrations for some time now. I am delighted that we have received a legislative consent Motion from Scotland, and we will of course continue to ensure that we legislate for reciprocal healthcare in a way that fully respects the devolution settlements.

In particular, I note concerns raised in the EU Home Affairs Sub-Committee report debate in July, especially by my noble friend Lord Ribeiro, regarding the importance of protecting healthcare in the island of Ireland. I reassure the House that the UK and Ireland are committed to protecting reciprocal healthcare rights fully and appreciate how important it is that UK and Irish nationals can continue to access healthcare when they live in, work in or visit the other country. We also want to maintain co-operation between the UK, Northern Ireland and Ireland on a range of medical issues, including planned treatment, public health and workforce, in both a deal and no-deal scenario.

Having set out the general purpose of the Bill in broad terms, my priority today is to hear from the House so I can begin what I know will be a robust process of scrutiny and strengthening of the Bill. Reciprocal healthcare arrangements enjoy broad public support and the Bill is designed to ensure that we can give British nationals living in European countries and EU citizens living in the UK certainty and continuity of care. It is designed to protect tourism and economic mobility. It is a Bill that looks to the future, giving us the ability to strengthen existing reciprocal healthcare agreements with non-EU countries and explore new agreements in the future.

I look forward to hearing the views of all noble Lords as we enter into the detail of the Bill. I will listen carefully and seek to engage as fully as I possibly can, whether with groups, by party or with individuals, so that we can ensure that proper scrutiny is given to the content and intent of the Bill. It is a necessary and pragmatic Bill. It is one that respects Parliament and the devolution settlements and looks to the future of reciprocal healthcare for generations to come. It is with that in mind that I commend this Bill to the House. I beg to move.

--- Later in debate ---

[Baroness Blackwood of North Oxford]

My Lords, I thank the House for a most robust and incisive debate. It is great for me to be welcomed into a very balanced House, with the noble Lord, Lord Marks, admitting that he campaigned against me and my noble friend Lord Lansley having campaigned for me. I feel as though I have been welcomed into a warm embrace. The debate has been strong and, as anticipated, a great lesson for a former Member of the other place. I will attempt to answer as many questions as I can and address the major issues raised. If I cannot, I will write to noble Lords.

First, I am grateful for the widespread support for the intent of the Bill, which, as the noble Baroness, Lady Thornton, said, is essential. As the noble Lord, Lord Bethell, reminded us, it has strong public support. There is a desire to maintain robust reciprocal healthcare arrangements, which benefit many people across the country when working, living, studying and travelling abroad. Every day, the lives of people across the country are improved by these arrangements. Examples range from a young British student with severe asthma, able to study for a year abroad at a European university, to a British grandmother with multi-morbidities, able to visit her newly born grandchild—or, in my case, a young bride with a rare disease honeymooning in perhaps one of the most romantic cities in the world: Venice. On the value of this scheme, it is notable that many noble Lords have their own stories to tell about the importance of us maintaining reciprocal healthcare. I will write to the noble Baroness, Lady Thornton, about her mother’s case when I have found out the details for her.

All these journeys are made easier by a reciprocal healthcare system ensuring that if you require healthcare in another EU member state, you will be looked after. The British Government want such arrangements to continue; the Bill provides a legislative framework for that. I recognise that a number of noble Lords have raised important and substantive issues concerning the Bill. I will address as many of them as possible in the time available but I look forward to debating them further in the coming weeks.

The noble Lords, Lord Foulkes, Lord Marks and Lord Thurlow, the noble Baronesses, Lady Barker, Lady Brinton and Lady Jolly, and my noble friend Lord Dundee mentioned the DPRRC report. It was characteristically robust, as I said in my opening remarks. The Government responded to it; I placed a copy of that letter in the Library for your Lordships’ consideration. The committee will consider that response on 13 February, which I will take into account and reflect on very carefully. On the Bill’s powers, we must find a balance between the flexibility and agility we need as we go forward into our EU exit, and appropriate scrutiny, as my noble friend Lord Bridgeman said so eloquently.

