Debates between Edward Argar and Justin Madders during the 2019 Parliament

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Ambulance Services in England

Debate between Edward Argar and Justin Madders
Thursday 10th February 2022

(2 years, 2 months ago)

Commons Chamber
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Edward Argar Portrait The Minister for Health (Edward Argar)
- Parliament Live - Hansard - -

Reflecting the rest of the week, Mr Deputy Speaker.

I am grateful to the hon. Member for Ellesmere Port and Neston (Justin Madders) for securing this important debate. In the same spirit, this is rather nice; it is like déjà vu: he used to shadow me at that Dispatch Box and in Committee. It is a pleasure to respond to his debate on this occasion.

However, I must say that responding to the hon. Gentleman is a pleasure slightly tempered by caution on my part, because I know the depths of his expertise on this subject after his many years shadowing the Minister for Health—I think he shadowed my predecessors as well. He has great depth of knowledge in this space. He is and has been a notable advocate for our ambulance service and what it needs, and he looks forensically into those issues. I also know that he is a diligent reader of The BMJ, the Health Service Journal and various other excellent trade and specialist publications. It is a genuine pleasure to respond to him on this extremely important issue. It is a shame that the way in which the House allocates debates means that this is the last debate of the day, so there are few Members in the Chamber for it, because it is important. However, those we have in the Chamber are quality, and I look both at the shadow Minister—sorry, the former shadow Minister—and the hon. Member for City of Chester (Christian Matheson).

As the hon. Member for Ellesmere Port and Neston highlighted, ambulance services have faced extraordinary pressures during the pandemic. I am sure that the House will join me and the shadow Minister—the former shadow Minister; by force of habit, I keep calling him the shadow Minister. The hon. Gentleman and I have not always agreed, but we have been as one in paying tribute to all those who work in our ambulance services up and down the country. They have done an amazing job over the past two years, during the pandemic, to the very best of their ability. Of course, they do that amazing job day in, day out; irrespective of pandemics, they always do everything they can to support those who need them.

The hon. Gentleman rightly highlights that the pandemic has placed significant demands on the service. In January 2022, it answered more than 800,000 calls. That is an increase of 11% on January 2020 and is one of the factors placing significant pressures on ambulance services, the wider NHS and the A&E departments to which they will take people when they feel that there is a clinical need. Although 999 calls tend to highlight the demand related to more serious medical conditions, many ambulance services are also responsible for 111 calls, which, in December last year, saw an increase of 15.5% compared with December 2019.

I use those statistics to illustrate the demand pressures, but I understand that behind those numbers, in every case, lies a human story—someone in need of care, someone worried and anxious, with friends and family anxious for them—so before I seek to go into the reasons, statistics and our plans and support, I want to say that I am sorry for patients who have suffered the impact of those service pressures. I want to be very clear that patients should expect and receive the highest standards of service and care.

The hon. Gentleman highlighted some specific examples, including the case of Bina Patel. He is right that the right hon. Member for Ashton-under-Lyne (Angela Rayner) has raised that with me. I have asked for full information because I want to get back to her with as full an answer as I can, and I hope that he can convey that to her, if he speaks to her before I do. I am fully aware of her correspondence raising this on behalf of the family.

Let me turn to ambulance response times and the reasons sitting behind some of the pressures. The ambulance service is facing a range of challenges that are impacting on its performance. The hon. Gentleman will be familiar with many of them, including the impact, still, of infection prevention and control measures not only in the ambulance service but particularly in A&E departments and wider acute clinical settings. Higher instances of delays in the handover of ambulance patients into A&E as a result of some of those factors, which I will turn to, are therefore leading to ambulances waiting for longer in queues and not being as swiftly out and about on the road and able to respond to calls. So there are knock-on effects there.

One of the key challenges, which the hon. Gentleman will be very familiar with, remains the question of flow through an A&E and through a hospital. I am referring to the flow of patients out of ambulances into the A&E, who are then able to be treated in the A&E and discharged, hopefully, or who are then, in some cases, able to be admitted to a bed in a hospital ward. To do that, we have to see discharges continue of patients who no longer meet the criteria to reside because they have recovered sufficiently, and the national discharge taskforce has done a huge amount of work on addressing that challenge.

In recent months, we have seen the combined pressures of winter—the hon. Gentleman and I are familiar with those on an annual basis—and the impact of the omicron variant on the number of hospitalisations, which have not been as high as many feared and predicted, thankfully, but which have still had a significant impact on hospital beds. The combination of those factors, coupled with a high level of workforce sickness absence rates, including through positive covid tests—particularly over recent months with omicron—has created pressures that we would not expect to be systemic or built into the system. That partly reflects longer term pressures, and I will move on to what we are doing to address those, but a large element of it is down to the specific circumstances of the past winter.

The hon. Gentleman touched on the support in place to improve services, and asked what we are going to do about it, and what is being done to address these issues. He is true to form from when he shadowed me, as he will always set out the challenge and ask me what I am going to do or am doing about it, rightly holding the Government to account. Because of the pressures I mentioned we have put in place strong support to improve ambulance response times, including a £55 million investment in staffing capacity to manage winter pressures to the end of March. All trusts are receiving part of that funding, which will increase call handling and operational response capacity, boosting staff numbers by around 700.

NHS England has strengthened its health and wellbeing support for ambulance trusts, recognising the pressure of the job on those working in the ambulance services, with £1.75 million being invested to support the wellbeing of frontline ambulance staff during the current pressures. NHS England and Improvement is undertaking targeted support for the most challenged hospitals, to improve their patient handover processes, helping ambulances to get swiftly back out on the road. That is focused on the most challenged hospital sites where delays are predominantly concentrated, with the 29 acute trusts operating those sites being responsible for more than 60% of the 60 million-plus handover delays nationally. That is targeted support for trusts that have particular challenges, either from the current situation or where there are underlying issues that we need to resolve.

There is capital investment of £4.4 million to keep an additional 154 ambulances on the road this winter, and a £75 million investment in NHS 111 to boost staff numbers by just over 1,000, boosting call taking and clinical advice capacity that will better help patients at home, and better help triage those who genuinely need an ambulance and those who can be treated safely in a different context. There is continuous central monitoring and support for ambulance trusts from NHS England’s national ambulance co-ordination centre, and we have also made significant long-term investments in the ambulance workforce. The number of NHS ambulance staff and support staff has increased by 38% since July 2010.

More broadly, alongside the ambitious plan set out by the Government earlier this week, showing how we will invest the significant additional resources in outcomes for patients, just over a year ago we invested £450 million in A and E departments, to help mitigate the impact through increased capacity of infection prevention and control measures. I have regular direct meetings about discharge rates, and what we can do further to improve the flow of patients through hospital trusts within NHS England, with members of the taskforce on that.

I am pleased to reassure the hon. Gentleman that those measures have had an impact, and we are seeing improvements in response times from the peak of the pressures in December. Performance data for January, published today, shows significant improvement against all response time categories. Performance for category 1 calls—the most serious calls, classified as life-threatening—has largely been maintained at around nine minutes on average over the past several months, and improved to eight minutes and 31 seconds in the latest figures. That is despite a 19% increase in the number of incidents in that category compared with December 2019. Average responses to category 2 calls improved by more than 15 minutes compared with December, and the 90th centile responses to category 3 calls by more than two hours.

We recognise that that is welcome progress, as I am sure the hon. Gentleman would agree, but there is much further to go to recover fully from the pandemic’s impact on response times and to sustain that improvement. We welcome the service’s hard work and dedication and pay tribute to it for making those changes and delivering the significant improvements on which I am updating the hon. Gentleman.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As always, the Minister is being courteous and comprehensive in his response. Will he comment on the concern expressed earlier about patients being told, when visited by the service, that they needed to go to hospital but should find their own way there? That is extremely worrying, and we should be clear that it is not what we expect to happen.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Gentleman—I keep feeling tempted to say shadow Minister; he is a shadow Minister but he is no longer my shadow—for that point. He is right that when people ring 999 they should be given the appropriate clinical advice on whether they need to go to hospital, and if they do, an ambulance should be sent. I suspect that in individual cases a call handler may have made a tough clinical decision about the fastest way to get someone to hospital given the availability of ambulances, but the hon. Gentleman is right that if someone rings 999 and their condition is clinically deemed to require an ambulance and swift transfer to hospital, they should be able to expect an ambulance to come, assist them and take them to hospital.

At a time when the NHS is facing unprecedented demand, ambulance services are absorbing some of the increase in pressure. They are treating more people over the phone and finding other ways to reduce pressure in a clinically safe way. With clinical support in control rooms, the ambulance service is closing around 11% of 999 calls with clinical advice over the phone. That is far more than the 6.5% achieved in January 2020 and saves valuable ambulance resources for response to genuinely more urgent clinical needs.

Let me say a little about North West Ambulance Service, if that is helpful to the hon. Gentleman—I know that he and the hon. Member for City of Chester take a close interest in their local ambulance service. Our support and investment has benefited the North West Ambulance Service. The hon. Member for Ellesmere Port and Neston’s local trust received £6.2 million of funding, which it has used to increase its workforce for operational and contact centre teams. The trust is also engaged with regional NHS England and Improvement and commissioning teams to develop a six-point winter plan that seeks to address six key areas throughout the winter period. As it starts to get a little warmer and the daffodils start to come out, it is tempting for people to think that winter has passed, but winter pressures in the NHS can continue into late February and occasionally a bit beyond. I wanted to add that caveat.

Three systems-led initiatives focus on the reduction of hospital handover times, the improvement of pathways for patients with mental health presentations and ensuring that alternatives to emergency departments—including access to primary care and other non-emergency-department pathways—are available to North West Ambulance Service in a timely and responsive manner.

Hospital handover delays continue to challenge the North West Ambulance Service footprint. Through its Every Minute Matters collaboration, which began three years ago, the trust has been working with other hospital trusts on improvements by working with senior leadership teams in hospital trusts to ensure there is a shared understanding of the risks of handover delays and a lack of ambulance resources to respond to patients in the community, to revisit action cards for operational commanders and, crucially, to recognise and thank staff for their continued reporting of delays and willingness to highlight problems to their managers or to the trust.

The trust’s strategic winter plan has been activated and includes details of the measures in place to handle winter pressures and mitigate the effects of increased demand and a loss of capacity. The plan is comprehensive and covers a wide range of topics and details on the preparation for various scenarios. It includes several continuous improvement initiatives for support during the winter period.

In summary, North West Ambulance Service is increasing its double-crewed ambulance capacity in line with winter funding arrangements, reducing conveyance to emergency departments and reducing the number of lost operational hours caused by day-to-day operational challenges. The trust has already seen significant improvements in the number of patients managed effectively through telephone advice, which helps free up ambulances to be deployed to where they are most needed. The trust has recruited additional paramedics and emergency medical technicians and upskilled its ambulance care assistants to blue light driving standard, thereby enabling the trust to deploy 269 additional frontline staff by the end of December.

I close by reiterating the Government’s commitment to support the ambulance service. We retain regular contact with ambulance services, trusts and those delivering on the frontline to help to ensure that patients and the ambulance service receive the care and support that they need. I am grateful to the hon. Member for Ellesmere Port and Neston for bringing this matter to the House.

Question put and agreed to.

Health and Care Bill

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful for the manner in which the hon. Lady puts her points. She is right; we have debated this previously. We have been publicly clear that we do not believe that the exemption or exception should be extended to the ombudsman. She is right that there are campaigns saying we should have no exceptions or that we should widen the exceptions. We believe we have struck the right balance with this measure, while respecting the fact that a coroner is a judicial office holder and has a very specific function to perform, as set out in legislation in—this is where my memory may fail me—the Coroners and Justice Act 2009, which recognises their particular and special status. I suspect that she and I may have to agree to disagree on whether the appropriate balance is struck, but that sets out why we have done what we have done.

How best to achieve an effective safe space is complex and the current drafting has been arrived at through years of detailed policy work, including pre-legislative scrutiny before the Health Service Safety Investigations Bill was introduced in the other place in autumn 2019. The issue was also debated at length in Committee, and I look forward to hearing contributions from Members on that, particularly the hon. Member for Central Ayrshire.

Turning to the two minor and technical Government amendments to the health service safety investigations body provisions, amendment 24 is a technical amendment to clarify the definition of “investigation” that applies to part 4 of the Bill. Investigations carried out by HSSIB by agreement under clause 114, which relate to Wales and Northern Ireland, were never intended to be part of the main investigation function of HSSIB and therefore will not be covered by the safe space or other investigatory power provisions provided for in the Bill. The amendment ensures that the drafting of the Bill fully reflects that original policy position. I hope that hon. Members on both sides of the Chamber will be content to pass this technical amendment.

Finally, I turn to Government amendment 88 to schedule 13. Schedule 13 contains a regulation-making power which allows the Treasury to vary the way any relevant tax has effect in relation to associated transfer schemes. Regulations made under this power will be used to ensure that no unintended tax consequences arise. The amendment ensures that value added tax is included in the taxes which the Treasury can, by regulations, vary when considering the transfer schemes in this Bill. Without this amendment, it is possible that complications with VAT bills may arise when transfer schemes are made and transactions take place. It is for those reasons that I ask hon. Members to support this amendment.

I am conscious that other hon. and right hon. Members may wish to speak to their amendments. I look forward to addressing those that I have not directly addressed thus far when I wind up debate on this group of amendments. With that, I conclude.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Parliament Live - Hansard - - - Excerpts

I thank the Minister for his introduction. It seems like only yesterday that we were having a similar exchange across the Dispatch Box.

I will begin with our new clauses 28 and 29 and amendment 10. This discussion about workforce could well be the most important of all today. Just this weekend, Chris Hopson from NHS Providers was trying to get the Government to acknowledge the seriousness of the problem when he tweeted:

“93k NHS staff vacancies. £6bn spend on temporary staff to fill gaps. 55% of staff working unpaid extra hours each week. 44% saying they’ve felt ill with work related stress. NHS desperately needs long term workforce planning. Govt must make this happen this week.”

Everything comes back to workforce and the failure to invest in it consistently over a sustained period. Today we have a chance to correct that.

While we favour our new clause 29, it is obvious that amendment 10 has captured the attention of many and may well be put to a vote. In many ways, as the Minister said, it closely mirrors what we have put forward, so I will be making my general points on both the new clauses and the amendment. In supporting amendment 10, I pay tribute to the right hon. Member for South West Surrey (Jeremy Hunt), the Chair of the Health and Social Care Committee. Given his previous role, he is well placed to have an informed view on what needs to be done, and he has done that with this amendment without undue hype or drama. The support he has obtained more widely from stakeholders outside the House is impressive; indeed, the way he has united just about the entire sector shows not only his powers of persuasion, but the importance of the issue. He has come close to uniting the entire sector in the past, but that was usually in opposition to something he was proposing, rather than in support. There may be many other areas where we have disagreed in the past, but that does not diminish our support for his call.

Health and Care Bill

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
- Hansard - -

I am afraid I am about to conclude. I suspect that the hon. Gentleman will come back in with a speech and I will endeavour to pick up on that in the wind-ups.

There are a number of similar amendments, such as amendment 101 in the names of the hon. Members for Wirral West (Margaret Greenwood) and for Brighton, Pavilion (Caroline Lucas). I hope they might feel, to some degree, reassured by our amendment and the intent behind it, but that is obviously for them to say. We believe that the Government’s amendment puts beyond doubt what we believe was already entirely clear but were determined to put beyond doubt—that ICBs will not and cannot be controlled in any way by the private sector, as NHS-accountable bodies guided by the NHS constitution and with NHS values at their heart. These principles, I believe, irrespective of other debates we may have this evening, command respect from both sides of this place. I therefore commend the amendments to the House.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Parliament Live - Hansard - - - Excerpts

A wide range of issues that are part of this group of amendments demonstrate the cold reality of this Bill. It is a jumble sale of bits and pieces. Of course a Bill can be wide-ranging, but having breadth is not the same as having coherence, or indeed clarity. Such are the issues within scope in this grouping that I will not comment directly on every new clause and amendment but hope to have time to say at least a few words on those emanating from the Opposition Front-Bench team, as well as on any Government new clauses or amendments that we oppose. Some amendments refer to matters that have been dealt with in Committee where we have expressed our views and put forward amendments that failed to persuade the Government. Sadly, we have insufficient time to go over the same ground again, particularly given the rapid shifting of the goalposts we have seen in the past week.

I turn first to integrated care boards, or ICBs, and, more widely, the issue of governance. The question of governance and accountability remains an important matter to us and needs greater clarity than currently appears in the Bill. For Members who may not be familiar with the detail, the Bill proposes yet another reorganisation of the NHS, creating 42 new integrated care systems where decisions on how NHS and care spending will be made. The decision-making bodies within these systems are the ICBs, replacing the CCGs, which fall away into the annals of history alongside the primary care groups, the primary care trusts and all the other permutations that we have seen.

Our discussions on these matters in Committee showed that our disagreements tended to centre around an intention by Government to limit what is in statute and to leave maximum flexibility at local level, as opposed to our desire to ensure that safeguards and protections were in place for those matters we felt were too important to be left out. It is wholly ironic, therefore, that the Bill proclaims, on the one hand, local freedoms and flexibilities, yet on the other proposes sweeping top-down powers for NHS England and the Secretary of State. Our view remains that some flexibility is fine to allow shaping to local needs, but that some key principles need to be put into the Bill to ensure that there are no misunderstandings or unintended consequences.

We know that the genesis of this Bill has been the realisation that increasingly large parts of the NHS were ignoring the 2012 Lansley Act. Along with changes to procurement and pricing, this grouping deals with the main elements of reversing parts of that Act. We could spend all our time referring to what we said 10 years ago, and how the Health and Social Care Act 2012 has proved to be the disaster that we said it would be, but we will spare the Government the “We told you so” lectures, because even those on the Government Benches are now aware that the 2012 Act has been among the worst policy mistakes in the history of the NHS. Whether that damage was worse than the damage done by a decade of austerity remains to be seen, but repairing the damage done by austerity is not for today, as there is little in the Bill to address the ongoing consequences of a decade of underfunding, particularly the wholly appalling waiting times that we now see across the board.

