Healthcare (International Arrangements) Bill

Baroness Brinton Excerpts

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

[Baroness Brinton (LD)]

My Lords, I join others in welcoming the noble Baroness, Lady Blackwood of North Oxford, and congratulating her on her maiden speech. It is always slightly bizarre for a maiden speech also to be a ministerial introduction to a Bill, but she did it extremely well and set out the case. Along with my colleagues on the Liberal Democrat Benches, I may disagree with some of the things that she said, but she set out the Government’s position eloquently.

In addition to thanking the Library for its very good briefing, I want to thank the BMA for its own. One point that it makes has not been covered so far in our debate today. It says:

“It is essential that any alternative cost-recovery system introduced post-Brexit should not place an undue burden on either the NHS or on doctors or allied health professionals working within the health service”.


In view of the rearrangement of the BBC charter, whereby the BBC is taking on responsibility for the public benefit of TV licences for the over-75s, I worry that a Government in future might take the attitude that it is perfectly acceptable to offset—so I completely support the BMA in saying that it must not affect costs.

Others have spoken eloquently about the number of UK residents who hold EHICs and have received reciprocal treatment. I speak as someone who lost their father-in-law 10 years ago in France. He had the most wonderful treatment over a three and a half-week period after a brain haemorrhage, but sadly died. At no stage of the treatment, moving from a front-line hospital to a big regional hospital of excellence, was there any problem with the card or the E111 form. The only slightly bizarre thing that happened was that, after he died and all treatment was concluded, my mother-in-law received a bill for the ambulance service. It was not that she had to pay it, because if one is covered by E111/EHIC form the cost is met by the state, but every family gets a copy of the ambulance bill because it reminds them how expensive it is—and, guess what, in France there is no abuse of the ambulance paramedic system whatever.

At paragraphs 75 and 76 of the EU Committee report, Brexit: Reciprocal Healthcare, published in March last year—about one year ago—the committee sets out its concerns about making sure that negotiations should start early. It stated:

“We applaud the spirit underlying this ambition”—


of wishing to maintain reciprocal healthcare arrangements—

“but it is difficult to square it with the Government’s stated aim of ending freedom of movement of people from the EU”,

which is of course symptomatic of the principle of reciprocal healthcare. It went on to state:

“More generally, reciprocal healthcare arrangements will only be achieved by agreement between the UK and the EU. The Government has not yet set out its objectives for the future UK-EU relationship. We … urge the Government to confirm how it will seek to protect reciprocal rights to healthcare of all UK and EU citizens post-Brexit, as part of any agreement on future relations”.


It is worth noting that, 52 days away from 29 March, we are still not clear about what the UK wants from the arrangements. We seem to be going back to the negotiating table. I suspect that that explains what the noble Lord, Lord O’Shaughnessy, said about the sparsity of information. It is almost as if Ministers are saying, “Trust the Government, because we don’t quite know yet where we are”.

Some of the points made later in the EU Committee’s very good report give a signpost to where we might be. Chapter 6, on reciprocal arrangements, private healthcare and insurance, talks about contingency planning for the S1 and S2 arrangements and the EHIC. I will not dwell on those, because colleagues have mentioned them, but I remain concerned about arrangements with insurers. The chapter’s final conclusions state:

“Time is now short for the Government to provide much-needed clarity to the insurance industry to help with planning, particularly for multi-trip travel insurance policies that will include the period beyond March 2019”.


It goes on to say:

“There will be consequences not just for the insurance industry, but for tourism and individual travellers. While the industry might derive some benefit should it be required to play an expanded role in providing cover, we recommend that any move for greater reliance on private medical insurance by UK citizens travelling within the EU post-Brexit be subjected to careful scrutiny, particularly in terms of the further regulatory oversight that might be needed to ensure that patients and consumers are treated fairly”.


In November last year, my noble friend Lord Bruce of Bennachie asked the noble Lord, Lord Bates, about the arrangements and advice that would be provided to UK residents planning to book a holiday in an EU member state commencing after the end of March 2019. The noble Lord, Lord Bates, said, in summary, that he did not have details, but went on to say:

“The Government continue to strongly encourage all British nationals travelling abroad, including within the EU, to take out comprehensive travel insurance that covers their personal circumstances and meets their needs. In the unlikely event of no deal, travel insurance policies will remain valid”.—[Official Report, 1/11/18; col. 1424.]