It may be helpful for me to outline the five delegated powers in the Bill in a little more detail. Four of those powers come under Clause 2, and one under Clause 4. The first, in Clause 2(1)(a), would be used to set out in detail complex payment arrangements under reciprocal healthcare deals. The second, in Clause 2(1)(b), is needed to provide healthcare abroad outside reciprocal healthcare arrangements. The third, in Clause 2(1)(c), is needed to give effect to comprehensive healthcare agreements entered into in another country or international organisation, such as the EU. The fourth, in Clause 2(3), is needed to allow the Secretary of State to give directions to a person to whom they have delegated functions under the Bill. The fifth, in Clause 4(6)(e), enables the Secretary of State to make regulations to add to the list of people who can process data for the purposes of the Bill, for example a future arm’s-length body that does not currently exist. I know that data issues have been raised by a number of your Lordships, which I will return to later.

I know of a lot of legitimate concern over the inclusion of Henry VIII powers in EU exit legislation. The only Henry VIII power in the Bill comes under Clause 5. It is not a standalone power: it is a tidying power to ensure that the statute book is coherent when implementing future arrangements under the Bill. In particular, I have heard noble Lords’ preference for wider use of the “made affirmative” procedure, which I will reflect on more as we head towards Committee.

The noble Lords, Lord Marks and Lord Foulkes, and my noble friend Lord Dundee asked about financial reporting procedures in future reciprocal healthcare. In the letter to the DPRRC, we committed to issuing an annual ministerial Statement on the operation of reciprocal healthcare arrangements, which will be published as soon as is practicable after the end of each financial year to allow for accurate financial reporting. The Statement would include, but not be limited to: information on the expenditure and income of healthcare provisions overseas as a whole, which would include aggregated expenditure, income from the financial year and a country-by-country summary of expenditure and income; an update on the operation of arrangements, which could identify areas of successful operation or where arrangements are being improved to promote efficiency; and the strategic direction of reciprocal healthcare arrangements, which could be a statement either on future priorities for the current operation or on where the UK is engaging with other countries to establish new arrangements. I hope that that is helpful.

The noble Lord, Lord Foulkes, was absolutely right to identify the importance of EU workers to the NHS. I want to put on record again both my and the Government’s appreciation of the work of EU staff in the NHS. Let me be very clear: we want those staff to stay. I am very pleased to report that more than 4,300 more EU workers are now working in the NHS than before the referendum. We wish to continue with that positive trend.

My noble friend Lord O’Shaughnessy has already clarified the point regarding right of access to NHS services for those ordinarily resident in the UK, but the noble Lord, Lord Thurlow, and the noble Baronesses, Lady Brinton and Lady Jolly, raised the issues of the impact of these changes on the NHS and charging. Let me be clear that we do not need to have any new front-line NHS services to charge visitors or tourists from the EU, either directly or via reciprocal healthcare arrangements. We already have these processes in place as part of our current EU reciprocal healthcare arrangements. EHIC claims and EU visitors are identified for the purposes of whether they are chargeable or directly covered through the current system. This is done by overseas visitor managers in the NHS trusts, who manage charging. The Government have been the first to make significant progress regarding charging overseas visitors and recouping funds. To reassure the noble Lord, Lord Thurlow, since 2015 we have increased identified income for the NHS with reciprocal arrangements by 40%. Directly charged income has increased by 86% over the same period. We are not satisfied with that progress, but it is certainly moving in the right direction.

I also reassure the noble Baroness, Lady Brinton, that we have work ongoing with NHS Improvement, which is now working with 50 NHS trusts, to improve further its practices in this regard, with a bespoke improvement team in place providing on-the-ground support and challenge, and identifying and sharing best practice. That should be of great assistance as we move into this next period.