Hospital Building Programme

Debate between Edward Argar and Justin Madders
Wednesday 3rd November 2021

(2 years, 5 months ago)

Westminster Hall
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Edward Argar Portrait Edward Argar
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My hon. Friend, quite wisely, presses his advantage. I can give him some reassurance on that, as I did to the shadow Minister when talking about the criteria, that safety and risk will not be the only criterion, but that will be a key factor in the consideration.

I turn now to the contribution of my hon. Friend the Member for North West Norfolk. The other day in the Chamber, I inadvertently paid tribute to my hon. Friend the Member for North Norfolk (Duncan Baker) for the work being done by my hon. Friend the Member for North West Norfolk in one of my responses. I pay tribute to my hon. Friend for North West Norfolk, who has quite rightly raised with me on several occasions the Queen Elizabeth Hospital King’s Lynn and the challenges posed by RAAC planks there. I know he is campaigning both in Parliament and locally on that issue. Courtesy of him, I have met his trust in the past and we have provided more than £20 million in this financial year for critical risk remediation. I know that, quite understandably, my hon. Friend is saying very clearly that that is welcome and will help, but it will not solve the problem. He will continue to press the case for a new hospital. He, too, has kindly invited me to his constituency, so I think I am due to go on tour around the country at some point, visiting various hospitals and colleagues.

Turning to some of the broader underlying themes that have emerged in the debate, I will seek to answer some of the questions posed by the shadow Minister. He gently tempted me on definitions. I am clear that the definitions we have—the three key elements he alluded to—not only pass the common-sense test and the understanding of what the reasonable person in the street would consider a new hospital. Equally, he teased me gently about VAT notice 708. I mentioned that at the Dispatch Box because—he says that we should be transparent and have a logical reason for how we define, do and choose things—our starting point was that there can be a VAT exemption for new builds, but not necessarily for refurbishment. I took that as a starting point for developing the common-sense definition. A lot of what he sees in the definitions is reflected in the same one used there, so there is consistency.

The shadow Minister talked about skills and inflation and whether we will have the people to build the hospitals. He is right to do that, because, as we have seen following the bounce back after the pandemic, builders and construction firms are very much in demand. There is pressure on materials as well, not just inflationary pressure, but on quantities. That is one of the reasons why, even before the impact of the pandemic, this is a phased programme. These hospitals will be built over a period of years up to 2030, allowing for market capacity.

Equally, one of the reasons why we have set out this long-term plan is so that we can make the market aware of what our plans are. If there is certainty in the market that the hospitals will be coming through, we will see firms investing, because they know there is potential for long-term business and work for them. That is one of the ways in which we have helped to handle that.

The shadow Minister asked about funding, and what would be available for what period. He will be aware of the initial £3.7 billion that has been allocated to this project, which takes us to 2024. Future funding will be subject to future spending reviews for that period. Between the 2024 period and 2030 there will be a general election at some point, and I suspect that may play a part in the spending review as well. We have the funding up front to get going with this programme, and off the top of my head, I think we already have eight hospitals in construction. The Cumberland Cancer Hospital has already been opened by my right hon. Friend the Health Secretary. Over this period, we will continue to start further construction of new hospitals.

The shadow Minister also alluded to geography and the distribution of the hospitals. Off the top of my head, 30 of the 40 are outside London and the south east, so we have sought to achieve geographical spread for the new hospitals and, equally, will seek to do that with the new eight. He also asked about the quantum needed for a new hospital, and he had a particular figure in mind. If he looks at the list of 40, many of them are very different hospitals, from the major acute district general hospital to a community hospital with in-patient beds; it is clearly a new hospital. The costs vary in the nature of what is built, its scale and size.

The shadow Minister also asked whether there would be a cap and whether trusts have complete freedom. No—as he would expect, there is a balance is to be struck between delivering what a trust wants for its plans and the need for financial prudence and recognition of the need to safeguard taxpayers’ money; it is not a limitless amount. Conversations are going on between the national team and local projects to ensure that their schemes are affordable and not hugely over budget. That is a pragmatic, ongoing process.

The shadow Minister also touched on some of the criteria for the scheme and how we are making the national scheme work. We include in this modular build modern methods of construction. We have a national set of standards for what we would expect from a new hospital, but a degree of local flexibility for the delivery of that. We recognise that each trust is slightly different, but we want to standardise where we can, because that keeps costs down and provides certainty in the market and speeds up construction. We have also built into our plans, since they were originally announced, even more ambitious green targets and energy efficiency targets for those trusts.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful to the Minister for giving way. He has made a valiant attempt to answer all my questions.

Edward Argar Portrait Edward Argar
- Hansard - -

I thought the hon. Gentleman would lob another one at me.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

No, but there is one that the Minister has overlooked, on the sum announced in the spending review last week. Was that additional money on top of what had been previously announced?

Edward Argar Portrait Edward Argar
- Hansard - -

I omitted to mention two things to the shadow Minister: the spending review and backlog maintenance—he always avails himself of the opportunity to gently raise that issue. We have seen a confirmation of the money already in place for the new hospital programme, but we have also seen further moneys announced for capital in the spending review—new money—for example, just over £5 billion for community diagnostic centres, surgical hubs and the IT infrastructure around that. We have therefore seen a reconfirmation of money, plus new money in the capital space.

I turn now to maintenance, which the shadow Minister rightly always highlights. He will know—he occasionally quotes it at me at the Dispatch Box—that backlog maintenance across the entire estate is around £9 billion-worth. That is pretty constant from the previous financial year; it has not particularly increased. It may have gone up by a tiny fraction, but it has remained broadly constant.

Health and Care Bill (Twenty First sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
- Hansard - -

There is no doubt that the climate emergency is also a health emergency. Climate change threatens the foundations of good health, with direct and immediate consequences for our patients, the public and the NHS.

The NHS accounts for around 4% to 5% of UK emissions, and the hon. Member for Ellesmere Port and Neston is right to highlight the critical role the NHS has to play in achieving net zero. Although I have some sympathy with the intention of the new clause, I remind the Committee of the commitment. The commitment to be net zero by 2040 applies only to NHS direct emissions, such as those from building energy and does not apply to supply chain emissions that are the target of the new clause. While ICBs should and will consider the environmental impact of their procurement, that consideration must go wider than the commitment made by NHS England to net zero direct NHS emissions.

To support that work, NHS England is already leading the way on the agenda through a dedicated programme of work, which includes ambitious targets for achieving net zero for the NHS carbon footprint plus by 2045 and for its direct emissions by 2040. We fully welcome and endorse those ambitions. As part of that programme of work, under the 2021-22 NHS standard contract, every trust is expected to have a green plan. As NHS England has made clear in its guidance on green plans, published in June 2021:

“Every trust and every ICS is expected to have a Green Plan approved by that organisation’s board or governing body. For trusts, these should be finalised and submitted to ICSs by 14 January 2022. Each ICS is then asked to develop a consolidated system-wide Green Plan by 31 March 2022, to be peer reviewed regionally and subsequently published.”

On the question of procurement, the NHS is already publicly committed to purchasing only from suppliers who are aligned with its net zero ambitions by 2030. Earlier this year, NHS England set its road map giving further details on the expectations of suppliers to 2030. That work is supported by a broad range of additional action on NHS net zero. NHS England will publish the world’s first net zero health building standard; it will apply to all projects being taken forward through the Government’s new hospital programme, which will see 48 new hospitals built across England by 2030—I can almost see the slightly cynical smile through the hon. Gentleman’s mask.

I know the shadow Minister will argue that the new clause would give impetus to the NHS to move towards net zero in the work it is already doing. I am afraid I am not convinced that it is necessary, given the substantial work already under way. The NHS is already showing its commitment, backed up by clear plans.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I wonder whether the Minister’s nickname in the Department is Steady Eddie, given his consistent responses to many of my new clauses and amendments—consistent, but not always correct. It is very important that the commitment is delivered. We are clearly going to have a disagreement about the best legislative framework in which to do that, but I am not going to push this to a vote. It is clearly an issue that all Members are very keen to see delivered.

I am sure that we will debate the new build programme on a number of other occasions—we may get beyond how many new hospitals it is and on to some of the wider issues. It is a matter we will come back to on a number of occasions.

I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 46

Exclusion of NHS bodies from ability to withhold information requested under the Freedom of Information Act 2000 on commercial grounds

“(1) Section 43 of the Freedom of Information Act 2000 is amended as follows.

(2) After subsection (3), insert—

‘(4) Subsection (2) does not apply to information held by NHS England, integrated care boards, NHS Trusts and NHS Foundation Trusts except to the extent that subsection (5) applies.

(5) Subsection (2) applies to information held by NHS England, integrated care trusts, NHS Trusts and NHS Foundation Trusts relating to another organisation if disclosure of the information would in the opinion of the organisation pose a real and significant risk to the commercial interests of that organisation.’” (Justin Madders.)

This new clause would prevent NHS bodies from withholding information on commercial grounds unless the information related to another organisation and that organisation considered that its disclosure would pose a real and significant risk to the commercial interests of that organisation.

Brought up, and read the First time.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

I can reassure the shadow Minister, the hon. Member for Ellesmere Port and Neston, that I am not aware of how many FOIs he tables, which is possibly as it should be; it suggests that they are handled in the appropriate way by officials, and not by me. I am sure he keeps officials busy with those requests.

I think we can all agree that transparency and openness are of key importance but—this is where the hon. Gentleman and I may diverge slightly in our views—it is also vital that genuinely commercially sensitive information is adequately protected. Section 43 of the Freedom of Information Act recognises the balance that needs to be struck. It exempts from disclosure any information that would, or would be likely to, prejudice the commercial interests of any person, including the public authority holding the information. It is, however, as he will be aware, a qualified exemption. Merely identifying that the information is commercially sensitive is not enough. The public authority holding the information must weigh up the “genuine public interest” arguments in favour of and against disclosure.

I remind the Committee that there is a robust system in place for testing such decisions. We have an independent commissioner who can scrutinise the decisions, who has the right to see the information in question and who is more than capable of challenging public authorities where he believes that disclosure is in the public interest. Beyond that, of course, those requesting the information have a right of appeal to the tribunal.

There genuinely needs to be a level playing field between public and private contractors, but the new clause would, I fear, place NHS bodies at a disadvantage in some commercial negotiations. It could mean that the NHS was not able to protect its commercially sensitive information, whereas other parties could. I struggle to see how an uneven playing field would benefit the general public and protect taxpayers’ money. I fear that the new clause would also place a significant additional burden on NHS bodies at a time of real strain and, as I have highlighted, there are already remedies in place that meet its stated aim.

I am also concerned about the power the new clause could place in the hands of those conducting commercial negotiations with the NHS. It would be for them, not the public authority, to decide if and when the release of information would pose a real and significant threat. It is difficult to see how the opinion of the organisation could be tested or challenged through the usual route of appeal, as they would not be a public authority within the scope of the Act. The Information Commissioner’s Office would be assessing an NHS body on the basis of judgments reached by a third party. I also point out that

“pose a real and significant risk”

is not a test used elsewhere in the Freedom of Information Act, and so could be open to novel interpretation by the originator of the material. For those reasons, I do not think that the new clause would achieve in a fair way what the hon. Gentleman seeks.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am relieved to hear that the Minister is not personally dealing with my FOI requests. I know he is very busy dealing with all the foundation trust applications in his in-tray. He made some fair points about ways in which the new clause might cause unintended consequences, but we wanted to put on record our concern about the way the Freedom of Information Act has been used by some trusts to avoid proper scrutiny. As my hon. Friend the Member for Bristol South said, this is unfortunately part of a pattern in patient safety issues, and that is obviously something we have discussed in this Committee. I will not put the new clause to a vote, and I beg to ask leave to withdraw it.

Clause, by leave, withdrawn.

New Clause 49

Protection of the title of “nurse”

“(1) A person may not practise or carry on business under any name, style or title containing the word “nurse” unless that person is registered with the Nursing and Midwifery Council and entered in sub part 1 or 2 of the register as a Registered Nurse or in the specialist community public health nursing part of the register.

(2) Subsection (1) does not prevent any use of the designation ‘veterinary nurse’, ‘dental nurse’ (for which see section 36K of the Dentists Act 1984) or ‘nursery nurse’.

(3) A person who contravenes subsection (1) is guilty of an offence and liable on summary conviction to a fine not exceeding level four on the standard scale.”—(Justin Madders.)

Brought up, and read the First time.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

I go back to the point I made: there are some perfectly legitimate professions—where there is an expectation and understanding of what they do and a respect for what they do—who use that title, as she alluded to. That is why we have to think a little more carefully about how we might do that, and whether it is the most effective way of assuring and enhancing patient safety.

Protection of title is only one part of the protection regime; it is important, of course, but there are other parts. We should also look at prosecutions of protection of title offences, which are extremely rare; we need to look at that in the context of how that might be enforced. Part of the reason for that is the availability of offences such as fraud by false representation that carry more substantial penalties including custodial sentences, which, I suspect, are sometimes the mechanism used to prosecute in such cases. Depending on the context in which the title is used, other legal action could be taken against a person, including criminal proceedings, civil proceedings and employment disciplinary proceedings, particularly where the person used the title to gain work or employment. There is also the opportunity to prosecute employers who hold their staff out to be regulated healthcare professionals when they are not.

To give some succour to the hon. Member for Ellesmere Port and Neston, we are committed to reviewing the protection of titles as part of the ongoing Government review of the regulation of healthcare professionals.

Edward Argar Portrait Edward Argar
- Hansard - -

Just one more sentence, then I will give way to the hon. Gentleman before I sit down.

We need to gather further evidence to better understand the case for change and whether it represents the most effective and enforceable way to promote patient safety. However, I will certainly carefully consider the proposals he has put forward, in that context, as will my colleagues. I have a few sentences left, so I will give way while I can.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

The Minister is sympathetic and has highlighted why the issue needs careful consideration throughout the debate. Are we able to get a formal commitment to public consultation on the issue from the Minister today?

Edward Argar Portrait Edward Argar
- Hansard - -

The shadow Minister pushes me a little further than I can go today. However, what I can say is that I have considerable sympathy with what he has said. I will undertake to look at what he and the right hon. Member for Leicester South have said in the context of that review.

Any subsequent change from that review and from consideration thereof probably sits most effectively, in terms of legislative reform, as part of the reform programme for the Nursing and Midwifery Council, which is most effectively taken forward via secondary legislation under section 60 of the Health Act 1999. In the context of that review, and any secondary legislation flowing from it under section 60, we will look at what he set out in his new clause.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful to the Minister for his positive comments. We were probably pushing our luck with getting a formal commitment from him, but it sounds like we are probably as close as we are going to get to progress on the matter without pushing the new clause formally to a vote. We will keep a close eye on the issue and will, no doubt, come back to it if progress is not made in orderly time. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 50

Access to innovative medicines and medicinal products review

“(1) The Secretary of State must undertake and publish a review of the use by the NHS of innovative medicines and medicinal products.

(2) The review must—

(a) conclude before 31 December 2022;

(b) consider ways to improve the use of innovative medicines and medicinal products within the NHS in England.

(3) The review may consider—

(a) the creation of a specific pathway to assess medicines and medicinal products for rare and less common conditions;

(b) improvements to the way in which patient and clinical experience is accommodated when considering the adoption of new medicines and medicinal products.”—(Alex Norris.)

This new clause would require the Secretary of State to carry out a review of the assessment and use of innovative medicines and medicinal products, and to consider how to improve access to medicines and medicinal products for people with rare and less common conditions in particular.

Brought up, and read the First time.

Health and Care Bill (Twentieth sitting)

Debate between Edward Argar and Justin Madders
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

It is a pleasure to see you in the Chair this morning, Mr Bone.

The NHS needs to have a core duty to have regard to carers and to promote their health and wellbeing. New clause 39 would put on a statutory footing the requirement for integrated care boards to collect information on carers and their families, and then to use it to develop strategies to promote their health and wellbeing. This is an attempt to ensure a strategic approach to the need for the NHS to demonstrate that it has considered carers in its policies and practice. In other words, all parts of the NHS would have to think carer.

The new clause would avoid situations arising in which carers had been omitted from consideration, for instance in hospital discharges, by ensuring proper care-proofing throughout the entire NHS. We believe that could help integration. Social care sees carers as an equal partner in care and very much part of the system, but sometimes there is a less favourable experience in the health service.

There would also be benefits to the NHS overall, through improved health and wellbeing, improved satisfaction with services, reduced admissions and readmissions, reduced crisis and reduced need. The new clause would avoid the significant omission of carers in recent guidance and improve the general approach to carers. It would also be good for NHS staff, one in three of whom couple working in the NHS with unpaid caring for family members and friends. Research shows increased job satisfaction when employers recognise carers, and the Minister will know how important it is to improve retention rates.

There is definitely an issue here. Surveys have consistently shown a problem, with 55% of carers saying that they agree or strongly agree with the statement, “I feel invisible to the NHS”. They are often providing more than 50 hours of care a week, which is more than a full-time job, and are essential to the NHS, yet that goes unrecognised. There are a range of other statistics on how carers feel about the recognition of their role; 56% agree or agree strongly with the statement, “Health services and professionals do not share information with me, even if it is essential for me to be able to care”. More than half are not involved in decisions on hospital discharge, two thirds of carers do not feel listened to by healthcare professionals about their willingness and ability to care, and a majority are not given enough information and advice when a person they care for is discharged from hospital to care for them safely. Most carers—60%—say that at the point of hospital discharge, they receive insufficient support to protect the health and wellbeing of the patient, or their own health.