Last week, my honourable friend Tom Brake, who is the Liberal Democrat Brexit spokesman in another place, reported that we had done some mystery shopping for travel insurance in the preceding week, in January 2019. Of the seven travel insurers spoken to, only two firms said that insurance would be paid out as normal in the event of a no-deal Brexit. Three said that they did not know what would happen if a no-deal Brexit came into force. Most worryingly, two of the companies said that holidaymakers would not be covered in this event because they had not yet got any policy on it. That is why I am really worried by the lack of detail in the Bill, which is symptomatic of the lack of detail and discussions going on with the industry itself.

I will briefly touch on Northern Ireland. The noble Lord, Lord Foulkes, has spoken about the importance of arrangements elsewhere in the union. The arrangements that pertain in Northern Ireland at the moment are absolutely not the same as elsewhere in the European Union. Joint health services allow patients to get medicine at any pharmacy, north or south of the border, irrespective of the location of the GP responsible for the prescription. Ambulances on both sides of the border are currently free to travel across it to attend emergencies. People across the island of Ireland are allowed to receive radiotherapy at a new £50 million centre for cancer patients from both sides of the border in Derry. It is important that that specialist provision is available, yet there is no pathway for managing these difficult cross-border issues in Ireland. Will these current arrangements remain in place after 29 March, in the event of a no-deal Brexit? Even in the event of a deal, will it continue if there is no final agreement? Are specific discussions going on between the Republic, Northern Ireland and the UK Government to ensure that there are no cliff edges for residents of Northern Ireland or the Republic? This is not just holidaymakers, or a handful of workers abroad. This is a full, two-way process.

Finally, I move on to the Henry VIII powers. I am grateful to my noble friends Lord Marks and Lady Barker and to the noble Lord, Lord Foulkes, for expressing their concerns in detail. I will not repeat them, but I agree with them about the enormous scope of the Bill and of the underlying arrangements it sets in place. The noble Lord, Lord O’Shaughnessy, responded to the DPRRC saying that there were “too few constraints” on power by saying that there needed to be flexibility because of future trade deals. He will know of my concerns in this area, because I raised questions with him about the protection of the NHS when he was the Minister. One of the lesser-known pillars currently protecting our NHS is the EU directive on public health procurement. It governs the way in which public bodies purchase goods, services and works and seeks to guarantee equal access and fair competition for public contracts in EU markets.

I was concerned by the noble Lord’s mention of future trade deals. We know that the United States of America wanted, through TTIP, to use trade deals to get a foot in the door of larger contracts within the UK. In the past I have said to colleagues on the Labour Benches that we have the protection of the EU directive. I now worry that that will disappear in a puff of smoke if we have a no-deal Brexit on 29 March. I am grateful to the noble Lord, Lord Livingston of Parkhead, who answered my question on this issue in November 2014 by saying:

“Commissioner de Gucht”—


from the EU—

“has been very clear: ‘Public services are always exempted ... The argument is abused in your country’”—

the UK—

“‘for political reasons’”.—[Official Report, 18/11/14; col.274.]

Can we count on the Prime Minister’s statement that all EU law will be enacted fully in the UK and that if changes are to happen they will follow later? Can I take it from that that this EU directive will be enacted and in force on 29 March to protect the NHS from unscrupulous trade deals that we were promised would not happen?

I am particularly concerned. When I asked these questions in the past, Barack Obama was President of the United States. Under President Trump I remain even more concerned about the protection of the NHS. The Minister may say that this should not be affected, because this is about arrangements, but I worry that the scope which sits behind it might actually allow it to happen—so I look forward to hearing from the Minister.

Brexit: Health and Social Care Workforce

Baroness Brinton Excerpts

Thursday 13th December 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is absolutely right. The Government certainly do not hold those staff in low esteem—quite the opposite. As we know, we need increasingly to think of health and care staff as one workforce and ensure that professional paths lead through all those professions. I am sure he will be aware of the work being done by Skills for Care, which provides the overarching policy in this area, has made recommendations about pay and helped to inform our increase in the living wage, and is providing better training facilities for those staff.

[Baroness Brinton (LD)]

My Lords, in addition to the report referred to, Coram has today published its annual survey confirming that there is not enough care available for older people, with only one in five local authorities reporting enough care in the area to meet demand. As a result, more than 4.3 million people aged 75 and over are living in an area with insufficient social care. The Minister talks about discussions with the Home Office, but we also see from the report that there was a big peak of EU staff leaving, and a big reduction in nurses, dentists and allied healthcare workers coming in from the EU. This is a perfect storm, so when will the Home Office understand that we need a range of staff in this country? Secondly, can the Minister confirm when the Government’s paper on health and social care will be published?