A number of noble Lords raised the global scope of the powers, in particular the noble Lord, Lord Bethell, and the noble Baronesses, Lady Jolly and Lady Thornton. As I have noted, the Government’s immediate priority with the Bill is our reciprocal healthcare arrangements with the EU. That is absolutely right, but we already have a number of existing reciprocal healthcare arrangements with countries outside the EU, such as Australia and New Zealand, as my noble friend Lord Bridgeman noted. The passage of the Bill through Parliament presents us with a natural opportunity to consider how we can best support Britons in an increasingly global world. International travel is under- taken by increasing numbers of people for professional, social, recreational and humanitarian purposes. More people travel greater distances and at greater speed than ever before. Global reciprocal healthcare agreements have the potential to protect public health by supporting international visitors to access emergency and needs-arising treatment when they need it.

In addition, international collaboration through reciprocal healthcare agreements can also make it much easier for people to receive treatment, including specialised treatments, such as those mentioned by the noble Baroness, Lady Thornton, which may be more clinically effective or better for a person to access abroad. For example, as I mentioned in my opening speech, in 2017, 1,352 UK patients received pre-planned treatments in the EU, while 1,241 EU patients received pre-planned treatment in the UK. Some of those treatments would not have been possible if we did not have that scheme in place. We do not want to prevent ourselves being able to strengthen our agreements with non-EU countries by curtailing the Bill’s scope, but we must obviously ensure that appropriate scrutiny and parliamentary oversight is in place as we do that.

I move on to the questions raised by the noble Lord, Lord Marks, and the noble Baronesses, Lady Brinton, Lady Thornton and Lady Jolly, regarding trade. The Government are completely committed to the guiding principles of the NHS—that it is universal and free at the point of need. Our position is definitive: the NHS is not and never will be for sale. The Bill’s powers are to allow the department to enter into reciprocal healthcare agreements, either bilaterally or with international organisations, entirely independently of any other international organisations or agreement. I hope that that statement is clear enough.

To reassure noble Lords even further, I will briefly set out the scrutiny powers available to the House for the international treaties under which these agreements would be agreed. It is obviously the Executive’s responsibility to negotiate these treaties under the royal prerogative. The Bill does not replace or limit the prerogative power to enter into international agreements, in the healthcare sphere or more generally. We already have international healthcare agreements, as I have stated, with non-EU countries such as Australia and New Zealand, and Crown dependencies, allowing them certain free access to NHS services.

Parliamentary scrutiny of international treaties is of great importance. Ministers are accountable to Parliament for the exercise of those functions. The principal statutory framework providing scrutiny of these treaties is the Constitutional Reform and Governance Act 2010—CRaG—established by Parliament under its own powers. CRaG has enshrined in statute the long-standing convention known as the Ponsonby rule that was the product of lengthy consultation and dialogue. The Act enables either House to object to the ratification of a treaty and the House of Commons can block ratification of a treaty indefinitely.

I understand that the House of Lords Constitution Committee has an ongoing inquiry into future scrutiny of international treaties. The Committee will look into all aspects of treaty scrutiny, which is obviously apposite at this moment, including what, if any, new committees need to be set up to deliver scrutiny of treaties post exit. I obviously look forward to the review’s findings, but noble Lords can be reassured that this Bill’s purpose is the implementation of international treaties that can be scrutinised under the CRaG process. Noble Lords can also be reassured that all international healthcare agreements will be subject to the scrutiny route considered most appropriate by Parliament.

[Lord Lansley]

At the commencement of the Committee stage of the Trade Bill the House voted for a Motion whose effect was that the Government should bring forward their proposals for the future scrutiny of further treaties before the Report stage. The expectation from the debate on the Trade Bill was that we would go beyond the CRaG legislation. It would be helpful for my noble friend to make it clear that Ministers will be doing that for the Trade Bill and that that bears directly on this Bill. It would be very useful for the Bill to proceed in the light of that same response from Ministers.

[Baroness Blackwood of North Oxford]

I thank my noble friend Lord Lansley for that intervention. One of the reasons why I raise that process is because I am aware that there are ongoing discussions in other parts of the House. We will reflect on that as we progress the Bill.

My noble friend Lord O’Shaughnessy spoke of positive engagement with his EU counterparts on bilateral arrangements in the event of no deal. A number of noble Lords raised what would happen should the withdrawal agreement not go forward. My noble friends Lord Ribeiro and Lord Lansley both raised the question of no deal. My noble friend Lord Lansley is right that we should be careful and seek to reassure those who currently rely on reciprocal healthcare that they will be able to rely on these arrangements going forward. Great interest has been expressed by our counterparts in the European Union, where we are seeking bilateral arrangements with relevant member states in the event that we reach 29 March without a deal with the EU.