Under the Health and Social Care Act 2012, carers have parity of esteem, and an equal right to receive information and advice and to have their needs considered. The Government accept that that is right for social care, so we think it should apply equally in healthcare. The NHS has very few responsibilities towards carers when compared with the social care sector. Carers were left out of the original Joint Committee on Vaccination and Immunisation decision on vaccination, even though they were in the green book. They were completely left out of the White Paper that underpinned this Bill; they were left out of two versions of the “Discharge to Assess” guidance; and they barely get a mention in integrated care partnership guidance—there is one reference in there to unpaid carers.

Several organisations are keen to support the approach set out in the new clause, including the Patients Association and the MS Society. The new clause would serve as an important marker in laying out the importance of carers, and it would help us work towards proper strategies to ensure that their value is recognised and that they are supported.

Turning to new clause 40, carers are mentioned in clauses 5 and 19, but are not defined anywhere. They could in theory include carers of any age. The new clause seeks to ensure absolute clarity about who the term “carer” refers to: it would refer to unpaid carers only—not volunteers or paid staff, but friends and family, commonly, who provide care. This keeps the definition consistent with other legislation, and includes parents of disabled children and, most importantly, young carers, who are particularly vulnerable to being forgotten. Young carers face more health inequalities than other children of the same age, and that persists into young adulthood. Every GP patient survey has shown that it is essential that it is made clear and explicit in legislation that provisions on carers include young carers.

In conclusion, we want to acknowledge the vital contribution that carers make, which can be quantified as running into billions of pounds. The NHS could not function without the daily support of unpaid carers, and during the pandemic the extra caring responsibilities that carers took on stopped the NHS being completely overwhelmed. These new clauses ensure carers’ needs will be at the heart of NHS decision making and polices. That is why we hope the Minister is sympathetic to them.

Edward Argar Portrait Edward Argar
- Hansard - -

New clauses 39 and 40 focus on carers. First, I join the shadow Minister, as I suspect all hon. Members wish to, in recognising and paying tribute to the enormous amount of work that carers, both formal and informal, do. We want to strengthen the system by which carers are supported, and ensure that those receiving care have choice and control over how they access services.

New clause 39 would create an obligation on integrated care boards to collect information, and understand and respond to the needs of carers with regard to their health and wellbeing. The Bill provides an opportunity to ensure the views of carers are properly embedded in integrated care boards. The Bill confers a duty on integrated care boards to promote the involvement of carers, along with those who access care and support, in decisions relating to the prevention, diagnosis and treatment of illness, and care. There are equivalent provisions for NHS England-commissioned services.

Furthermore, the joint strategic needs assessment, prepared by health and wellbeing boards, will continue to have to consider the needs of carers, and that will shape the strategy developed by the integrated care partnership and the plans of the ICB. That means the services commissioned through these routes in the area where a carer lives will have considered the impact on carers in that community. Carers UK has welcomed the clauses for recognising

“the crucial role carers play day in, day out supporting their relatives’ health”,

and it says the clauses

“give carers more of the visibility they need within health legislation.”

--- Later in debate ---
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move, That the clause be read a Second time.

Continuing healthcare ought to be something that we do not need to think about in a truly integrated care system. Hopefully, when the next White Paper comes along, it will address some of our issues with continuing healthcare—no doubt the Minister will tell us whether that is correct.

We all know that continuing healthcare is a huge source of contention between the NHS and local authorities. Arguing about who pays for what is not productive or efficient, and of course it is always the patient who is stuck in the middle. I have numerous examples, as I am sure other hon. Members do, of constituents who have been wrangling, for years after the care was provided, about who is picking up the bill for what. It seems a highly bureaucratic, unfair and at times deeply distressing experience for the families involved.

It has been clear for decades that we are moving into a world where many people will have multiple long-term conditions, with both health and social care needs. The new clause was tabled with that in mind, and with the assistance of the Motor Neurone Disease Association. As one would expect, those with MND often fall into the CHC web. I cannot allow a reference to MND to pass without paying tribute to Rob Burrow and the many other magnificent campaigners who have put the spotlight on the challenges that those diagnosed with MND face. I had the privilege of knowing Rob when he was a professional sportsman, and he has taken equal vigour, determination and courage into this field. He has been an absolute star in campaigning on these issues.

Under the current complex and poorly understood rules, some qualify for free social care—in other words, the NHS pays for it, rather than the local authority—but it is for adults only, and in order to qualify there has to be an assessment by professionals of all a person’s needs. If the needs change, the eligibility can change, and of course there are endless arguments about what the needs are at any particular time. That demonstrates why the integration of care is very important and will probably be more efficient in the long run. Those in receipt of, or possibly eligible for, continuing healthcare should be fully involved in the assessment process and kept informed. Carers, who we have already discussed, and family members should also be consulted. There are the personal experience aspects of the process to look at, as well as the arguments about who pays for what.

The new clause accepts that we cannot fix all these things overnight. It suggests that in some cases someone should be responsible for ensuring that the system works properly in the interests of those with continuing needs. This is all part of the wider application of proper openness, and of transparency being the strongest and best form of good governance.

Clinical commissioning groups have a legal responsibility to meet the assessed health and care needs of every person in their area who is found eligible for continuing healthcare. Their responsibilities are laid out in the national framework and supporting guidance, but I am afraid there is extensive evidence that they do not always fulfil those responsibilities, and that the monitoring of delivery of continuing healthcare is inadequate. In 2018, a Public Accounts Committee inquiry on continuing healthcare found:

“NHS England is not adequately carrying out its responsibility to ensure CCGs are complying with the legal requirement to provide CHC to those that are eligible.”

It also found that

“there are limited assurance processes in place to ensure that eligibility decisions are consistent”,

and that existing measures

“may not go far enough to address the variation in performance”

across CCGs. These findings were echoed in a November 2020 report by the Parliamentary and Health Services Ombudsman, which warned that

“people continue to be seriously let down by failings in the way…healthcare is handled by CCGs.”

Patient organisations, represented collectively through the Continuing Healthcare Alliance, have reported a wide range of significant problems in CHC delivery, including CCGs not adhering to the national framework or associated guidance for assessment and care delivery, leading to significant inconsistency and variation across the country. Not enough data is collected about who receives continuing healthcare and multidisciplinary teams are frequently not used to conduct assessments, which leads to them sometimes being carried out by individuals with no knowledge of that person’s history or their medical condition. Care packages are frequently inadequate to assess needs, particularly when individuals require complex care or specialist care input. There is no effective system or process in place to monitor the quality of delivery across the country, to address that unwarranted variation and to take action when commissioners fail to live up to their legal responsibilities in respect of CHC.

We are seeking to address some of those issues through the new clause. We have what we would describe as an accountability gap, where there is no effective mechanism to monitor delivery of CHC and hold to account those who are meant to be responsible for delivering it. It goes without saying that people in receipt of CHC are sometimes the most vulnerable in the population, by definition, and it is surely unacceptable that a group of individuals continue to be let down by a failing system with no mechanism to identify and address those failings.

We hope that the new clause will address that issue and support better patient experience and outcomes with CHC. I do not intend to press it to a vote, but I would appreciate some responses from the Minister. The issue is not going to go away, so I would like his thoughts about the future of the whole idea of continuing healthcare and how we best monitor and ensure consistency and compliance throughout the country. Any thoughts on how we can make the system better would be most welcome.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Gentleman and join him in paying tribute to the work of the MND Association and other campaigners who do so much to bring these issues to our attention, both as individual MPs and in debates such as this.

The new clause would impose a new duty on the Care Quality Commission to conduct a review and assess the performance of NHS continuing healthcare, or CHC, by integrated care systems each year. It would also require the CQC to publish a report of its assessment. Again, as with many of the hon. Gentleman’s proposals, I understand and have a degree of sympathy with the intention behind what he seeks to do with the new clause. It is right that clinical commissioning groups, as they are currently called, are held accountable for NHS continuing healthcare within their local health and social care economy. That will also be the case with the national move to integrated care boards, where the board will discharge those duties and be accountable for NHS continuing healthcare as part of its NHS commissioning responsibilities.

I am grateful to the hon. Gentleman for suggesting that the new clause is, in essence, a probing amendment to highlight the issue, because I am not convinced that it is necessarily the most effective way of doing that, although it certainly airs the issue in Committee. I reassure him that the Government share his view about the importance of ensuring adequate oversight in how health and social care services are delivered, including in this space.

First, by way of some reassurance, NHS England has a core role in overseeing ICBs in the exercise of their functions. The Bill requires NHS England to assess the performance of each ICB every year and ICBs are required to provide NHS England with their annual report, which will include oversight of NHS commissioning and thus, in that context, continuing healthcare.

In addition, as Members will be aware, we have debated an amendment to give the CQC a duty to assess integrated care systems at a system level. The intention is for these reviews to provide the public and the system with independent assurance of the work within the ICS and, in particular, the effectiveness of joined-up working and integration. They, too, will be a valuable way to improve the services provided. The scope would include NHS commissioning and NHS continuing healthcare. We also intend for the CQC to work closely with NHS England, which will be conducting its own assessment of integrated care boards. We therefore think that those are the most effective vehicles for that oversight.

However, I share the hon. Gentleman’s view and suspect that we will all, possibly with a degree of regularity, have constituency cases about continuing healthcare payments and whether the system is working efficiently or otherwise. Local healthcare systems must continue to focus on this and seek to do what they can to make the system as smooth and efficient as possible. We believe that the mechanisms in the Bill are an effective way of doing that, but that in no way implies that individual systems should stop looking at ways of continuing to improve that provision and the mechanism by which continuing healthcare funding is delivered to individuals.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful to the Minister for his comments—it seems that the message has been received. Obviously, if the ambitions in the Bill to improve integration, collaboration and joint working are to be delivered, this will be one area where we would expect to see significant improvements. I have no doubt that we will return to this in future, but I beg to ask leave the withdraw the motion.

Clause, by leave, withdrawn.

New Clause 42

Alcohol product labelling

“The Secretary of State must by regulations make provision to ensure alcoholic drinks, as defined by the Department for Health and Social Care’s Low Alcohol Descriptors Guidance, published in 2018, or in future versions of that guidance, display—

(a) the Chief Medical Officers’ low risk drinking guidelines,

(b) a warning that is intended to inform the public of the danger of alcohol consumption,

(c) a warning that is intended to inform the public of the danger of alcohol consumption when pregnant,

(d) a warning that is intended to inform the public of the direct link between alcohol and cancer,

(e) a full list of ingredients and nutritional information.”—(Alex Norris.)

This new clause requires the Secretary of State to introduce secondary legislation on alcohol product labelling.

Brought up, and read the First time.

Health and Care Bill (Nineteeth sitting)

Debate between Edward Argar and Justin Madders
Committee stage
Wednesday 27th October 2021

(2 years, 5 months ago)

Public Bill Committees
Read Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 27 October 2021 - (27 Oct 2021)
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

It is a pleasure to follow my hon. Friend the Member for Bristol South, who gave a superb analysis of why the new clause is important and she picked up on many of the themes that we have already debated. The topicality of NHS senior management is there for all to see, with some of the recent headlines being orchestrated to divert from the growing waiting list crisis in the NHS.

Our view is that NHS senior management cannot be all that bad because they have seriously outperformed the private sector on efficiency for nearly a decade. If the NHS is one of the most efficient services in the world as many international studies have demonstrated, that is a credit to the managers who form a relatively small proportion of the overall workforce. I hope the Minister will join us in congratulating NHS managers, along with all the other brilliant staff, who have got us through the pandemic over the last 18 months—although, as we know, we are not through it yet. The contrast with some of the political decisions made has been exposed recently by the joint report by the Health and Social Care Committee and the Science and Technology Committee.

As we have discussed on a number of occasions, the Bill seems to specialise in the centralisation of power, with more and more being explicitly given to the Secretary of State. Do we want the Secretary of State appointing every chair, non-executive and chief executive, even in bodies that are meant to be independent from the Department? Amendment 18, which we debated earlier, would have gone some way to addressing that: alas, it was not to be. This is a serious issue that needs tackling. My hon. Friend is an expert on these matters through her own knowledge and experience, and I absolutely support what she has said.

While good governance might sound a little cheesy, I am sure that we could spend a lot of time discussing what exactly this new clause should be called.

I think we can all understand what good governance means and what it should look like, because we have certainly seen what it does not look like in how the Department operates at the moment. As my hon. Friend said, there was something similar in place previously, before it was burned in the bonfire of quangos under the coalition Government. Something should be in place, be it a revitalised appointments commission or even some independent standing committee or panel—something that has independent oversight of these very senior positions.

As we have said before, we would like more direct democracy in our integrated care boards. We are not going to get that, by the looks of it, but we would at least like some independence in appointments. When my ICB chair is finally appointed, I want him or her—it is a “him” at the moment, and it is an interim position—to be looking outwards, not upwards to NHS England all the time. That is something that a good governance panel would help facilitate.

A fit and proper person test should be applied independently, even to get on a shortlist, and there should be some process for removing those who should not be on there. This needs to be applied by people who are independent and competent, and not people who are already on the lists or making the appointment decisions. Perhaps we should even have some people who have oversight of how people in senior positions are appraised, trained and supported. There is a lot of experience and expertise out there that we could harness. I hope that, whatever this body ends up looking like, it can assist the NHS in dealing better with issues such as diversity, succession planning and leadership—all areas on which we can always strive to do better.

I hope that nobody mentions bureaucracy or cost as an excuse to leave things as they are. We know from published NHS experience that having an appointments commission was not really an overhead; in fact, it was a valuable resource that, in the end, saved money. We know how much it costs to replace someone who has proved unsuitable, and to undo the mistakes that they made. Appointing the right people in the first place is the best solution. The Minister will, of course, be aware of the importance of recruitment and retention across the whole NHS. I think that we can do more in respect of senior leadership roles.

As my hon. Friend the Member for Bristol South said, transparency is key throughout the systems. Where the funding goes is a key question that will become even more key as we move into the ICBs, with larger areas and different funding streams merging into one. Transparency will be important there. Of course, there will be local differences, as she said, but there should still be accountability to someone for where that money goes and who is taking those decisions. We have what we have described as a permissive approach to running ICBs at the moment, but that does not mean that we cannot have transparency and accountability. That is why we support the new clause.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - -

It is nice to see you back in the Chair, Mr McCabe. I am grateful to the hon. Member for Bristol South. Although we may not fully agree, again I take the new clause in the spirit in which she tabled it. I will reflect on what she said, but I will also set out why I cannot accept what she is proposing. I will always reflect on what she says and proposes; when she proposes things, they are well thought out. We may come to different conclusions, but the points she made are certainly deserving of reflection. I can give her that assurance up front.

As in our oral evidence sessions, I join the hon. Lady and the shadow Minister in paying tribute to those in our amazing NHS and care workforce. It is also important that we recognise, as I think she said during questioning of witnesses, that the complexity of the organisations we are talking about—the complexity of an acute trust, for example—means that strong and effective leadership, both financial and administrative, are hugely important to the overall success of the enterprise of our NHS. I therefore join her in paying tribute to those staff who often find themselves, particularly in media commentary and similar shorthand critiques, on the receiving end of criticism. People may ask, “What are they there for?”. They are hugely valuable—just as much as frontline clinicians, nursing staff and those who work in the canteens or clean the wards. It is a team.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

Although I do not always agree with the hon. Lady, I find myself in complete agreement with her. She made a couple of points that referred back to those made by the hon. Member for Bristol South. The hon. Lady is absolutely right that the system needs high-calibre, high-quality people with the right skills, particularly given what we are seeking to do with integrated care systems. We must foster an environment in which those high skills are valued, continually reinforced and refreshed.

On the point about the Kark review, the hon. Member for Central Ayrshire is right. How should I phrase this delicately? People may move on, or be moved on, from posts because it was not a success for whatever reason; I will phrase it like that. We need to look at the challenge posed by those people suddenly reappearing in another equivalent senior post in a different part of the country. There may be a reason why someone has not been a success that is not due to particular circumstances or something beyond their control, and we need to look at the recycling of those people who have not been found to have hit the mark. We need to look at that carefully.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Will the Minister give way?

Edward Argar Portrait Edward Argar
- Hansard - -

I see the look on the shadow Minister’s face, which makes me wonder what is coming.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am not trying to catch the Minister out. I can think of a specific example where what he mentioned has happened. I am, frankly, angry that this individual has been able to do that. What does the Minister think can be done to ensure that the revolving door is shut on those whom it deserves to be shut on?

Edward Argar Portrait Edward Argar
- Hansard - -

The shadow Minister is right. It is a challenge, and it is something I continually reflect on, because it intersects with legal employment rights, the nature of the terms on which someone leaves, how these matters work and the fact that NHS trusts around the country are individual. It is not a simple issue. It is one that I continue to reflect on. I hasten to add that it is not just the shadow Minister but Members from both sides of the House who have, on occasion, raised the issue. It requires further thought and reflection.

New clause 8 would involve creating a new special health authority, effectively, to provide independent oversight of NHS appointments. I recognise the importance of such appointments, and everyone would agree that good governance arrangements should and must be in place for managing them. Appointments to NHS trusts, NHS England and special health authorities are public appointments; they are managed in line with the principles of the governance code for public appointments and are regulated by the Commissioner for Public Appointments. The chair of an ICB would be appointed by NHS England, with the approval of the Secretary of State. That reflects a point that has been considered on a number of occasions during the passage of the Bill, namely that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, Parliament, as part of a national health service.

I acknowledge what the hon. Member for Bristol South said about the need for people to be answerable and responsive to their local community. The counter-challenge is avoiding the fragmentation of the national health service and the vertical arrangement. She mentioned police and crime commissioners, and although our police forces operate in a similar way, the difference is that we have never had a national police force. Each force is based on a county—or a city, in the case of the Metropolitan Police Service—and works on a locality basis, as local authorities do.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

In respect of Ministers or senior civil servants? When it comes to Ministers, though I suspect that is not the point he wishes to push—

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I think we can see who the Ministers are, at least this week. I was referring more to the senior civil servants.

