Health and Social Care (Re-committed) Bill

Caroline Lucas Excerpts

Wednesday 7th September 2011 Commons Chamber

[Andrew George]

On that basis, Madam Deputy Speaker, I will end that part of the conversation and move on, acknowledging that my hon. Friend has made a point that is worth considering.

Amendment 1224 would restore the duty to provide or secure provision of health services. Although that is seen as the headline proposal, it is consequential on new clauses 16 and 17, hence my intention to draw attention to the likelihood of my seeking to divide the House on those issues.

Amendments 1222 and 1223 seek to establish why the Bill has never provided for the Secretary of State to provide or secure a comprehensive health service rather than promote a comprehensive health service. This is an either/or situation, but I draw attention to the possibility that instead of pressing new clause 16, I may, in discussion with others, seek to divide the House on amendment 1222.

Amendment 1183 would beef up a duty of the Secretary of State—a theme that runs through a number of amendments. The purpose of amendments 1183 and 1194 is to address the conflict between having regard to reducing inequalities and placing above that duty the other duties that apply—for example, on choice. Amendment 1183 seeks to ensure that it is the duty of the Secretary of State, in reducing inequalities, to

“act with a view to”

rather than merely “have regard to”. Otherwise, the responsibility, and the duty, on the Secretary of State is rather weak. That applies to amendment 1194 in the same manner.

New clause 18 would impose a new duty on the CQC, the NHS Commissioning Board and clinical commissioning groups not to undermine existing NHS services in an unplanned way through the operation of competition. Rather than extending my description of this issue, it might be worth referring to the debate that we had yesterday about the regulations surrounding the functions and duties of Monitor, as the same question arises. We have to look at the impact that competition is likely to have on the provision of essential services such as major trauma and accident and emergency, where its existence may destabilise emergency services through the loss of, for example, important underpinning elective services provided by the hospital.

New clause 20 would ban the wholesale outsourcing of commissioning work with regard to clinical commissioning groups. That was demanded in a Liberal Democrat conference motion but has still not been delivered. The commissioning process is a public function, not a private function. The amendment therefore seeks to change schedule 2 in different ways to prevent private entities on clinical commissioning group committees and sub-committees from commissioning and making other decisions. This also applies to amendments 1224, 1245, 1244 and 1249.

The Minister said that the work of the Neurological Alliance is important to preserve. I hope he will recognise that new clause 20 talks only about commissioning work being

“predominantly retained as a function by staff directly employed by the clinical commissioning group.”

There is nothing in the Bill that prevents the bulk of the commissioning work—not the decision, but the work—of a clinical commissioning group from being done by a private company and thus, potentially, in secret. I hope he will accept that under the current wording of schedule 2, private entities will be able to sit on clinical commissioning committees and sub-committees and make commissioning decisions.

Amendments 1184 to 1188 and 1195 would demote choice to a subsidiary duty of commissioners to tackle fair access and inequality of outcomes. They relate to page 17 of the Bill. The priority of choice over inequity and inequality was introduced by the Government after the pause and the NHS Future Forum report as a way of promoting competition in ways other than through the role of Monitor. The amendments would reverse that priority for the NHS commissioning board.

Amendment 1211 provides that clinical commissioning groups should be more coterminous with local authorities than is the case under the Bill. The Minister said that there is no intention that clinical commissioning group boundaries will cross local authority boundaries. However, we all know that district councils do not cross local authority boundaries. In Cornwall, for example, we are likely to move from one PCT to three clinical commissioning groups, which will make the streamlining of the pathways between health and social care a lot more difficult. The purpose of amendment 1211 is to enforce that point.

I am aware of time and I hope that the House will appreciate that I will not explain every aspect of the many other amendments I have tabled. I am aware that there are significant issues that other people wish to raise. I simply emphasise that what the Minister said about health and wellbeing boards being able to refer matters to the Secretary of State is once again something that we have always argued for. Local authorities should of course be given a far greater say in commissioning decisions and in setting the strategy for health services in their area. As a back-stop, it is important that matters can be referred to the Secretary of State. My hon. Friend the Member for Cheltenham (Martin Horwood) has tabled some important amendments in respect of public health, some of which I have supported, and I hope that the Minister will consider them. I apologise for the amount of time I have taken, but I hope that the Minister will address the important issues advanced by the amendments.

[Caroline Lucas (Brighton, Pavilion) (Green)]

I apologise for not being present for the first half hour of this debate. I was in the Environmental Audit Committee, where I had specifically asked for certain witnesses to be invited, and I have not yet worked out how to be in two places at once, although it is on my list.