[Lord Foulkes of Cumnock]

The Minister has been really helpful in her reply and has dealt extremely well with the points raised. She has come to a crucial one now. I think that everyone understands that if there is a deal along the lines that have been agreed, reciprocal arrangements will continue. That is one of the positive things about it. However, if there is no deal the Minister and the Government need to be honest with us and the public about it. It will not be easy to negotiate bilateral deals with 27 different countries if we come out with no deal. If the Minister and the Government are honest about that, it will make people understand that it is vital, if we are to leave the European Union, that there must be some kind of deal, because no deal would be a real disaster for healthcare.

[Baroness Blackwood of North Oxford]

The noble Lord, Lord Foulkes, raises a very important point, and he is absolutely right that the Government do not seek to have no deal. The best way to avoid no deal is to have a deal. Under the withdrawal agreement there is protection of reciprocal healthcare arrangements for EU citizens in the UK and for UK citizens abroad, and that is what the Government seek to deliver. We have set out a number of steps to ensure that individuals who currently receive reciprocal healthcare can be protected as much as possible under a no-deal scenario. One of them is to put in place the powers in this Bill so that we can go very quickly to seeking bilateral arrangements. That is why I hope we will receive the support of the noble Lord as we go forward with this legislation.

[Lord Marks of Henley-on-Thames]

I think the point made by the noble Lord, Lord Foulkes, was that it is very dangerous to give the reassurance that the Minister was giving and to tell the public that all will be well in the event of no deal. The public need to know that all will not be well in the event of no deal. Even if this Bill and the regulations go through as quickly as they can, there will be a very serious hiatus. It is important that, rather than reassuring the public, the Government—which want a deal, as I know the Minister does—should say how dangerous it will be to leave without a deal on 29 March.

[Baroness Blackwood of North Oxford]

The noble Lord, Lord Marks, has made an important point. The Government have not in any way avoided the consequences of no deal. They have been very clear in outlining some of the risks associated with no deal and exactly why they are seeking a deal, with strength and authority. Those currently using reciprocal healthcare arrangements abroad can find advice on the GOV.UK and nhs.uk websites. Any of your Lordships who would like more specific advice are very welcome to write to me or to seek a meeting with me on that.

I would like to make a little more progress, as there are only two more minutes before I must close and I have not dealt with a number of issues your Lordships raised with me. On Ireland, which was raised by a number of important Members—the noble Baronesses, Lady Barker, Lady Brinton and Lady Jolly—I reassure noble Lords that the UK is firmly committed to maintaining the common travel area and to protecting the rights enjoyed by UK and Irish nationals in each other’s states, whatever the terms of the UK’s withdrawal from the EU. The common travel area facilitates the principle of free movement for British and Irish citizens between the UK and Ireland and the reciprocal enjoyment of rights and entitlements to public services of citizens in each other’s states.

In addition, on negotiations with the devolved Administrations, we are very pleased to have received a legislative consent Motion from Scotland and are continuing to negotiate.

To conclude, I hope that I have been able to summarise the main issues and topics. There are clearly still some important questions that need to be answered, and I will write on the further points. It is clear from this debate that there is much work still to be done on the Bill, and I am sure that we will have adequate time in what my noble friend Lord Bridgeman predicts—I suspect rightly—will be a lively Committee to make sure that the Bill is in the best possible shape. However varied our views may be on the future relationship with Europe, I think that we can all agree that access to healthcare is essential both for British nationals living in European countries and for EU citizens living in the UK. We have heard that reciprocal healthcare arrangements enjoy broad public support. This Bill is designed to ensure that we can give British nationals living in European countries and EU citizens living in the UK certainty and continuity of care. With that in mind, I beg to move that this Bill be committed to a Committee of the whole House.

Bill read a second time and committed to a Committee of the whole House.