Edward Argar Portrait Edward Argar
- Hansard - -

I like to think that I am a constant in the Department, this week and in previous weeks. It is piece of work that we have done. If one looks at the very senior civil servants—the directors general and permanent secretaries—there is a good gender balance. He is absolutely right, however; having assumed responsibility for workforce more broadly a few weeks ago, it is a piece of work that I want to do. I was responsible for the implementation of the Lammy review and race disparity audit when I was at the Ministry of Justice, and it is an interest that I have taken with me to my new Department. The last year has been a little bit busy, but it is something of which I have not lost sight.

I do not believe that it is necessary to create a new body to oversee appointments, given that good governance arrangements are already in place. I therefore remain unconvinced by the argument. As ever, and as behoves me when the hon. Lady proposes something, I will continue to reflect on it carefully.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move, That the clause be read a Second time.

We have wandered down the avenue of reconfiguration before in this Committee, and I am sure that we will do so again. The Opposition have been far from reassured about the Secretary of State’s ability to intervene at any moment when there is the slightest hint of movement in a podiatry clinic or a change of hours at a walk-in centre, but that is where we are.

We all know that in a few more White Papers’ time, there will be more changes in the NHS and in social care, and possibly more integration—who knows what is in store for us? There will be changes in the way that services are delivered, with, we hope, the aim of making them better. For more than three decades, there has been an acceptance that changes to services can be of vital interest to the patients who receive them and the staff who deliver them.

The Committee has already discussed several times the importance of involving people in those debates, and there is an acceptance that there must be a process that engages with patients and all service users. That is what we are trying to achieve through new clause 11. I hope we all agree that any proposals to change the way that services are delivered have to be subject to consultation with patients and, as we have seen in other parts of the Bill, with carers. I hope that we start from that uncontentious common ground. The big issue is just how well that consultation is delivered in practice.

At this point, I take the Committee to the Cabinet Office guidelines of 2018 and the consultation principles, particularly paragraph D, which states:

“Consultations are only part of a process of engagement. Consider whether informal iterative consultation is appropriate, using new digital tools and open, collaborative approaches. Consultation is not just about formal documents and responses. It is an on-going process.”

The NHS does not always understand that they should consult before making a decision, and not on a decision that has already been made, using consultation as a tick-box or rubber-stamp exercise. Genuine consultation, with open dialogue on both sides, before decisions are made almost always results in a better decision in the end.

Of course, the Minister will tell us that the NHS constitution talks about those things and pledges,

“to engage staff in decisions that affect them and the services they provide, individually and through their representative organisations and local partnership working arrangements, and empower all staff to suggest ways to deliver better and safer services for patients and their families.”

That is a pledge, not a requirement, and those fine words are often ignored when it comes to consultations with staff groups.

Even the Health and Social Care Act 2012—the Lansley Act—accepted that there were issues, because it states:

“In exercising functions in relation to the health service, the Secretary of State must have regard to the NHS Constitution.”

Having due regard to the constitution also formed part of the licensing conditions for NHS Providers.

We know what “due regard” means and we have already debated its limits. We know that it means that there must be some sort of formal documentation to demonstrate that consideration has been given to representations. Even that sometimes does not happen, or it happens after a decision has been made. On a number of occasions, no attempt has been made to empower staff and proactively ask for their views on how to deliver the service in a better or safer way for patients. A decision is made and presented as a take it or leave it.

A helpful factsheet that was issued for the 2012 Act states:

“Our reforms will enable change to be driven from the bottom-up, by the clinicians who know the health needs of their patients best, and underpinned by proper local engagement, partnership working and effective local authority scrutiny.”

I draw the Committee’s attention to the words “partnership working”. Again, the NHS can do better in respect of that.

In the new clause, we are trying to codify something that the NHS should be doing anyway when we look at the documents, guidelines, explanatory notes and good intentions, but on a number of occasions fails to do. We therefore move from “due regard” to an actual requirement. That is a beacon of best practice, which we should aim for rather than watering it down. What harm can it do? What is the disbenefit of involving the people who know the service best and deliver it on the ground? That is why there must be consultation with patients, their carers and staff.

The latter part of the new clause provides that there has to be an agreement to provide a business case. Any significant proposal should have a business case attached to it. Paragraph C of the Cabinet Office guidelines states:

“Give enough information to ensure that those consulted understand the issues and can give informed responses. Include validated impact assessments of the costs and benefits of the options being considered when possible; this might be required where proposals have an impact on business or the voluntary sector.”

It stands to reason that giving people the full pictures means that they can give a fuller and more informed response. That is at the heart of the new clause. It will mean delivering better outcomes, better services for patients and better engagement with staff. If we refer back to the evidence sessions––gosh, some six weeks ago; it seems longer but it was only six weeks––this was one of Unison’s highest priorities. Witness Sara Gorton said of principal staff involvement

“I think trade unions and staff would feel as though they had a stake and would be reassured that they had involvement in future decisions with workforce implications made by those new bits of the system if that pledge were placed in the legislation and were the underpinning principle.”––[Official Report, Health and Social Care Public Bill Committee, 9 September 2021; c. 93, Q119.]

That is what we are seeking to do here.

It goes without saying that any significant service change should have the business case disclosed, as we discussed earlier with the new clauses tabled by my hon. Friend the Member for Bristol South. Business cases are where proposals are developed and where challenge, and teasing out of alternatives and improvements, can be found. That is the heart of what good consultation should be. We value our staff and the input they can have. We value the impact that service changes can have on patients and the importance of involving them at an early stage with full information. That will improve decisions in the long run and that is why new clause 11 should be supported.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister for giving us the opportunity to debate this issue further. As he suggested, we have touched on it at various other points in the passage of the legislation, but it is right that we debate it again.

The new clause would require the Secretary of State to consult staff, staff representatives and patient representatives on any reconfiguration of services or any service change impacting more than 20 staff. NHS bodies would be required to publish their response to the results of any such consultation and an NHS body proposing significant changes to services would need to produce a business case in a specific model to be published for consultation.

Health service bodies are already under wide-ranging duties on public involvement and consultation on proposals for changes in commissioning arrangements and the reconfiguration of services set out under the National Health Service Act 2006 and regulations made under the Act. In addition, the current guidance issued by NHS England makes clear the importance of engagement and appropriate consultation. That approach will continue to be reflected under new guidance produced under the reconfiguration provisions in the Bill, set out at paragraph 8 of new schedule 10A inserted into the 2006 Act.

Guidance can provide a level of detail that is not always suited to inclusion in primary legislation and allows for flexibility so that the system can work as efficiently as possible. That approach has worked well under the current reconfiguration system and guidance has played an important part. The Government are unconvinced that there is a need for an additional duty to consult patients’ representatives when NHS commissioners and providers must already involve service users in any proposals to change health services delivered to those users and which service users can access.

Moreover, it would not be appropriate for the Secretary of State to carry out a consultation for each reconfiguration or service change affecting staff. To run national consultation for every local change would be disproportionate. It would not be the best use of resource or lead to the local level of engagement that is so important. It is right that NHS bodies responsible for arranging for or providing health services should lead the consultations on proposed changes. These should be done primarily at local level with local expertise. There is always a challenge between the national and the local. I was not quite sure whether the hon. Member for Bristol South was alluding to that when she said that she was more Morrison than Bevan, and suggested that I was more Bevan than Morrison in my approach. Neither comparison has been made about me in the past, but when I next see her, I will ask. There is a real challenge in the local-national balance that runs through several clauses and in respect of the way the NHS has operated for decades.

The new clause would require consultation not just of patients but of staff and staff representatives. Staff views are of course vital in the design of service changes. That is made absolutely clear in the current guidance issued by NHS England, which repeatedly emphasises the need to involve clinicians whose practices would be affected by proposed changes. This approach will not change in the future, and updated guidance will continue to reflect that position and ensure that affected staff provide meaningful input.

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Alex Norris Portrait Alex Norris
- Hansard - - - Excerpts

That is a very kind offer and I am almost certainly going to avail myself of it. On that basis, I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 16

Licensing of beauty and aesthetics treatments

“(1) No person may carry on an activity to which this subsection applies—

(a) except under the authority of a licence for the purposes of this section, and

(b) other than in accordance with specified training.

(2) Subsection (1) applies to an activity relating to the provision of beauty or aesthetics treatments which is specified for the purposes of the subsection by regulations made by the Secretary of State.

(3) A person commits an offence if that person contravenes subsection (1).

(4) The Secretary of State may by regulations make provision about licences and conditions for the purposes of this section.

(5) Before making regulations under this section, the Secretary of State must consult the representatives of any interests concerned which the Secretary of State considers appropriate.

(6) Regulations may, in particular—

(a) require a licensing authority not to grant a licence unless satisfied as to a matter specified in the regulations; and

(b) require a licensing authority to have regard, in deciding whether to grant a licence, to a matter specified in the regulations.”—(Justin Madders.)

This new clause gives the Secretary of State the power to introduce a licensing regime for cosmetic treatments and makes it an offence for someone to practise without a licence. The list of treatments, detailed conditions and training requirements would be set out in regulations after consultation with relevant stakeholders.

Brought up, and read the First time.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move, That the clause be read a Second time.

It will be noted that new clause 16 has attracted considerable support from a wide range of Members across the House. I pay tribute to the beauty, aesthetics and wellbeing all-party parliamentary group, whose work in the area has been influential in producing the new clause. Many of the Members who put their name to it are also members of that group. I pay tribute to a constituent of my right hon. Friend the Member for North Durham (Mr Jones), Dawn Knight, who has been assiduous in this area, as has my right hon. Friend himself. Their tireless campaigning, which I suspect will continue for some time, has been vital so far. This is such an important area and it needs an awful lot of attention. We know there is a lot more to be done.

As we know, cosmetic treatments can include a wide range of procedures aimed at enhancing or altering appearance. Many common treatments are offered on the high street and include lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and—one that we are more familiar with—tattoos. Perhaps one day the Minister will show us all of his. If the Minister wants to respond on that point, he is more than welcome to.

Edward Argar Portrait Edward Argar
- Hansard - -

He clearly knows something I do not.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Many of these procedures are becoming increasingly popular. There is a well-articulated concern that non-medically and medically trained practitioners are performing treatments without being able to evidence appropriate training, or the required standards of oversight and supervision. One need only look on Facebook, for example, to see the proliferation of adverts for all types of treatments. These are usually done by unlicensed individuals who call themselves doctors. We have talked recently about the lack of proper regulation of social media. Although such a debate is not for today and falls outside the scope of the new clause, it is a matter that also needs to be addressed.

Cosmetic treatments can cause serious harm if not carried out correctly, in a safe environment and by competent, trained practitioners. Anything that punctures the skin carries the risk of the transmission of blood-borne viruses. There are countless tragic stories of people who have had life-changing injuries and conditions as a result of poor treatments. The amendment seeks to put the protection of the public at the forefront by giving the Secretary of State power to bring into force a national licensing scheme for cosmetic procedures. It would be a departure from the wild west we face at the moment. We recognise that significant research and engagement with all stakeholders would be needed to develop a scheme that will work well for all cosmetic treatments, as well as providing a practical and efficient system that will be understood and adhered to by members of the public, regulators and practitioners.

Any new scheme would have to have some flexibility in order to capture new cosmetic treatments coming on to the market in future. It would need to be able to set standards for training, qualifications and competency requirements of practitioners, including, we think, periodic checks of premises. Importantly, it would provide for continuous professional development of the practitioner. There would be a requirement for indemnity insurance and access to redress schemes for members of the public to be provided, should complications arise as a result of any aesthetic procedure. There are a number of sad stories about supposedly reputable companies doing damage to their customers, going into liquidation and their insurers then refusing to pay out. I do not think any Member wants to see that happening anymore if we can do something about it.

We would hope that any licensing scheme would have the characteristics that I have set out, and there would be accompanying sanctions for those who contravene it. At present, there is no provision to ensure that prescription-only medicines, such as Botox and anaesthetic creams, adrenaline and hyaluronidase, which are prescribed by regulated prescribers, are actually prescribed in accordance with safe practice. For example, beauty therapists are reliant on registered prescribers prescribing injectables, such as Botox, which they are unable to obtain without a prescription.

Although doctors are required to have a face-to-face individual assessment of each service user prior to prescribing to third parties, such as beauty therapists, a significant body of evidence exists to confirm that individual assessments are not actually taking place in many cases and that telephone prescriptions are being provided remotely. The proposed licensing scheme would provide a requirement for all prescribers to be officially named and to operate in accordance with required practice standards.

Of equal importance is the need for a licensing scheme to close the loophole that currently exists relating to the import of unlicensed injectable products from Korea, such as Botulax. There is a registration scheme in England for certain specialist treatments, such as electrolysis, tattooing, piecing, semi-permanent make-up and acupuncture. However, some of the riskier and newer types of cosmetic treatment cannot be included within the scope of the current regulatory regime. The system also does not allow regulators to specify conditions, qualifications or competency requirements, or to remove anyone from the practitioner register.

Only a small handful of areas across England have introduced their own licensing schemes in order to protect the public—London, Nottingham and Essex are notable examples. There are currently two Professional Standards Authority-approved voluntary registers of accredited practitioners, and one voluntary register of approved education and training providers that operate in the sector. However, joining is not mandatory, which means there are many unaccredited practitioners providing treatments to members of the public without any checks.

The creation of a national licensing scheme in England for practitioners of cosmetic treatments would ensure that all those who practise are competent and safe for members of the public, and it would also cover some of the newer practices not covered by existing licensing laws. There is a large body of support for such a move, including the Chartered Institute of Environmental Health, the Royal Society for Public Health, the Institute of Licensing, the Joint Council for Cosmetic Practitioners, the UK Public Health Network, the Faculty of Public Health and Save Face, as well as about 90% of the public, accordingly to at least one survey.

The Minister is keen on giving the Secretary of State additional powers, but I know that he is also keen on finding savings wherever possible. Were he to support this new clause, there would undoubtedly be a saving to the wider NHS in the long run—for example, through reduced visits to A&E and GPs to correct mistakes made by poorly trained and unregulated practitioners.

Here are some examples of the impact on the NHS of that lack of regulation: outbreaks of infection at skin-piercing premises, resulting in individuals being hospitalised and, in some cases, disfiguration and partial removal of the ear; second and third-degree burns from lasers and sun beds; allergic reactions due to failure to carry out patch tests or medical assessments, which have led to hospitalisations; and blindness in one eye caused by the incorrect administration of dermal fillers. Those are all tragedies for the individuals involved and mistakes that could be avoided. They are a cost to the NHS and to wider society. I believe that a system of licensing would put a stop to a lot of those tragedies.

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Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Member for Ellesmere Port and Neston for bringing this discussion before the Committee today, and I join him in paying tribute to my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) and the right hon. Member for North Durham. I know that both are tenacious campaigners, and both are due to meet me in the coming days to discuss their work in the context of the all-party group and the constituency case, exactly as the hon. Member for Ellesmere Port and Neston mentioned.

I also pay tribute to my hon. Friend the Member for Sevenoaks (Laura Trott) for her success, within a year or so of coming to this place, in getting her private Member’s Bill through. It imposed some further restrictions in relation to botulinum toxin treatments or procedures, particularly in terms of the age limit from which they could be undertaken.

This new clause would give the Secretary of State the power to introduce a licensing regime for beauty and aesthetics treatments, and make it an offence for a cosmetic practitioner to practise without a licence. I appreciate the intention behind the new clause, and I am sympathetic to its intended purpose. As we are aware, cosmetic treatments are an ever-expanding, multi-million pound industry, and we need to ensure that that industry operates in a safe way.

The breadth of the recent beauty, aesthetics and wellbeing all-party group inquiry into non-surgical procedures, which the shadow Minister alluded to, demonstrates that this is an extremely complex area to tackle and address. There is a huge range of non-surgical cosmetic procedures available, which vary in their level of complexity and invasiveness. The Government are carefully considering the findings of that report and the need for additional regulation in this area in the light of it.

We are considering the case for a licensing system alongside the other specific, and in some cases more narrow, recommendations made in the all-party group’s report. As part of that, we need to work further with stakeholders and within Government to clarify the scope of any further regulation and which procedures it might apply to. The private Member’s Bill introduced by my hon. Friend the Member for Sevenoaks came into force at the start of October. It prohibits the availability of botox and dermal fillers to under-18s, apart from in a very narrow set of defined circumstances. We will consider the impact and effectiveness of this important legislation in parallel with the all-party group’s report in assessing whether to expand further the role of local authorities in overseeing cosmetic procedures.

I reassure the Committee that my priority is to ensure that the right regulatory framework is in place to provide consistent and high standards of practice, and the Government are committed to improving the safety of cosmetic procedures through better training for practitioners and clear information so that people can make informed decisions about their care. I hope I can reassure the Committee that we are actively considering whether increased oversight of practitioners performing some of the most invasive non-surgical procedures is the right way forward, and one that we could work with.

We continue to explore carefully how to achieve a proportionate system of practitioner regulation. The all-party group’s report is a very valuable contribution to that work and that active assessment. As soon as that work has been done, we will look to determine the need for and scope of further regulation in this area, and we look forward to reporting our conclusions from that assessment in early 2022. I therefore encourage the shadow Minister not to press the new clause to a Division, and I invite him to work with us in looking at the issue.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am encouraged by what the Minister has said. I am pleased to hear that he is meeting the right hon. Member for Romsey and Southampton North and my right hon. Friend the Member for North Durham shortly, and that we will hopefully have some progress on this in the new year. In the light of that information, I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 17

Secretary of State’s duty to maintain safe staffing levels

“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—

‘1GA Secretary of State’s duty to maintain safe staffing levels

The Secretary of State has a duty to maintain safe staffing levels in the health and care service in England.’”—(Justin Madders.)

Brought up, and read the First time.

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Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister, the hon. Member for Ellesmere Port and Neston, for his framing of the new clause in his opening remarks.