[Lord O'Shaughnessy]

Of course, care needs are increasing—a fact that flows from having a growing and ageing population. I should point out that the Government have increased funding for social care by more than £9 billion over three years in recent Budgets, so we recognise the seriousness of the issue. We of course want to retain those staff—it is good that there were more EU staff in the NHS in June 2018 than in June 2016, and we want them to stay. As for the social care Green Paper, it will be issued shortly.

Children: Gender Dysphoria

Baroness Brinton Excerpts

Wednesday 17th October 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is right that this is an international trend; we see in many countries similar figures for people coming forward, although, frankly, some cultures deal with the issue better than others. I am sure there are international health forums—indeed, I know there are—that deal with trans health issues and I can write to her with specific details

[Baroness Brinton (LD)]

My Lords, following the comments of the noble Baroness, Lady Nicholson, will the Minister take back also the alternative view? This is an extremely complex issue—on the current consultation on gender recognition, the survey is complex, the information provided by the Government is extremely helpful and, as a result, it has informed a lot of people as well as enabling them to answer questions properly.

[Lord O'Shaughnessy]

I am happy to do so.

Adult Social Care

Baroness Brinton Excerpts

Wednesday 11th July 2018 Lords Chamber

[Lord O’Shaughnessy]

I reassure the noble Baroness that it will be addressed. When we have the consultation, there will be more opportunity to explore that.

[Baroness Brinton (LD)]

In addition to looking at funding mechanisms from abroad, will the Green Paper look at some innovative solutions, such as the projects in Holland where students live in sheltered accommodation with the elderly, improving the quality of life for the elderly and financial support for students, which is much cheaper for the state?

[Lord O’Shaughnessy]

That sounds like an excellent idea, and I would be delighted to consider it, as well as any other ideas that the noble Baroness has.

NHS and Social Care Services: Parity of Esteem

Baroness Brinton Excerpts

Thursday 5th July 2018 Lords Chamber

[Baroness Brinton (LD)]

My Lords, what advice would the Minister give to the management of organisations throughout the NHS and social care services about maintaining morale, retaining staff, promoting professional development and rewarding good work when there is often little increase in funding from local authorities, which themselves face continuing cuts in their grant from central government?

[Lord O’Shaughnessy]

I recognise that staff work under a great deal of pressure and there are two ways we can help alleviate it. One is obviously to have social care and NHS staff work more closely together, and that is a stated ambition that we all want to achieve. The other is making sure that there are more resources, both to pay people better and to make sure that there are more people. That is what we are focused on delivering.

Health and Social Care Act 2012

Baroness Brinton Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord O'Shaughnessy]

That is one of the areas we need to look at to make sure that there is proper regulatory reform. It does not necessarily require legislation, primary or secondary. There are actually fewer managers in the NHS today than in 2010. We have tried to transfer responsibility to clinical staff. But if the NHS identifies any barriers, we are committed to looking at them.

[Baroness Brinton (LD)]

My Lords, the Minister has referred to the NHS five-year plan, but does he agree that that plan is worthless without a clear proposal for social care funding in the future, including on how the NHS and social care can fully integrate?

[Lord O'Shaughnessy]

I absolutely agree with the noble Baroness that they have to go hand in glove. That is why the Green Paper has been delayed, so that it can co-ordinate properly with the NHS plan. It is also important to point out that the Prime Minister was very clear in her announcement that, as a result of the settlement on social care, there would be no further pressures on the NHS.

Hospices: Impact of NHS Pay Increases

Baroness Brinton Excerpts

Monday 18th June 2018 Lords Chamber

[Lord O'Shaughnessy]

I was not aware of that proposal but I will certainly look at it and write to the noble Baroness with our response.

[Baroness Brinton (LD)]

My Lords, it is not just hospices and social enterprises that are affected by the differential in the proposed NHS scales; the existing framework in Her Majesty’s Prison and Probation Service demands formal nursing qualifications but there is no contractual obligation on private operators such as G4S, Serco and Sodexo to follow those grading scales and there is already wide disparity. What will the Government do to ensure that HMPPS follows both the pay scales and the NHS scales?

[Lord O'Shaughnessy]

It is important to reiterate that, in looking at one of the consequences of the Agenda for Change pay deal, the Government have committed to look at the impact not just on hospices but on staff who are not employed on Agenda for Change NHS contracts and to make sure that they are properly rewarded for the work they do.