I will make a few general points about this part of the Bill before turning to a couple of the amendments that are in my name. I echo the many concerns that have been expressed around the Chamber this afternoon. Many of us argue that there is no legal duty on the Government to provide health services. The new hands-off clause limits the Government’s ability to intervene should health care provision be deemed inadequate, because it says that clinical commissioning groups, the new agents of health provision that can include private companies, must be free to exercise powers and duties without “unnecessary burdens”. I am equally concerned that the powers and duties of a commissioning group, including its ability to award contracts and charge for commercial activities, could be exercised by a private health care company. The Bill opens the way for private companies to determine much of English health care and takes away the Government’s duties and powers, which is why I believe it should be opposed.

--- Later in debate ---

[Andrew Percy]

The hon. Lady is making an interesting argument, and I would just ask her two things. First, how is she suggesting that we should pay for the idea? Secondly, is she seriously suggesting that we should return to millionaires being provided with dental treatment and eye care free of charge?

[Caroline Lucas]

It seems to me that if Wales and Northern Ireland have been able to abolish prescription charging altogether, it is certainly possible to do it. I would also argue that although everyone collectively having a stake in our public services may well mean that millionaires get a free eye test, under the type of regime that I would like to see they would be paying an awful lot more tax than they are under the Conservative party’s regime.

[Fiona O'Donnell]

I am aware that the hon. Lady sits close to Scottish National party Members, who may not have given an accurate picture of what has happened in Scotland. We have free prescriptions, but we also have 1,200 fewer nurses. People such as me are getting our prescriptions free, but that puts strain on other parts of the service.

[Caroline Lucas]

I thank the hon. Lady, but I do not agree that the two points that she makes are causally linked. Of course I do not want to see the abolition of nurses, but that does not mean that we should have to pay for our prescription charges. Either we want an NHS free at the point of delivery and with free eye tests and so forth or we do not. [Interruption.] Someone is speaking from a sedentary position, no doubt asking how we will pay for it. I will be very clear that there is massive potential in cracking down on tax evasion and avoidance, higher tax for the rich, higher corporate tax and so forth. We are essentially talking about political priorities. The priority that I represent—a great many more people are coming to this view—is that we should be willing to pay for the public services that we want.

Hon. Members may oppose amendment 48 on the basis that charging for prescription or for dental and eye care is an important way of raising revenue. In England, eligible patients pay a prescription charge of £7.20 an item. In Scotland the charge is £3 and Wales and Northern Ireland have abolished prescription charging altogether. England raised just £470 million through the charges in 2009-10, which was just 0.5% of the NHS resource budget.

Crucially, we should remember that income from charging in the NHS is not pure profit. There is a real cost to administering the plethora of exemptions and reduced charging rates for which different groups are eligible. For example, there are 11 different groups that are eligible for free dental care, 15 that are eligible for free sight tests and 12 that are eligible for free prescriptions. I hope that hon. Members will see the benefit of doing away with that convoluted and complex system, which provides little benefit in terms of income, and which goes directly against the NHS principles by significantly reducing people’s access to all forms of health care simply because of their inability to pay.

Much has been said by hon. Members on both sides of the House about the founding principles of the NHS, and it will continue to be said. However, I put it to hon. Members that amendment 48, more than any other, seeks to point out that much important NHS care and treatment is charged for, and that we need to go back to NHS services as they were envisaged by its architect, who has been referred to many times this afternoon. Hon. Members might recall that he resigned as Health Secretary as early as 1951, in protest at his Chancellor’s efforts to impose charges for prescriptions, dental treatment and eye care.

Amendment 1181 raises serious concerns about the way in which CCGs will be able to charge for services. Although the power to charge, under proposed new section 14Z3 to the National Health Service Act 2006, is intended to be of benefit to the health service, it is very disturbing. Its scope is unclear—I wrote to the Minister last week to ask for clarification—but the fact is that important limitations on how the Secretary of State can exercise that power would apparently not apply to CCGs. The measure could run a coach and horses through the principle of a free health service, and Parliament needs to be clear on its impact in practice.

It is extremely worrying that CCGs will be able to decide that certain specialist services—for example, for pregnant women or women who are breast feeding young children, or aftercare—are not appropriate as part of the health service. That would mean that the statutory guarantee that the NHS will be free will not apply, because CCGs can decide that certain services and facilities should not be provided as part of the NHS. If that happened, CCGs could use the charging power to decide to charge for supplying, for example, goods to pregnant women, or for instructing people how to use their rehabilitation equipment.