The new clause would place the Secretary of State under a statutory duty to maintain safe staffing levels in the health and care service in England. I fear that its effect would be to detract from the responsibility of clinical and other leaders at a local level to ensure safe staffing, supported by guidance—I certainly take on board the point about guidance made by the hon. Member for Central Ayrshire—and regulated by the Care Quality Commission. I am afraid that the Government cannot agree with the new clause as worded for a number of reasons, which I will enunciate for the shadow Minister to illustrate my thinking.

First and foremost, we do not believe that there is a single ratio or formula that could calculate what represents safe staffing. It will differ across and within an organisation and, indeed, across organisations. Reaching the right mix requires the use of evidence-based tools and, crucially, the exercise of professional judgment and expertise and a multi-professional approach.

Consequently, we think that responsibility for staffing levels is best placed with clinical and other leaders at a local level, responding to local needs and supported by guidelines, all overseen and regulated by the CQC. Those guidelines, notwithstanding the challenges posed by the hon. Lady and the shadow Minister, are issued by national and professional bodies such as the National Quality Board and National Institute for Health and Care Excellence. They are based on the best available clinical evidence and are designed to ensure patient safety.

Appropriate staffing levels form a core element of the CQC’s registration regime for health and social care providers. Providers are required by the CQC to provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the care and treatment needs of the people using the service at all times. Staff must also receive the support, training, professional development, supervision and appraisals necessary to carry out their role and responsibilities.

Secondly, the new clause would require the formulation of safe staffing ratios against which performance could be assessed. I fear that that could be a retrograde step and inhibit the development of the skill mixes needed for a more innovative and productive future workforce, which will be crucial to the successful implementation of the new models of integrated care that the Bill is intended to support. Just as there is no one-size-fits-all approach for the new models of care, there will be no identikit approach to the mix of staff needed. The ultimate outcome of good quality care is influenced by a far greater range of issues than how many of each particular staff group are on any particular shift, according to a prescribed ratio. It requires the professional expertise and judgment of those who know the situation best in a given circumstance. The point I seek to make is that, although those numbers are a key part, they are not the only part.

This is, perhaps, more of a technical point than a point of substance, but the specific wording of the new clause is incredibly broad. It would potentially require the Secretary of State to assess safe staffing levels across all healthcare settings across the whole of England for all medical and clinical staff. Such a duty would, I fear, be challenging to implement, notwithstanding the shadow Minister’s assertion that he would not expect the Secretary of State to sit there each morning going through shift rotas and shift patterns himself. It would be challenging for not only the Department but the wider system and, in particular, clinical leaders in individual settings.

For those reasons, while I appreciate the sentiment and the objective sought by the shadow Minister, I do not believe the new clause is the appropriate practical solution.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful for this Minister’s response. I am not surprised that he is not prepared to the support the new clause. Unfortunately, I think there is a large chasm where responsibility for workforce issues probably lies, and this is an example of that. It was certainly not our intention to expect the Secretary of State to deliver each individual setting, but for someone in the system to have that responsibility of advising the Secretary of State. No doubt we will return to this. We will see the practice in the devolved nations and how that has proved to be a success or otherwise, which may strengthen or weaken the argument. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 18

Workforce responsibilities of integrated care boards

“(1) Each integrated care board must at least every two years publish a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.

(2) In drawing up the report the Board must consult—

(a) the Trusts and Foundation Trusts that provide services in its area,

(b) providers of primary care in its area, and

(c) the recognised trade unions.”—(Justin Madders.)

Brought up, and read the First time.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move, That the clause be read a Second time.

We are back on the workforce. We had a brief discussion about the proposals in clause 33 on the Secretary of State and workforce planning, and how they are by universal acclaim wholly inadequate. Now is not the time to repeat that debate, although I may shoehorn in one or two references to it. We hope that at some point there will be a better proposal on the national efforts to assess and meet workforce needs.

The new clause tries to repeat the intentions of the amendment to clause 33, and to take some of that thinking and translate it to ICB level. That makes a lot of sense to us, and in an ideal world some of the national plan would be made up of individual local assessments of need and add together the 42 ICBs into one national workforce plan. We will see where we end up with that. As I said, we have had some attempt at this with each STP trying to produce its own plan to a very abrupt timetable. I do not think anyone actually added up all their assessments to come up with a national figure. Because of the truncated timetable they faced, there was not a great deal of engagement with the workforce on that.

There is therefore a bit of a precedent in the work that was done on that. It is probably what you would call a gap analysis: what is needed against what we are likely have unless something is done to close that gap. The new clause follows that approach, which has had some support in some other areas. We felt that a two-year cycle was about right, with reporting on that two-year cycle covering short, medium and longer-term need.

It is hard to see why we will not have local plans if we are going to have national plans, to make sure that there is alignment when, as we hope, the Government come back with something better on clause 33. Looking at the total staff in the NHS and social care for an ICS, some of the larger ones will be running into hundreds of thousands of people. It is hard to think of any system with that many staff where some sort of workforce planning is not going on. If we are looking at things across system level, as the ICS is, surely workforce needs across the system would be part of that. We know that ICBs, together with the relevant trusts and foundation trusts, have the general duty to produce a plan annually, setting out how they propose to exercise their functions over the next five years. They will not be able to do that without the right staff.

A lot of the ground work entailed in the new clause will have been done already. It is our intention that it will try to remove any possibility of blame shifting, where inadequate resources lead to reduced services and the service providers are blamed, rather than those who hold the purse strings in Whitehall. The reporting required by the new clause will make it clear whether there are enough staff to meet all the reasonable requirements of the ICB.

The other key point covered by the new clause is who is consulted in the local planning process. We believe it vital that recognised trade unions are involved. That should be a given anyway, in the light of the general commitments from the NHS over partnership working, but as we have covered before, we think that needs to be explicit in the legislation because of the behaviour of a few NHS bodies in trying to marginalise staff involvement in recent times.

The ICBs will new bodies, and they will need to understand the importance of partnership working from day one. If the levelling-up and devolution agendas are to continue to flourish, surely the regional and sub-regional identification and development of skills in this important area ought to be part of the mix. It feels, I am afraid, as though the whole issue of workforce is being assiduously side-stepped by the Department. That is the Department’s prerogative, but it is a mistake and it is those on the frontline who will bear the brunt. We need someone to take responsibility, so why not the ICBs?

Without its workforce, the NHS is nothing. We are grateful to each and every one of its staff for the work that they do. We owe it to them, the patients and the taxpayer to have in place a proper system of workforce planning. Although we do not pretend that the new clause is the whole answer, it would begin to put in place the building blocks to achieve that.

Edward Argar Portrait Edward Argar
- Hansard - -

The new clause would place a new statutory responsibility on integrated care boards to publish, at least every two years,

“a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.”

Under the new clause, ICBs drawing up that report would be placed under a statutory duty of consultation with the trusts and foundation trusts in their area, providers of primary care and the recognised trade unions. The Government’s view is that that is an unnecessarily prescriptive duty on ICBs, and that clause 33 —alongside our non-legislative work and investment—remains the right way to develop the NHS workforce.

On the workforce nationally, what is needed is greater transparency and accountability for the various bodies involved in workforce planning. Clause 33 requires the Secretary of State to produce a report describing the workforce planning and supply system—including the roles of DHSC and its arm’s length bodies; NHS bodies, including ICBs and others; and how they work together—to provide that greater transparency.

To support local ICBs on workforce matters, work is already being taken forward on workforce planning through NHS England and NHS Improvement’s draft guidance to ICBs on the discharge of their functions. The draft NHSEI guidance, published in August 2021, states that the intended outcomes for ICBs will include,

“Growing the workforce for the future and enabling adequate workforce supply”,

as well as,

“Leading coordinated workforce planning”.

The guidance notes state explicitly that ICBs will have the responsibility to develop

“plans to address current and future predicted workforce supply requirements”,

which I believe addresses the core intention of the shadow Minister’s new clause.

The production of those plans will require ICBs to develop and regularly refresh collaborative workforce plans for their integrated care area, with demand and supply planning based on population health needs. As part of that work, we can expect ICBs to work with local stakeholders in their areas. ICBs will also be supported by Health Education England on such workforce planning matters. Under the guidance, ICBs will also have the responsibility to provide workforce data to regional and national workforce teams to support workforce planning and inform the prioritisation of workforce initiatives and investment decisions.

We join the shadow Minister in putting on the record our gratitude to our health and care workforce, but we think that that guidance already sends a strong signal to the system about the importance of the issue, and we therefore do not support his new clause.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am not surprised, although I am a little saddened, that the Minister has once again adopted the permissive rather than prescriptive approach. We think that the issue is so important for the NHS that it needs a firmer hand. I am sure that I will quote back to him his comments about the need for greater accountability and transparency in workforce planning, because that is something that we absolutely agree on. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 19

Secretary of State’s duty to provide access to occupational health services to NHS staff

“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—

‘1GA Secretary of State’s duty to provide access to occupational health services to NHS staff

The Secretary of State must provide access to occupational health services to meet the reasonable requirements of all persons who are employed in an activity which involves or relates to the provision of services as part of the health service in England.’”—(Alex Norris.)

This new clause would place a new duty on the Secretary of State to provide access to OH services to meet the reasonable requirements of all NHS staff. The duty would apply to all healthcare professionals delivering health care including doctors, dentists, nurses, midwives, pharmacists, healthcare scientists and the allied health professions.

Brought up, and read the First time.

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Edward Argar Portrait Edward Argar
- Hansard - -

The hon. Gentleman’s new clause would effectively prevent NHS foundation trusts from increasing their income from private patients year on year unless a number of specified conditions were met.

If hon. Members are students of history, they will recall that in 2012 we abolished the private patient cap, while clarifying that the foundation trusts’ principal purpose was

“the provision of goods and services for the purposes of the health service in England”,

meaning that foundation trusts must make the majority of their income from NHS activity. That was a more rational and sensible way of managing the issue than the previous cap, which caused practical problems for some NHS organisations that wanted to become foundation trusts and were prevented from doing so by the prescriptive nature of the previous regime. We also retained the requirement that additional income be used to benefit NHS patient care. It has been used across the system to offset maintenance costs, finance alternative transport such as park and ride, and fund patient care.

I should also be clear that we are talking about a very small percentage of the NHS’s income. The most recent set of provider consolidated accounts for 2019-20 shows income from non-NHS sources as 2% of income, of which less than 1% relates to private patients. Again, all that income has gone to improving care for NHS patients.

The new clause introduces a new cap by a different door; it creates a requirement for foundation trusts to agree with their ICB and ICP their income from non-NHS sources, and if they raised more than in the previous year, they would no longer be fulfilling their primary function as a foundation trust. That would be a significant bureaucratic and administrative burden on foundation trusts, and it would require them to either forgo raising additional income, or seek agreement via a multi-stage process before raising it.

The provision would also mark a significant new restriction on foundation trusts’ freedoms and autonomy, and could potentially dissuade some from wishing to become foundation trusts. As all non-NHS income must benefit NHS patient care, and an NHS foundation trust must always have as its primary purpose the delivery of NHS services, I fear that would potentially be putting ideological purity over practical interests and the practical working of the system.

New clause 23 would only apply to foundation trusts, as I read it, not NHS trusts. NHS trusts do not have a limit on the amount of income they can raise from private patients, and a very small number of trusts raise significant income in this way. Putting an additional requirement on foundation trusts before they can raise non-NHS income, but not doing the same for NHS trusts, would potentially further unbalance the playing field and give an additional nudge in the direction of foundation trusts.

The hon. Gentleman raised the issue of the costs or spending on the independent sector in the context of the pandemic response. I have been clear throughout that when the accounts are fully consolidated and audited, those figures will have to be reported. I cannot say exactly when that process will be complete, but it is a requirement that those accounts be gone through, consolidated and audited. I would hesitate to give him an inaccurate figure, but it is my intention for those figures to be made available at the appropriate time. With that, I invite the hon. Gentleman to consider withdrawing his new clause.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I hesitate to withdraw the new clause, because I have to say that the Minister’s arguments about not wanting to deter foundation trusts from making applications rang a little hollow, but we would not want to be accused of preventing that procession from continuing. We have set out very clearly why we do not think this residue from the 2012 Act should remain on the statute book. We think it sends out the wrong message and is actually unhelpful at this time, but we will not push the new clause to a vote. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 24

Requirement for NHS trusts to publish Royal College invited review reports

“Each NHS Trust in England must publish the reports produced by Royal Colleges of invited reviews of the Trust, including any conclusions and recommendations.”—(Justin Madders.)

This new clause would require Trusts to publish Royal College invited review reports.

Brought up, and read the First time.

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Edward Argar Portrait Edward Argar
- Hansard - -

The new clause would require each NHS trust in England to publish any report by a medical royal college of an invited review of the trust. That includes any conclusions and recommendations. It is right, as the hon. Gentleman mentioned, that trusts are open and transparent in managing any concerns about the quality and safety of their services, and, in particular, regulators should have access to any royal college invited review of a trust.

I have considerable sympathy with the intention of the new clause. We all want to improve patient safety and care, and I recognise the key role that transparency can play as part of that. However, I will explain why I am not convinced that this objective is best advanced by acceptance of this particular new clause. Managing concerns about clinical quality openly and transparently is essential for trusts if they are to provide consistently high quality, safe care, to show quality of leadership and to maintain trust in the trust and the service it delivers.

When the CQC finds that there has been a failure to do so or that fundamental standards of care are not being met, it is reflected in the CQC’s reports and ratings and in the range of enforcement powers it can use. The CQC’s inspection teams maintain ongoing engagement with trusts and make it clear that they expect trusts to be open and honest about issues of quality and safety of services. Furthermore, the CQC has been clear with trusts that reports, including invited reviews by royal colleges, should be made available to relevant commissioners and regulators, including the CQC. The CQC, NHS England and NHS Improvement expect trusts to take prompt actions to address appropriate recommendations, and the framework for invited reviews from the Academy of Medical Royal Colleges is clear that trusts and royal colleges undertaking reviews should share any serious patient safety issues from reports with the CQC.

As part of the CQC’s monitoring and inspection activity, it assesses how trusts have acted on recommendations from these reviews, including implementing any learning to make improvements. Since July 2018, the CQC has set a very clear expectation on trusts to share copies of the full final report of external reviews, including those by royal colleagues, and to inform it of steps they are taking to implement any recommendations. The CQC, working with providers, NHS England, NHS Improvement and the Academy of Medical Royal Colleges, has seen improvement in the development of an open and transparent culture.

The CQC has powers to compel a trust to share an invited review where it is aware of that review. Where serious issues of care are uncovered, NHS England and NHS Improvement can also compel a trust to take whatever steps are necessary to address them. This includes the sharing of an invited review to itself. The CQC is now reviewing its regulatory model, including its approach to monitoring and gathering evidence from providers. In doing so, it will continue to work with trusts and royal colleges, including on sharing and responding to findings from external reviews to encourage a culture of openness and transparency.

There are robust and transparent systems in place to ensure that providers learn from and improve their services. This includes publishing more than 100 reports every year, covering 40 clinical specialisms as part of the clinical audit programme by NHS England and NHS Improvement. NHS England and NHS Improvement also publish regular data on patient safety incidents, other safety indicators and patient safety alerts. They also provide support to challenge providers to improve governance and culture.

Invited reviews are a voluntary process. They are an advisory, non-regulatory and non-statutory way for trusts to assure patient safety and quality of care through the use of an independent review, but compelling the publication of the full report could lead to some unintended consequences. First, it could discourage some trusts from commissioning these invited reviews. That could lead to trusts overlooking specific actions to address safety and quality concerns and opportunities for improvements and learning. Secondly, it could lead to trusts inviting consulting firms and other professional bodies with less expertise in the delivery of clinical care than a team from the royal college to undertake reviews. Thirdly, invited reviews can vary widely in their scope and may not be directly patient safety-related. Therefore a blanket requirement to publish all reports may not be appropriate.

Fourthly, the specific information that a trust can make publicly available will vary from review to review, depending on the circumstances. Invited reviews can often involve sensitive and complex circumstances and cover confidential issues about staff and patients. Trusts need to take account of legislation on patient confidentiality and data protection each time a report is developed. It may therefore not be possible for every invited review to be a published document. The Academy of Medical Royal Colleges recommends that trusts should take steps to make available to the public a summary of the review and the steps they are taking.

Finally, requiring publication of invited reviews could attract attention in a way that affects staff morale and organisational learning, and not in a constructive way. It could make future invited review reports weaker or drive necessary conversations and actions off the record. For these reasons, while I can understand the hon. Gentleman’s point and where he is coming from, we believe that the mechanisms already in place are sufficient and achieve the right balance.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am slightly heartened by what the Minister said there. He obviously takes the matter seriously. We are not going to press this to a vote, because we recognise that there is some concern in the sector about this proposal. I ask him to reflect on what he said about a requirement possibly discouraging trusts from seeking invited reviews in the first place. That shows that reputation management is still at the forefront of their considerations rather than patient safety. That is the heart of the problem that we have been seeking to tease out with this new clause. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 25

“Secretary of State’s duty to report on disparities in maternal mortality rates

The Secretary of State must prepare and publish a report each year on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including the steps being taken to address these disparities and improve outcomes for patients.”—(Justin Madders.)

This new clause lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including what steps his department is taking to address these disparities and improve outcomes for patients.

Brought up, and read the First time.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move, That the clause be read a Second time.

This clause, in the words of Ronseal, does exactly what it says on the tin. It lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England. The report would include details of the steps that the Department was taking to address these disparities and improve outcomes for patients. We all know that this issue is of paramount importance and has been debated in the House several times recently. I hope that the Minister agrees that it is important that we take whatever steps we can to tackle all forms of inequality in our society and this is another example of how that manifests itself.