Carers: Health and Well-being

Baroness Brinton Excerpts

Tuesday 12th June 2018 Lords Chamber

[Lord O’Shaughnessy]

Children’s hospices do an extraordinary job. They get less statutory funding as a percentage of their total; there are good reasons for that, both historically and to do with the type of care they provide. The Government are providing £11 million of support in 2018-19 through the children’s hospices grant to support them, in addition to funding from local clinical commissioning groups. But I will take his proposal for a palliative care strategy back to my right honourable friend the Minister for Care. I know that she is very interested in this issue.

[Baroness Brinton (LD)]

My Lords, the advice for local authorities on short breaks for carers of disabled children says on page 7 that short breaks should not just be there for those at crisis point. Given that many short break centres are now being closed across the country, removing help even at a crisis point, what are the Government doing to ensure that short breaks for children and their carers—for our most vulnerable and disabled children—will be guaranteed for the future?

[Lord O’Shaughnessy]

In addition to the £130 million in the better care fund, there is a commitment in the carers action plan to develop examples of best practice that can be spread around local authorities to make sure they all reach the highest standards. At the moment, unfortunately, only some of them are doing so.

Carers: Back Pay Liability

Baroness Brinton Excerpts

Wednesday 16th May 2018 Lords Chamber

[Lord O'Shaughnessy]

I agree with the noble Lord that there is a retrospective element to this, but it is around the clarification of the law. The Government have put a support scheme in place through HMRC to provide that support to resist, for example, enforcement notices on workers who ought to be paid in arrears. That is up and running and it has been open since September 2017. But clearly, as that continues we are also looking at whether other interventions might be necessary.

[Baroness Brinton (LD)]

My Lords, it is quite clear that the £2 billion extra for adult social care in the 2017 spring Budget had absolutely no relevance to this £400 million deficit and liability for providers, and it would be unwise for the Government to assume that it should be used for back pay. While it is wonderful that HMRC has slightly deferred payment, until the Government are able to help providers we will continue to see provider after provider going to the wall. Allied Healthcare cites £11 million as its own back pay on this issue. When will the Government help these providers?

[Lord O'Shaughnessy]

On the extra £2 billion of funding, I have not tried to link it with this; it is of course at the discretion of local authorities to use that to support the social care sector in the way they see fit. It is worth pointing out that Allied Healthcare is in this social care compliance scheme. My honourable friend the Minister for Care has written to it to express her disappointment at the approach it has outlined. Its liabilities have not crystallised yet, so it is not right for it to refuse that and she has written to it to demand clarification. However, clearly we understand that the clock is ticking and that there is an urgency to this.

NHS: Cybersecurity

Baroness Brinton Excerpts

Wednesday 2nd May 2018 Lords Chamber

[Lord O'Shaughnessy]

The PAC review found that the use of Windows XP was at the heart of the problem, as an unsupported and unpatched system. Several things have happened as a consequence. First, XP usage has gone down from 18% in 2015 to 1.7% now. We also have a customer support agreement with Microsoft now and are transitioning to Windows 10, which is of course fully supported and much more secure. We also have a system now called cursor collect. The notifications that go out, called cursor notifications, are due to be acted on within 48 hours. That exposes the fact that we did not have a way of tracking that. We now have a way of tracking that and enforcing action at trust level. So there is a much higher degree of security than there was. Of course, no security is ever perfect and our vigilance carries on.

[Baroness Brinton (LD)]

My Lords, in Scotland it is possible for your records to be transferred from one hospital to another or from your GP to your hospital without any consequences at all. One of the concerning things about the Public Accounts Committee report is the systemic failures in IT overall in NHS England. One example is where regional hospital A cannot receive data from district hospital B, even if it is a simple blood test, because they use different systems; the consultant I spoke to said that he actually advises people to use faxes. This is our NHS in the 21st century.

[Lord O'Shaughnessy]

The noble Baroness is highlighting a historic problem about interoperability between different bits of the NHS in England. That is absolutely fair enough. I would highlight two things that we are doing. First, the National Data Guardian for Health and Care has defined 10 data standards that should apply to both security and interoperability between different systems, and those now apply in all key NHS contracts, including the standard NHS contract. Secondly, we have launched a programme to appoint up to five local health and care record exemplars, which will provide interactive and interoperable data for patients for their direct care—so that the issue we have at the moment of data sometimes falling between different institutions will not happen any more.