Amendment 1181 would ensure that that could not happen. Ministers might say, “CCGs are commissioners and not providers”. If so, why is a measure that allows CCGs to charge necessary in the first place? The amendment would make it absolutely clear that there is no way in which a CCG could charge for anything that is related to the basic core health service, such as hospitals, doctors, nurses or ambulances, whether they are acting under section 3 or proposed new section 3A of the 2006 Act. The amendment would also impose on CCGs the same limitation that is already imposed on the Secretary of State. Why was that omitted from the Bill?

It is right that raising funds under that power should not interfere with a CCG’s functions. However, the Bill says that raising funds should not interfere significantly, but what on earth does “significantly” mean in that context? How is it to be determined or measured? If companies such as UnitedHealth got hold of that power and reckoned they could make money out of it, they will be on to it in a flash. The very least that they should be required to do is demonstrate that dealing in land and supplying goods and the like will not take them away from fulfilling their commissioning role. I would prefer it if those giant profit-driven companies were nowhere near the health service, but while they are, we need far greater safeguards than currently exist.

Unfortunately, the previous Government gave overseas companies the legal route into the NHS, and this Government are seeking to smooth that route yet further. Hon. Members may recall that at Prime Minister’s questions on 18 May, the Prime Minister claimed that he had not heard of Mark Britnell, one of his health advisers, who was also a key adviser under Tony Blair, until he googled him the previous Sunday. The Prime Minister’s interest was stoked by a report of a speech that Britnell, global head of health care at KPMG, gave to a group of private health companies in New York last October. Dr Philip Hammond pointed out in Private Eye that according to a brochure summarising the conference, Britnell said:

“GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process…In future, the NHS will be a state insurance provider, not a state deliverer…The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.”

That is a shocking thing to say, and no wonder the Prime Minister was keen to distance himself from it, at least in public.

My last point is about the final proposal in amendment 1181, which would mean that:

“Income raised by a clinical commissioning group as a result of the exercise of powers under this section shall be specified in its annual accounts, referred to in its annual report under section 14Z13, and paid annually to the Secretary of State.”

Without the amendment, it is completely unclear what CCGs will do with the money that they raise and how, if at all, it will affect their budget allocations. I think it would be madness for Parliament to give CCGs the right to charge for supplying goods, dealing in land and providing instruction for the purposes of raising more funds for the NHS, and then not to require them to account for it in any way, and not to ensure that the funds find their way back to the public rather than the private purse. This part of my amendment seeks to ensure that that is done.

Amendment 1234 refers to the fact that once they managed to get into the CCGs, multinational health companies such as UnitedHealth would be allowed to do the actual commissioning, thus creating a very unhealthy form of what is effectively in-house outsourcing. I understand that they will be able to charge for the supply of goods if the Government do not accept the amendment. Parliament cannot trust companies whose primary duty is to their shareholders to be in charge of so much taxpayers’ money, nor should such companies be given the right that the Secretary of State currently holds to charge for the supply of goods or for land deals. We should make it clear that CCGs cannot agree among themselves that their functions will be carried out by one of their private company members. Commissioning is a public function that should be exercised in the public interest, and private companies such as UnitedHealth should not be entitled to charge for any it.

[Nick de Bois (Enfield North) (Con)]

I refer Members to my entry in the Register of Members’ Financial Interests. I wish to speak to amendments 1172 and 1173, in my name, which require the Secretary of State to collect haematopoietic stem cells. The issue is, of course, that of the collection of umbilical cord blood and cord bank policy, which was first raised in the last Parliament.

I pay particular tribute to the work of the all-party parliamentary group on stem cell transplantation for its work under the leadership of the hon. Member for Alyn and Deeside (Mark Tami), and to the enormous contribution and determination of my hon. Friend the Member for Enfield, Southgate (Mr Burrowes). My previous lack of knowledge of the subject was probably no different from that of many other people, but after giving my hon. Friend and neighbour a lift home on several occasions I became a speedy convert. Quite simply, the collection of cord blood can be life-saving. I pay tribute to the work of the Anthony Nolan trust in that regard.

In 1974 the Secretary of State was not obliged to facilitate stem cell transplantation from unrelated donors. Because the Governments of the day took that position, advances made took longer to achieve, which undoubtedly cost lives. The situation is different now: both the Government and the Opposition support expansion of the practice, and in particular of the more modern use of umbilical cord blood for such purposes. However, it would be fitting for the Minister now to make it clear in the Bill that this issue is important, to lock in the bipartisan support while it is strong, and to send a message to future Governments and civil servants that for as long as the Bill remains on the statute book, the issue is not to be lightly disregarded or de-prioritised at a future date.

The amendments involve no financial or political cost, but they are not merely symbolic. They could be described as an insurance policy against the risk of thoughtlessness or distraction on the part of future Governments—a risk that would ultimately cost lives.