Covid has sharpened our awareness of health inequalities, but it is clear that it is not just with respiratory viruses where health outcomes can be staggeringly different for different groups. Maternity services are one of the areas where we can and must do far better. The Care Quality Commission report “Safety, Equity and Engagement in Maternity Services”, published in September, highlighted continued concern about the variation in quality and safety of England’s maternity services and presented analysis of key issues that persisted in some maternity services. It also highlighted where action was still needed to support vital improvements. In the UK’s poorest areas the stillbirth rate is still twice that in the UK’s most affluent ones, with pre-pandemic figures showing that babies in the poorest areas have a 73% excess risk of neonatal death. All mothers and babies deserve the very best care and it simply cannot be right that where people live might dictate the quality of the maternity care received. Action is needed to eradicate maternal inequalities.

It is not just geographical and socioeconomic inequalities that need to be tackled but ethnic inequalities. Evidence from MBRACE-UK––Mothers and Babies Reducing Risk Through Audits and Confidential Enquiries across the UK––shows that the maternal mortality rate is more than four times higher for black women compared with white women. The maternal mortality rate for Asian women is almost twice as high compared with white women. Those inequalities are an injustice, and we need action to address them.

I recognise that many black, Asian and minority ethnic women also do not feel that they are listened to during childbirth. A lack of cultural competency and medical training means that complications are not always spotted early enough. For example, black women have shared experiences of how anaemia has not been picked up soon enough because of their skin colour. We really ought to be doing better than that.

The Government have said that they have hosted several roundtables with experts and have commissioned more research to better understand the issue. However, they believe that a target to address maternal mortality disparities would have limitations in improving the quality of care. Why do they hold that view? NHS England’s long-term plan includes targets for addressing health outcomes in other areas. We need action to address the unacceptable disparities in maternal mortality rates as well.

The Joint Committee on Human Rights found that over 60% of black people did not believe that their health was equally protected by the NHS compared with white people. As we know, covid has had a disproportionate impact on BAME communities.

If not a target, then a report would ensure accountability and focus minds to address these unacceptable injustices. New clause 25 would put explicit accountability on the Secretary of State not only to monitor and report on variation in maternity services but, crucially, to set out the steps needed to tackle it. We need a national strategy to address this country’s health inequalities, which must include serious and urgent action to end the mortality gap between black, Asian and ethnic minority women and white women. The new clause is, of course, not the complete answer, but I hope the Minister will agree that it would be a welcome step in the right direction.

Edward Argar Portrait Edward Argar
- Hansard - -

Again, I am grateful to the shadow Minister. The new clause would require the Secretary of State to publish a report each year on variation in the quality and safety of England’s maternity services and on disparities in maternal mortality rates in England. Again, I understand the intention behind the new clause, which the hon. Gentlemen set out clearly, as it is paramount that we do all we can to ensure the safety of expectant mothers and their babies, which involves understanding and taking steps to address the variation in quality and safety of England’s maternity services and disparities in outcomes.

However, several organisations and bodies already publish reports each year on the variation of quality and safety of England’s maternity services and the disparities in maternal mortality rates. First, the CQC monitors, inspects and regulates maternity services across England to ensure they meet standards of quality and safety. Following an inspection, it provides findings, recommendations and an overall rating of the trusts. It also publishes monthly reports following inspections of maternity services and annual reports that explore areas for improvement in maternity services across England.

Secondly, “Better Births”, the report of the national maternity review, recommended that a nationally agreed set of indicators should be developed to help local maternity systems to track, benchmark and improve the quality of maternity services. In response, NHS England and NHS Improvement, in partnership with NHS Digital, have produced a national maternity services dashboard. The dashboard enables clinical teams in maternity services to compare their performance with their peers on a series of clinical quality improvement metrics, or CQIMs, and national maternity indicators, or NMIs, for the purposes of identifying areas that may require local clinical quality improvement.

Thirdly, MBRRACE-UK publishes annual reports on maternal deaths, stillbirths and neonatal deaths across the UK. Stillbirth and neonatal mortality rates are provided for individual NHS providers, commissioning boards, and local authorities in England, Scotland, Wales and the Crown dependencies. It would not be possible to report annual maternal mortality rates by NHS trusts because the numbers are very small—it would not be a meaningful statistic. That would also potentially risk individuals being identified and could result in contravention of data protection legislation.

The reports by MBRRACE-UK also look at health inequalities; its analysis has identified significant differences in maternal mortality rates, which the shadow Minister mentioned, between women from black or Asian minority ethnic backgrounds and white women, and between women from lower and higher socioeconomic backgrounds.

Finally, the National Maternity and Perinatal Audit, or NMPA, is a large-scale audit of NHS maternity services across England, Scotland and Wales. The NMPA publishes trust-level data and evaluates a range of care processes and outcomes to identify good practice and areas for improvement in the care of women and babies.

Health and Care Bill (Eighteenth sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait The Minister for Health (Edward Argar)
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Ah, a promotion—almost.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

Mrs Murray, it really is a pleasure to serve under your chairmanship this morning. I echo the comments from the Scottish National party spokesperson. She is correct that the Bill gives the Secretary of State extensive powers—almost carte blanche in some areas—to change the law. We think that taking back control means Parliament taking back control. Elected politicians are meant to serve the people, not the other way round. Some very valid points have been made about the themes and issues across the Bill, and we echo those.

Edward Argar Portrait Edward Argar
- Hansard - -

It is a pleasure to see you in the Chair again, Mrs Murray, and to hear of the inadvertent promotion of the shadow Minister. I am sure it is only a matter of time, certainly if his longevity in his current post and being master of his brief are anything to go by.

I am grateful to the hon. Member for Central Ayrshire for raising this matter. I will address amendments 114 and 115 together, as one is consequential on the other, and then I will address the clauses. As the hon. Lady rightly says, she has raised this matter with me not only in this Committee but outwith it. I would have been surprised had she not wished to air it in Committee, which is exactly what we are here for.

The amendments would require the Secretary of State to seek the consent of Ministers of the relevant devolved Administrations before making a consequential amendment to any matter that falls within the competence of the devolved legislature. Provisions such as clause 130—she suggested I might say this—are perfectly common in UK Acts of Parliament, and we believe they remain within the spirit of the devolution settlement. The UK Government’s clear position is that, in and of itself, clause 130 would not give rise to the legislative consent motion process, for reasons that I will set out. We deem that a requirement for the consent of the DAs for its use would therefore be inappropriate.

This power will enable the UK Government to make consequential amendments that might be necessary following the passage of the Bill. That includes most of the amendments that need to be made to secondary legislation as a consequence of the Bill’s provisions As such, amendments were not included in the Bill. There may also be minor changes, such as amendments to names of particular bodies—the hon. Lady knows me and the position that Her Majesty’s Government take on these things extremely well—as a result of measures in the Bill.

It is also prudent to retain the power to amend legislation in the event that anything has been missed. It is important for everyone concerned that we have the ability to make such amendments should they be needed to ensure that the legislation works as intended and that we are able to do so quickly, as required.

As I said, this power is quite common in UK legislation, particularly in a Bill as large as the Health and Care Bill, which—as we know, as we reach the end of the current set of clauses—comprises 135 clauses and 16 schedules. There are many examples of similar powers to clause 130 in existing legislation. Perhaps the one with the greatest relevance, giving the most directly analogous example, is section 303 of the Health and Social Care Act 2012.

As a general principle, it is appropriate that the authority passing the legislation makes the consequential provisions that flow from it, as that authority will be most familiar with the provisions of the legislation and the changes to other legislation that it necessitates. We are seeking legislative consent from the devolved Administrations in respect of a number of provisions in the Bill and we have debated those in recent days, but clause 130 does not, in and of itself, give rise to the LCM process. It is the substantive provisions in the Bill, on which any amendments under clause 130 would be consequential, that do or do not, as the case may be, give rise to the LCM process.

Finally, although this power will enable the UK Government to make consequential amendments to devolved legislation, in practice, any amendments would be discussed with the DAs, officials and legal advisers prior to and throughout the drafting process. These arrangements follow wider good practice and expectations of collaborative working.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful for the intervention—that is a very fair point. I recently spoke to a CAMHS worker who made that very point. One of their frustrations was that problems were not being addressed by early interventions, which only stores up more difficulties for later. Again, that is a symptom of the fact that we do not have parity of esteem, because early interventions can ultimately make a huge difference. We would like to see better access to services and appropriate waiting times being established for a wider range of mental health services, so that people with mental health problems know the maximum time for treatment, as is the case for people with physical health problems. I know the Department has been consulting on that fairly recently, and we think it would be a step change in how we assess and prioritise mental wellbeing.

Parity of treatments is required. Psychological therapies that are approved and recommended by the National Institute for Health and Care Excellence should be delivered as per the NHS constitution, and they should be put on a par with NICE-approved drugs. People need 24/7 access to mental health teams. The A&E presentations that we hear so much about have to be considered—that is probably not the optimum way to deal with such issues. There is a whole range of matters that really could make a practical difference in delivering parity of esteem, and we think that the report proposed in the new clause would be a way to drive through some of those changes.

I will not push for a vote on new clause 3, but we wanted to highlight the urgent need for more support for mental health services throughout the UK. Hopefully, the Minister will at least acknowledge that more needs to be done in this area.

Edward Argar Portrait Edward Argar
- Hansard - -

I welcome the spirit in which the shadow Minister brings this issue to the Committee. He is right to highlight not only the words “parity of esteem” but what they mean in practice, the importance of mental health services—particularly after the past year and a half with the rise in people suffering from mental health problems—and the challenges posed every day to our mental health services, irrespective of the pandemic. I suspect that throughout their time in this place, all Members present will have had multiple pieces of constituency casework relating to this issue, and particularly to CAMHS.

It is absolutely right that the shadow Minister has focused our debate on ensuring that mental health services are sufficiently funded to improve access, care and outcomes for patients. We know that, historically, mental health services under successive Governments have not received the same level of funding as NHS-funded services for physical health. By virtue of section 1(1) of the National Health Act 2006, which was inserted by the Health and Social Care Act 2012, the Secretary of State has a “duty to promote comprehensive health service” in England

“designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of physical and mental illness.”

Although there may be many things in the 2012 Act that I suspect Opposition Members do not agree with, I suspect they will agree with that clear objective. Given what the shadow Minister said, I am sure they do.

In line with that duty the Secretary of State, through the NHS mandate, ensures that NHS England must seek to treat mental health with the same urgency as physical health. That is monitored through three metrics: mental health services’ real-term expenditure growth, the number of people accessing Improving Access to Psychological Therapies services, and the number of children and young people accessing NHS-funded mental health services. The Secretary of State has a legal duty to keep under review the progress in meeting mandate objectives. NHS England and NHS Improvement provide reports on the above metrics for the Government’s review on a regular basis, and they have governance mechanisms in place to monitor both mental health spend and service delivery.

Health and Care Bill (Seventeenth sitting)

Debate between Edward Argar and Justin Madders
Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

It is a pleasure to see you in the Chair, Mr McCabe. I shall speak in support of amendment 146, which stands in my name and the name of other Opposition Members. There is a temptation to get teary-eyed and reminisce about the 2017-19 Parliament; it is almost overwhelming, but I will resist and battle on.

What we are discussing in this clause amounts to a significant amendment to the Healthcare (European Economic Area and Switzerland Arrangements) Act 2019, on which I had the pleasure of leading for my party, opposite not one but two of the Minister’s predecessors. I hope that the same fate will not befall this Minister as befell his predecessors who dealt with this legislation—although one of them actually got a promotion. Clause 120 renames that Act the perhaps more snappily titled Healthcare (International Arrangements) Act 2019, which is what the original Bill was called until Parliament, in its wisdom, decided that as this was a Brexit Bill, it was better to have it deal with matters associated purely with Brexit, and not to slip in wider powers almost wholly unrelated to our decision to leave the EU.

The clause gives the Secretary of State power to make regulations to pay for healthcare provided outside the United Kingdom where the payments give effect to a healthcare agreement. In the context of what has come before, that is no surprise, and it is certainly something we would expect to be pursued. It also means that the Secretary of State will be able to make regulations on the payment of healthcare provided in another country where the healthcare is outside the scope of healthcare agreements if he thinks that payment is justified by exceptional circumstances and the healthcare is provided in a country with which the UK already has a healthcare agreement. This discretionary power could, for example, be exercised to pay for a specific treatment that falls outside the scope of an existing healthcare agreement.

Not content with giving himself the power to enter into further healthcare agreements outside the EU, by doing this, the Secretary of State effectively gives himself another power to make further payments if he later discovers that there was another matter that he thinks we should have been paying for that had not been covered by those agreements. It may be that that situation would only arise in exceptional circumstances, but the whole genesis of the original Bill was that it was considered sensible to retain reciprocal healthcare arrangements with countries in the EEA, whereas the clause implies that things may not be quite so reciprocal in future. I wonder what the dynamic will be in negotiations with third countries if, on our side at least, we can just authorise further payments outside any agreement anyway.

These are potentially extraordinarily wide powers, and the regulations would be subject only to the negative procedure. Our amendment is not only consistent with the importance of parliamentary scrutiny, but would ensure value for money. The original Bill contained a similar power to that in the clause and was considered by the Delegated Powers and Regulatory Reform Committee in the other place. It set out clearly the power’s potential impact:

“If, without such amendment, the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure.”

[Interruption.] The Minister is chuckling. He may well know that I have used that quote before, because it highlights the extreme examples that are possible under the Bill. The Committee continued:

“Of course, these examples will not be priorities for any Secretary of State in this country.”

We should hope not. While the Minister may be able to rule out those two specific examples today, we have to consider how the powers could be used, and not just how they might be expected to be used.

The concern that this is a very broad power has been further strengthened by the inclusion of the power to make payments outside healthcare arrangements. We have to ask what the Secretary of State is trying to solve by giving himself these additional powers. Let us look at what the powers do. There is no limit to the amount of payments he can make. There is no limit on who can be funded worldwide. There is no limit to the type of healthcare being funded. Such powers without qualification or any criteria being applied in the Bill are simply unacceptable, so a resolution of both Houses should be required, alongside an impact assessment of the costs and demands any regulations might place on the NHS.

On the costs, there is no limit on what the Secretary of State might pay. If we are to assume that this will come out of existing departmental budgets, who will receive less? I mention this not just in the context of extra payments that the Secretary of State may make for things not covered by agreements, but in terms of the burden on the NHS of delivering any new obligations, because, to be blunt, cost recovery has been suboptimal. As the Law Society of Scotland said:

“As the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.”

The Government need to raise their game on cost recovery, and if there is an additional administrative burden on the NHS in setting up new systems of cost recovery because of new agreements reached, we need a commitment from the Minister to adequate resources to ensure that those services are delivered and the cost recovered.

We support the concept of reciprocal healthcare arrangements. They are a very good thing for our citizens and for visitors to the country, but it cannot be right to give the Secretary of State such a blank cheque. Amendment 146 will ensure transparency, accountability and a proper assessment of the obligations entered into by virtue of regulations under the clause.

Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - -

The hon. Gentleman alluded to being shadow Minister during the passage of the previous piece of legislation, and that reflects once again his longevity in his post. I am grateful to the hon. Member for Central Ayrshire for amendment 110, and for bringing the issue before the Committee. It is right that we debate and air it in this forum. I am aware of the concerns, which she expressed extremely clearly, about the Secretary of State’s ability potentially to confer functions on, or delegate functions under the 2019 Act to, Ministers from the devolved Administrations. She highlighted the perfect example: the challenge that we inevitably face with elements of the devolution settlement. Delivery may rest with the devolved Administration, and is therefore a devolved power; concluding international agreements is a reserved matter and therefore one for the UK Government.

Understandably, the point of principle on both sides is not to concede consent but, from our perspective, to consult. I will come on to that in a minute. I appreciate the perspective brought by the hon. Lady and her colleagues in the Scottish Government. Let me reiterate the UK Government’s strong commitment to meaningful and ongoing engagement with the DAs on reciprocal healthcare. There is already a statutory obligation under section 5 of the 2019 Act to consult the devolved Administrations before making any regulations under the Act in areas within the competence of the devolved legislatures.

We are working with officials in the devolved Administrations on the development of a memorandum of understanding setting out how we will fulfil that duty in practice. Indeed, the memorandum goes further in undertaking to engage and consult the devolved Administrations, not just at the end of the implementation stage but from a much earlier stage. I appreciate that the hon. Lady may say that, although that is progress, it does not go far enough. I believe that good progress is being made, but I suspect that on Report, I will have to report back on where we have got to, and whether we have managed to find a way forward. The work continues to be done.

Turning to amendment 110, the regulation-making powers in HEEASAA—I was going to say that was a shortened version of the Act’s title; I might just refer to “the aforementioned Act”, which may save us a little time—are important as they provide the UK Government with the ability to implement international reciprocal healthcare agreements. The Government fully support the devolution settlement and, as I say, we would not normally confer functions on the devolved Administrations under the Act without their agreement and consent.

To date, we have used the power only to ensure that Ministers in the devolved Administrations can have a role in authorising planned treatment applications if they wish, but we need to ensure that when negotiating agreements and committing to international obligations we can be confident that we can implement them. Further, we are keen to ensure that Ministers in the devolved Administrations can continue to have a role in devolved planned treatment applications. I reassure the hon. Lady that we continue to explore the issue with the DAs. I do not want to pre-empt what may emerge from that. For that reason, I encourage her not to press the amendment to a Division at this stage. She may reserve her right to do so at a subsequent stage in the passage of the legislation.

Amendment 111 would introduce a duty to seek the consent of the DAs before making regulations relating to international reciprocal healthcare agreements that contain a provision within a devolved competence. Reciprocal healthcare agreements benefit all our residents across the UK, providing safeguards and support for our most vulnerable, as well as greater opportunities to travel, for work or leisure. Where an agreement is in place, those living in the UK can access affordable healthcare when they need it when travelling abroad.

As I have said on multiple occasions, we recognise the need to work with our friends in the devolved Administrations, but we cannot include a statutory consent requirement. That would risk the UK Government not being able to comply with our international obligations, and it would, in a sense, give the devolved Administrations a veto over a reserved matter. I do not understate the complexity of the way the constitutional settlement works in this context.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I do so wish. I will not detain the Committee long on amendment 142. We are seeking to find ways of increasing awareness of rare and less common conditions among healthcare professionals. I readily accept that the amendment may not be a perfect vehicle for doing that, but the recent UK rare diseases framework included increasing awareness of rare and less common conditions among healthcare professionals as one of its four priority areas, partly due to the challenges that people within the community face in receiving accurate and timely diagnoses in primary care.

What mechanisms can be introduced to help to raise awareness of rare and less common conditions among healthcare professionals? Will the Minister consider introducing reforms to workforce training and resourcing to facilitate that because among the raft of the entire professional regulation process and a range of development issues, continuing development about and awareness of rare conditions is at the heart of proper and effective regulation?

Edward Argar Portrait Edward Argar
- Hansard - -

Amendment 142 would introduce a legislative requirement in section 60 of the Health Act 1999 for health and care professional regulators to raise professional awareness of rare and less common conditions where possible.

The purpose of regulating healthcare professionals is to protect the public. Regulators set the standards that registered professionals must meet; they also set standards relating to education and training. By ensuring that the standards are met, the regulators ensure that on an ongoing basis professionals have the right behaviours, skills, knowledge and experience to provide safe and effective care.

Section 60 of the Health Act 1999 provides powers to make changes to the professional regulatory landscape through secondary legislation. Each professional regulator has its own legislation that can be amended under the powers in section 60, which provides the framework for its establishment and remit. Although I have sympathy with the amendment’s aim and the points made by the hon. Member for Ellesmore Port and Neston about the need to ensure that health and care professionals are aware of rare conditions, I do not believe that writing such a requirement into section 60 of the 1999 Act is quite the right approach to achieve that.

All the healthcare professional regulators have the same set of objectives, which were placed on a consistent footing by the Health and Social Care (Safety and Quality) Act 2015. Those objectives are to protect, promote and maintain the health, safety and wellbeing of the public; to promote and maintain public confidence in the professions regulated under the Act; and to promote and maintain proper professional standards and conduct for members of those professions.

A key part of delivering those objectives is setting standards that require professionals to have the necessary skills and knowledge to practise safely. That includes knowledge and awareness of rare conditions where that is necessary for an individual’s practice. Regulators set the standards that healthcare professionals are required to meet in order to practise. Professionals have a duty to ensure that they provide a good standard of practice and care, which includes keeping their professional knowledge and skills up to date. That is set out in the guidance issued by the regulators.

For example, the General Medical Council’s “Good medical practice” sets out the standards required of a registered doctor. It specifies that a doctor must keep their professional knowledge and skills up to date, must be familiar with guidelines and developments that affect their work, and must recognise and work within the limits of their competence. That provides a clear framework that requires doctors to have knowledge of rare conditions where that is necessary for their practice.

The exact knowledge and skills required for each healthcare professional cannot be known or set by the regulator, but the current legislative requirements put in a place a framework that requires each professional to maintain the skills and knowledge needed to practise safely, including knowledge of rare conditions.

As experts in regulation, it is the responsibility of the regulators to determine what role they need to play in raising issues such as awareness of rare and less common conditions among their professionals. For those reasons, I encourage the hon. Member for Ellesmere Port and Neston to consider withdrawing his amendment.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

The clause provides additional powers that will widen the scope of section 60 of the Health Act 1999 and enable the Privy Council to make additional changes through secondary legislation.

The powers will enable the abolition of an individual health and care professional regulatory body where the professions concerned have been deregulated or are being regulated by another body; the removal of a healthcare profession from regulation where that is no longer for the protection of the public; or the delegation of certain functions to other regulatory bodies through legislation which previously had not been allowed. The powers will enable the regulation of group of workers concerned with physical and mental health, whether or not they are generally regarded as a profession, such as senior managers and leaders.

The UK model of regulation for healthcare professionals is rigid, complex and needs to be flexible and to change to better protect patients, support our health and care services and to help the workforce meet future challenges. The case for reforming professional regulation has long been acknowledged. Stakeholders have long expressed concern that having nine separate professional regulatory bodies is inefficient and confusing to the public. Our 2019 public consultation response reflected the desire for fewer regulatory bodies to deliver benefits to the professional regulation system. In addition, an independent review of the regulatory landscape, in particular the existing roles of regulators, has been commissioned and is due to report by the end of this year.

The powers in clause 123 will enable future changes to be made to make the professional regulatory landscape more streamlined and work more flexibly. The powers will also make it easier to ensure that the professions protected in law are the right ones and that the level of regulatory oversight is proportionate to the risks to the public.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As the Minister has told us, the clause seeks to amend section 60 of the Health Act 1999 in relation to making changes to the professional regulatory landscape through secondary legislation. It will simultaneously widen the scope of section 60 and extend the Secretary of State’s powers. Members may have picked up a theme by now: whenever there is a chance for the Secretary of State to seek more power, he uses this Bill to obtain it.

At the moment, the Government have powers to bring new professions into regulation or make modifications through secondary legislation, but can remove a profession from regulation only through primary legislation. This clause will enable the removal of a profession through secondary legislation and makes it clear that a profession would be removed from regulation only when that was no longer required for the purpose of protecting the public—but then I would hardly expect a statement from the Government about deregulating only where there is a risk.

While at one end of the spectrum one could argue that virtually all interactions with patients might have some element of risk, the more balanced view might be that while not all interactions carry the same risk, it is likely that all professions at some time undertake acts where the consequences of mistakes for the patient will be significant.

I am left wondering exactly what the yardstick will be and what criteria will be used to determine when there is no longer a need to protect the public. Is that the only criterion to be applied? Does professional regulation not also help to facilitate consistent common standards? What is lacking at the moment is any sense of the principles that will be followed to inform decisions to bring professions into regulation or to remove them. Will patient organisations, representative bodies and regulators be consulted on any new criteria to be applied?

I appreciate that, as the Minister said, section 60 of the Health Act 1999 already contains requirements that legislation should be published in draft, subject to a three-month consultation, specifically with affected professionals and service users, but it would be helpful if he confirmed that that is the absolute minimum. I have to say, though, that even if the answer to that is yes, it seems a fairly minimal procedure for abolishing an entire profession. I am not sure that will cut it in terms of Parliament, never mind the public being satisfied that due diligence has been done to assess the overall risk profile of any particular role in the system. I am concerned about where that would leave matters such as professional indemnity insurance, as well as about any knock-on effect on the reassessment of bandings under agenda for change.

The more one looks at this, the harder it is to see how it could be done properly in the timescales envisaged. There are just under 700,000 registered nurses in the UK. One can see how resource-intensive it would be if every one of them responded to a consultation to abolish their profession. I suspect the Minister will tell us that he has no plans to abolish professional regulation for doctors and nurses, but imagine if he did. This process would be wholly inadequate, which leads to the question: what exactly does the Minister, or more accurately the Secretary of State, have in mind when it comes to these powers? If we got some answers on that today, it might help us to decide whether these procedures were adequate and also whether the powers are necessary at all.

Moving the power to abolish professions to secondary legislation is not putting scrutiny and transparency at the forefront, and doing so without putting any indication on the record of which professions are being considered for derecognition under this power does not instil confidence that this power grab has been considered properly or is in fact needed at all. The implications for the devolved nations, particularly Scotland, are also important. There are differences in regulation and it is not clear what would happen if there were a difference of opinion between England and the devolved nations.

Clause 123(2)(d) inserts new subsection (2ZZA) into the Health Act 1999. I would welcome the suggestion that the scope of regulation could be extended to others who might not necessarily be regarded as professionals. It remains to be seen who or what this power will be used for, but I question whether the vehicle proposed is sufficient. More needs to be done. The 2019 Interim NHS People Plan states:

“It cannot be right that there are no agreed competencies for holding senior positions in the NHS or that we hold so little information about the skills, qualifications and career history of our leaders. A series of reports over the last decade have all highlighted a ‘revolving door’ culture, where leaders are quietly moved elsewhere in the NHS, facilitated by ‘vanilla’ references. These practices are not widespread, but they must end.”

I do not know whether this will be the right vehicle for tackling this issue, but it certainly needs tackling.

On clause 123(3) and the power to abolish regulatory bodies, the case has been made rather better—most notably by the Health and Care Professions Council, which sees this as an opportunity for some much needed modernisation, with a multi-professional regulatory model that would allow regulators to retain their individual identities and independence. That would see each regulator continue to operate its own register, oversee fitness to practise processes, liaise with relevant professional bodies and set its own educational standards relating to the professions they regulate, but there would be greater collaboration, with shared back-office services and other resources, which would presumably improve efficiency.

That approach has some benefits although I am also mindful of the evidence submitted by the Professional Standards Authority, which warned:

“Any mergers would be likely to lead to a period of turbulence of three-to-five years.”

It may be of interest that the authority also said that in the coming five or so years, it expected turbulence in the NHS and referred to the Bill as part of that turbulence. Of course, there are also the issues that we have discussed many times in this place about the pandemic’s impact.

On the overall impact of clause 123, I am sure that we can all agree on the need for robust, independent processes to ensure that any decisions made are in the public interest and based on a clear assessment of the risk of harm arising from practice. It is an obvious thing to do. It is important that individuals belong to a profession because that provides a framework of standards to uphold, encourages expertise and respect, and brings a higher level of professionalism, and, crucially, accountability to the public. However, it is far from obvious how the clause will assist those aims or why in going down the road of deregulation we would want to put those important principles at risk.

Edward Argar Portrait Edward Argar
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I am grateful to the shadow Minister. His points coalesce around a number of key themes that I shall seek to address. He highlighted his concern about why we would do this and the potential disruption of either a lack of regulation in some spaces were we to abolish regulators or of that caused by moving functions. The key point here is that this is about creating a power that enables flexibility in the system that is not currently there. It is not that we have any direct or immediate plans to do this but about creating, in the context of the opportunity provided by the legislation, a framework whereby we could move powers around. There are some points sitting underneath that which I shall try to address.

The current section 60 powers are limited in terms of the changes they can deliver in the professional regulatory framework. We can use secondary legislation to bring a new profession into regulation and create a new regulatory body, but we do not have equivalent powers to remove a profession from regulation or close a regulatory body and move functions without primary legislation. Widening the scope helps us to ensure that professional regulation delivers public protection more consistently and efficiently, recognising the dynamic, to a degree, nature of evolving professional regulation.

On his concern about abolishing regulators, I know the hon. Gentleman will appreciate that there is no intention of doing that. But he rightly asks, “But what if?” It is the role of the Committee to look at that. Were a regulator to be abolished, that would not necessarily mean that the professionals they regulate would cease to be regulated. Current legislation allows a number of professions to be regulated by a single body, and that creates the mechanism to allow those movements and transfers.

To give an example that some might raise, would that mean that the GMC could be abolished? It is an extreme example, but hopefully it illustrates the point. The scope of the power to abolish a regulator covers all health and care professional regulators. However, the key point is that a regulator will be abolished only if the professions have either been moved to another regulator or removed, or deemed to be removed, from regulation altogether. Any use of this power is subject to existing legislative provision, namely a public consultation and the affirmative procedure. However, to take the example I gave, there are no plans to abolish the GMC, because clearly there would always be a need for continued regulation of medical practitioners. Therefore, given that the GMC regulates them, it would continue to do so.

Underpinning that concern is whether the removal of a specified profession entirely from regulation would increase in any way risks to public safety. Again, a profession would only be removed entirely from regulation following an assessment that showed the profession no longer required regulation for the purposes of public protection and that risks could therefore be safely managed, effectively and efficiently, outside statutory regulation. Given the nature of the professionals that we are talking about here, that would be highly unlikely in any of those spaces and I do not anticipate it. Any use of the power to remove a profession from regulation would be subject to consultation and, again, the affirmative parliamentary procedure.

The counterpoint could be why more professions are not included in regulation. From time to time we debate particular professions as new treatments, such as cosmetic treatments, emerge. Given the risks that some may pose, the question of whether there should be greater regulation then arises. Although statutory regulation is sometimes necessary where there are significant risks in the use of services that cannot be mitigated in other ways, we believe that it is not always the most proportionate or effective means of assuring the safe and effective care of service users. Therefore, each situation needs to be assessed carefully on its own merits. We have seen colleagues from the across the House making the case for regulating different aspects of professions, or service providers that have effectively become professional or are providing a service that is regularly used. Rather than a blanket approach, we believe that remains the right way.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 116, in clause 124, page 106, line 34, at end insert—

“(4A) In subsection (4) in paragraph (e), after “examiners” insert “including the requirement to investigate stillbirths and deaths related to childbirth”.”

This amendment would extend the medical examiner remit to look at still births and maternity cases.

This place has come a long way in recognising, discussing and acting on the tragedy that is baby loss. It has taken us a long time to get there, and there is still a long way to go, but we hope that this amendment will help us to continue on that journey.

The Minister will be aware of the November 2017 announcement on the possibility of coroners being asked to conduct inquests into stillbirths and the subsequent consultation—I believe he was the Minister who initiated that consultation, which was needed. In 2017 the Court of Appeal highlighted the need for reform. It said that the law relating to coronial investigations of stillbirths had not changed since 1887, and:

“Still-birth is a tragedy that continues to befall many families in advanced societies but it was a phenomenon more common in the past… The public interest in establishing whether a child was or was not stillborn, and if it was not how it came by its death, is apparent and continuing.”

I am sure those words will resonate with all Members, who will recognise that during the tragedy of stillbirth, parents will want to know why it has happened to them. Although a coronial investigation is no guarantee that answers will be forthcoming, it may relieve the sense of loss that they feel and may help in some small way.

The Government response to the consultation has been delayed somewhat, and they have said that they are not seeking to replace the role of the NHS in investigating stillbirths, but coronial investigations would

“supplement and support those investigations and ensure that coroners can contribute to the learning and play a role in reducing the stillbirth rate.”

Any update on when the response to the consultation will be published would be appreciated.

In essence, the amendment seeks to build on the comments made by the Royal College of Pathologists, which stated when that announcement was made back in 2017 that medical examiners should in fact play a far greater role in investigating stillbirths, as

“medical examiners are ideally placed to identify trends relating to deaths”

and to highlight areas for further improvement. The Government’s roll-out of medical examiners so far has not included investigations into stillbirths. The purpose of the amendment is to get underneath the rationale for that and to press for the issue to be reconsidered. If we are to have a separate debate on clause stand part, I will leave my comments there in order for the Minister to respond.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Gentleman for giving us, through amendment 116, an opportunity to debate and discuss this issue. Every stillbirth and death related to childbirth is a tragedy, and it is only right that we remain absolutely committed to supporting parents and families during such a difficult time. However, we are not convinced that this amendment is necessary in order to do that, and I will explain why in due course.

Following the passage of the Bill, the Secretary of State will make, in relation to England, regulations underpinning the medical examiner system, which will set out that the functions of medical examiners include confirming the cause of non-coronial deaths as stated by the doctor on the medical certificate of cause of death. The intention is that that will include confirming the cause of deaths of mothers in childbirth. As part of proposals to improve and digitise the medical certificate of cause of death, we are proposing the introduction of a new section on the certificate that will allow information relating to pregnancy at the time of death to be recorded. Recording information relating to pregnancy on the medical certificate of cause of death will provide a more accurate way to measure maternal deaths, and bring the certificate used in England and Wales in line with certificates used in other countries.

On stillbirths specifically, it is the case that between March and June of 2019, as the hon. Gentleman alluded to, the Ministry of Justice—I was in the Department at the time, as he set out—and the Department of Health and Social Care jointly consulted on proposals for coroners to investigate term or post-term stillbirths. The proposals are intended to improve the independence and transparency of reviews through independent investigation by coroners as judicial office holders outside the NHS. Work on analysing the responses to the consultation was delayed during the covid-19 pandemic, but the Government hope to publish the response to the consultation as soon as possible.

The Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019 also requires the Secretary of State to make arrangements for the preparation of a report on whether and how the law ought to be changed to require coroners to investigate stillbirths, and provides a power to make those changes within five years. At such a time as the response to the consultation on proposals to provide coroners with new powers to investigate term stillbirths is published, it will be appropriate for the position on medical examiners also, potentially, to be considered.

There are existing processes for investigations of stillbirths, including the perinatal mortality review tool, introduced in 2018, and investigations by the Healthcare Safety Investigation Branch. I would like to highlight the importance of parents having the opportunity to be involved in the reviews and investigations. In early 2018 the perinatal mortality review tool was introduced to support NHS maternity and neonatal units in England, Wales and Scotland to undertake high-quality, standardised reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death. The aim of the perinatal mortality review tool is to support objective, robust and standardised reviews to provide answers for bereaved parents about why their baby died, as well as ensuring local and national learning to improve care and, ultimately, prevent future baby deaths.

Since April 2018 the Healthcare Safety Investigation Branch has been responsible in England for all NHS patient safety investigations of maternity incidents that meet the criteria for the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts programme, of which there are approximately 1,000 cases each year. That includes all cases in which a term baby was considered to be alive and healthy at the onset of labour but the birth outcome was severe brain damage, intrapartum stillbirth or neonatal death, and maternal deaths, to identify common themes and influence system change.

Both the perinatal mortality review tool and the Healthcare Safety Investigation Branch provide the opportunity for parents’ involvement in the investigation of stillbirths, which is essential to help provide answers for bereaved parents and to improve care.

I will not prejudge what the response might be to the consultation that we spoke about earlier, but I invite the shadow Minister to perhaps draw his own conclusions about my thinking on this, given that I believe it was my signature on the front of that document and I was the Minister who fought to be able to launch it. On that basis, I gently encourage him to consider not pressing his amendment to a vote on this occasion.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

In the light of the Minister’s encouragement, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

Clause 124 will amend the statutory medical examiner system in the Coroners and Justice Act 2009 so that English NHS bodies may appoint medical examiners to scrutinise deaths, instead of local authorities. Appointment of medical examiners by NHS bodies will facilitate their access to patient information in order to scrutinise the proposed cause of death while remaining clinically independent of the case. The medical examiner system will introduce a level of independent scrutiny, improving the quality and accuracy of the medical certificate of cause of death and thereby informing the national data on mortality and patient safety.

The medical examiner system will increase transparency and offer bereaved people the opportunity to raise concerns. It will provide new levels of scrutiny to help identify and deter criminal activity and poor practice. New duties on, and powers for, the Secretary of State to ensure enough medical examiners are appointed by English NHS bodies and are provided with sufficient resources and monitoring will help to facilitate and develop this system. As a result of the introduction of the medical examiner system, all deaths would be scrutinised by either a medical examiner or coroner, irrespective of the decision to bury or cremate, thus bringing the system on to an equal footing. I therefore commend the clause to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As the Minister has outlined, the purpose of medical examiners is to provide greater safeguards to the public by ensuring proper scrutiny of all non-coronial deaths; to ensure the appropriate notification of deaths to the coroner; and to provide a better service for the bereaved and, importantly, give them an opportunity to raise any concerns to a doctor who was not involved in the care of the deceased. It will also hopefully improve the quality of death certification and mortality data. These are all worthy aims that we can support, so the challenge for the Minister is to set out how the Government will benchmark the success or otherwise of medical examiners in achieving those aims. For example, can he tell us what improved quality of mortality data will actually look like? Does he envisage this leading to further system changes down the line, or is it too early to tell?

Another area I would be grateful for a little more detail about is set out in proposed new section 19(A3) of the Coroners and Justice Act 2009, which gives the Secretary of State the power to

“give a direction to an English NHS body—

(a) requiring the body to appoint or arrange for the appointment of one or more medical examiners,”

setting out the funds and resources that should be made available to such employed medical examiners, or setting out the means and methods that may be employed to monitor the performance of those medical examiners. Can the Minister tell us exactly who that body might be? Does the Secretary of State have a view on how many medical examiners might be needed, and what the appropriate level of funding might be?

I also want to ask about clause 124(8), which amends section 20 of the 2009 Act. That section provides a power to make regulation to require a fee to be payable in respect of medical examiners’ confirmation of cause of death. The clause will require any such fee to be payable to an English NHS body, rather than a local authority. Does the Department have a position on fees? Are they desirable? Has a level been set for them? What consultation has taken place about that level, and indeed the principle of charging a fee? It would be a shame if medical examiners were not accessible to the majority of people because of a barrier being created by a fee. If the Minister could answer those questions, it would be appreciated.

Health and Care Bill (Sixteenth sitting)

Debate between Edward Argar and Justin Madders
Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I thank the hon. Lady for that intervention, which articulates well what we are trying to highlight. It is a question of culture, which legislation can go only so far in addressing. As a Parliament, we need to address what more we can do to engender greater openness in the NHS. When things go wrong, there are better ways of handling that than what happens at the moment. When we have an £8 billion a year clinical negligence bill, it is incumbent on us all to look at ways that we can reduce that as well as assisting patients and their families to gain a better understanding of what has gone wrong.

Edward Argar Portrait Edward Argar
- Hansard - -

It is, as ever, a pleasure to serve under your chairmanship, Mrs Murray.

I am grateful to the hon. Member for Central Ayrshire not just for her amendments but for the opportunity to debate the issue, which goes to the heart of the challenges we face. I think there is broad consensus on clauses up to clause 119, perhaps with a challenge or a tweak here and there, but the provisions that we are considering are the one bit, as I know from the hon. Lady’s work on pre-legislative scrutiny and when the Bill was previously considered, that remains challenging. It is a matter of striking the appropriate balance to ensure the proper functioning of judicial authorities at the same time as achieving the overall objective of what we are trying to do with HSSIB: foster that learning culture, understand what goes wrong and avoid a repetition of it. It ultimately comes down to a subjective view of where that balance is most appropriately struck.

Clauses 106, 107, 108, 109 and 117, and schedule 14, address how HSSIB will protect the material it holds and outline the concept of safe space. Before getting into the detail of the clauses, I want to acknowledge that there has of course been extremely good and well-informed debate outside the Committee about how broad or narrow safe space should be; whether it should be as defined in the Bill with exceptions, or, to use the suggestion of the hon. Member for Central Ayrshire, flipped around to be the converse of that; and the merits of HSSIB sharing or not sharing information with other organisations. I feel it is important to set out how we came to the balance we propose.

The hon. Lady mentioned a previous Minister who visited Scotland. I am very conscious that I have a kind, outstanding invitation to visit from her and I look forward to taking that up at some point soon, I hope. I also spoke to the Scottish Cabinet Secretary for Health and Social Care, who endorsed that invitation. I therefore look forward to being able to come not only to Edinburgh, but possibly to Ayrshire, and finding a way to shoehorn that into the visit.

Key to our vision for a new model for investigations is that they are conducted in a safe space so that patients, families, NHS staff and other participants in an investigation are encouraged to speak freely and candidly and have the confidence that the information they provide will be protected, save in the most exceptional circumstances.

The objective is to encourage that open flow of information and get to the bottom of what may have happened with the best possible information available. Without guarantees that that information will not be shared—again, save in very limited circumstances, which I will come on to—we risk, as the hon. Lady said, eroding the confidence of all those who candidly trust HSSIB with that information.

We propose that information, documents, equipment or other items held by the new body in connection with an investigation will be considered protected material and must not be shared, apart from in certain limited circumstances, such as when necessary to address a serious and continuing risk to the safety of a patient or to the public, and then only to the extent necessary to allow a person to address the risk.

It is also important that people have certainty that the information they provide will not be used for the purposes of blame or liability. The current investigation branch does a good job under the current legislative framework but can only operate a weakened form of safe space. In addition, it has no powers to impose sanctions. We need to address that and put the HSSIB on a par with similar investigation bodies in the transport sector, as colleagues have said. Non-compliance with safe space protections may result in criminal sanctions.

Edward Argar Portrait Edward Argar
- Hansard - -

My hon. Friend is absolutely right. I should say that, even now, I am sure that many people in the health sector co-operate voluntarily, even when it is potentially challenging for them to do so. They do so because they want to foster that culture. This proposal will take that a step further forward and make it even easier for people to do so with confidence and to overcome any reticence that might exist because of, as she said, the fear of blame, the fear of opening up about something and the need to protect their sector and organisation, as they see it. She is absolutely right, and the key is to try to create a learning, rather than a blaming, culture. That is why the balance we strike in the definition of the safe space and exceptions to it is so important. We may or may not reach a consensus on where the balance should be struck, but this debate goes to the heart of the efficacy of the new body and how it will operate.

The Bill therefore sets out, on a statutory footing, a much stronger and more robust form of safe space. Clause 106 is the cornerstone of that. It is key to ensuring that all participants are completely candid with the information that they share, and it enables more thorough investigations and the development of meaningful recommendations. Investigations where protected material is held in the safe space should improve openness and co-operation between all participants and identify risks to the safety of patients, so that patients, families and the wider public can benefit from the experience of better investigations, and improvements can be made to the systems and practices in the provision of healthcare in England.

We believe that we have reached the right, balanced position after a lot of careful thought. In dealing with this legislation, my predecessors and I, along with my right hon. Friend the Member for Mid Bedfordshire (Ms Dorries), who is now Culture Secretary, wrestled a lot with the question of how to strike the right balance. I therefore turn to amendments 86 and 87. I am pleased that there is, I think, a consensus among all Members across the Committee that we need to protect materials, and about the value attached to protecting materials in the safe space, which is a key part of our approach to improving patient safety by allowing individuals to feel able to speak candidly.

Amendment 86 seeks to list in detail the types of material that will fall under the definition of protected material, while amendment 87, as the hon. Member for Central Ayrshire set out, is consequential on that. The definition given in clause 106(2) is intentionally broad. HSSIB will carry out a range of investigations, and it would be impossible to identify prospectively, in advance, all the material that will need to be gathered and should be protected by the safe space. By having a broad definition, we can give greater confidence to those who speak to HSSIB that all the material that it collects will be appropriately protected. There are very specific exceptions, which I will come on to.

As a future-proofing mechanism, the materials that are protected have not been listen in detail in the Bill. New technologies and ways of recording data are developing at a rapid pace. It is vital that HSSIB is able to adapt as these developments reach the frontline, rather than having to rely on returning to this House for further amendments to primary legislation. Listing the types of material in detail would have a number of practical implications. If we had a specified list, we could inadvertently leave out material that should be protected, when the vast majority of material the HSSIB will gather would be protected under the current definition. The Government endeavour to get everything right, but, as we all know, often do not.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Does the Minister think that there is anything missing from the amendment that ought to be included?

Edward Argar Portrait Edward Argar
- Hansard - -

I will take the intervention from the hon. Lady, and I will address both together.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I understand what the Minister is saying: we need the ability to make regulations to give us some flexibility. Equally, the definition of protected material is broad, to give Ministers and HSSIB flexibility as well. It seems that there is a bit of cakeism going on here.

Edward Argar Portrait Edward Argar
- Hansard - -

I think I know what the shadow Minister means by cakeism. I see his point, but I think the Bill strikes the right balance by building in a further degree of flexibility, but with the safeguard of the affirmative procedure. As he knows, because he has debated such things with me in the past, the affirmative procedure is not always a friend to Ministers in obliging them to come to this House and debate and explain everything. It is, however, an important democratic safeguard when regulation-making powers are inserted into primary legislation, and that is why we have adopted the affirmative procedure in this context. I hope that that gives him a degree of reassurance that the Secretary of State’s regulation-making power is simply a future-proofing mechanism, with sufficient parliamentary and democratic safeguards attached to it.

It is crucial, of course, that the integrity of investigations is protected and that we take a careful approach to how information is protected, so that there is public confidence in the work of HSSIB. That goes to the heart of what we are seeking to achieve with this part of the legislation. To ensure that confidence, the Bill provides for the creation of offences for unlawful disclosure. That is the backbone to the creation of statutory safe space. Clause 108 creates three offences of unlawful disclosure. The offences extend to HSSIB and connected individuals, individuals who are no longer connected with HSSIB, and persons who are not connected with HSSIB but receive certain protected material. It is important that we send a robust message that there will be consequences if protected information is disclosed unlawfully. It will be a criminal offence, and the person who commits an offence will be liable on summary conviction to a fine.

Clause 109 prevents a power in any other legislation from being used to require the disclosure of any protected material by HSSIB, or to seize protected material from HSSIB. That is, as we have debated, with the exception of certain parts of the Coroners and Justice Act 2009, which allows coroners to require disclosure in some circumstances due to provisions made in schedule 14 of the Bill. However, that provision respects the devolution settlement agreement and therefore does not apply to any provision that is within the legislative competence of the devolved Administrations. The clause will help to enhance HSSIB’s safe space protections by prohibiting the unauthorised disclosure of protected material. It is important to ensure that safe space cannot simply be breached by the use of a power elsewhere in another part of the statute book, and this provision makes that position entirely clear.

As we have debated, safe space encourages all participants to be completely candid with the information that they share with HSSIB, enabling more thorough investigations into what went wrong. That will also help more widely to protect the “learning, not blaming” culture that hon. Members have spoken about and that HSSIB is hoping to embed.

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Edward Argar Portrait Edward Argar
- Hansard - -

The clauses address HSSIB’s relationships with other bodies, including with the devolved Administrations.

Clause 110 places a requirement on HSSIB and a number of listed bodies, including the Care Quality Commission, NHS England and the commissioner for patient safety, to co-operate with each other when they carry out investigations into the same or related incidents. The duty to co-operate relates to the practical arrangements for co-ordinating those investigations.

Clause 110 would not require the sharing of any protected material held under the safe space. It will also require HSSIB to publish guidance regarding when an incident may be considered related to another incident. That will ensure that there is the necessary clarity across all organisations as to when co-operation is required in often complex investigations. HSSIB will, of course, still be able to co-operate with bodies that are not listed in clause 110, and the current investigation branch has already established many strong relationships with bodies not covered in that list.

However, clause 110 is crucial if we are to ensure that there is a consistent and cohesive approach to investigations in the same area or related areas. It is important that we encourage organisations to co-operate in this way so as to ensure that multiple investigations touching on the same incident can be delivered in the most stream- lined way. For example, the clause would compel two organisations that wished to interview the same individual to co-ordinate. Similarly, if two organisations need to visit a clinical area, it is important that they co-operate to minimise the impact on the day-to-day running of that clinical area.

Clause 110 helps to ensure that information is accessed effectively and efficiently. It ensures that organisations can carry out the important but different roles that they have in an efficient manner and also minimises disruption to patients and to others involved.

Clause 111 places a requirement on HSSIB to comply with any request for assistance from a relevant NHS body. That assistance would be in connection to an investigation into any incident that may have occurred during the provision of NHS services or at premises at which NHS services are provided. NHS England or the Secretary of State may also request that HSSIB provides a relevant NHS body with assistance. Assistance can be provided to trusts, foundation trusts, NHS England and the newly formed integrated care boards. Such assistance may include advice, guidance and training for those organisations in connection with an investigation.

The purpose of HSSIB’s investigations is to identify risks to the safety of patients and to address those risks by facilitating the improvement of systems and practices in the provision of NHS services or other healthcare services in England. HSSIB is designed to encourage the spread of a culture of learning within the NHS, and clause 111 allows HSSIB to support others in undertaking investigations and to share knowledge gained from its own investigations. The clause will help HSSIB to promote better standards for local investigations and improve their quality and effectiveness. To this end, HSSIB will disseminate information about best practice and standards to be adopted.

Clause 111 will also enable HSSIB to provide assistance to bodies other than relevant NHS bodies if they request assistance in relation to any matter connected with the carrying out of investigations. That will help to encourage the spread of learning and enable HSSIB to share its expertise across the wider healthcare sector, both within the UK and abroad, if requested. It will be able to charge a fee for such activities. Of course, we would not expect HSSIB to provide such assistance should doing so significantly interfere with the exercise of any of its investigative functions, and protections are included in the clause to ensure this.

Finally, clause 112 enables HSSIB to enter into agreements to carry out certain investigations relating to Wales and Northern Ireland, a provision that the Welsh Government and the Northern Ireland Executive were keen to see included. Those investigations would identify risks to the safety of patients and help to facilitate improvement of systems and practices. Investigations would not assess blame or involve the determination of any civil or criminal liability. It is important that HSSIB has the opportunity to share its expertise and help facilitate greater learning and improvement outside England. The clause allows HSSIB to charge for such investigations in Wales and Northern Ireland but only to cover the costs incurred through the course of the investigation. Of course, we would not expect HSSIB to provide such assistance should it significantly interfere with the exercise of its core investigative functions and, again, protections are included in the clause to ensure that.

These clauses are crucial to ensure that HSSIB has strong working relationships with NHS bodies, as well as regulators and, where requested, the devolved Administrations. I therefore commend the clauses to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As we have heard, the clauses deal with the requirement to co-operate and I will not go over the ground that we have already trodden on in respect of degrees of co-operation and how that might make a material difference to ultimate success. We hope that the many organisations listed in clause 110 will respond not simply because of the legislation but because the no-blame culture to which this body aspires is just as relevant to them as it is to individuals.

Is the long list of organisations in clause 110(3) the totality of NHS bodies or bodies associated with the NHS, or with running NHS services? I think the Minister mentioned that there may be others that have been involved but that are not in this list. Has any of them been excluded from the list and, if so, why?

The power to levy charges on NHS bodies for assistance shows why our amendment requiring the creation of the post of chief finance officer would have been sensible. While there are sanctions for individuals who block investigations and there is a debate about where co-operation ends and obstruction starts, I am unclear whether there is a similar sanction that could be imposed on the bodies listed in clause 110. Has the Minister considered that? Is there a process whereby the buck will stop with a named individual in any of these organisations or is that dealt with later in the Bill?

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Edward Argar Portrait Edward Argar
- Hansard - -

The clauses relate to the oversight of HSSIB’s functions. Clause 113 enables the Secretary of State to direct HSSIB to exercise its functions within a specified time period and in such a manner as the direction prescribes. That direction-making power, on which I suspect the shadow Minister the hon. Member for Ellesmere Port and Neston will question me, will apply only in the event that the Secretary of State considers that HSSIB is failing or has failed to exercise any of its functions, and that that failure is significant. Directions must be in writing and will ensure that appropriate action can be taken by the Secretary of State in the event of any failure on the part of HSSIB to exercise its functions.

Independence as a concept is fundamentally important, and indeed at the heart of HSSIB, and will be a crucial way to ensure that patients, families and staff have trust in its processes and judgments. However, the clause serves to help to safeguard the trust placed in HSSIB by patients and families in the event of its significant failure to exercise its functions. We believe this is a sensible and proportionate provision, which ensures that HSSIB is performing its vital functions. To maintain the independence of the investigatory process, such directions made by the Secretary of State will not be able to influence the outcome of any HSSIB investigation.

We do not expect to use the power—in fact, I hope that we will never have to use it—but it is right that the Secretary of State has the power to act in the event of significant failure. That is consistent with similar existing powers available to the Secretary of State in relation to other non-departmental public bodies, including the Care Quality Commission. Should HSSIB fail to comply with such directions, the clause enables the Secretary of State to choose to make arrangements either to undertake the exercise of HSSIB’s functions themselves or for another body to undertake them. That will ensure that the important investigatory work is sustained and delivered at the appropriate high standard, should HSSIB have experienced significant failures in achieving that.

Clause 114 requires the Secretary of State to undertake a review of and prepare a report on the effectiveness of HSSIB in undertaking its investigation function. That report must be prepared, published and laid before Parliament within four years of clause 94 coming into force, which sets out its investigation function. Given the trust that patients, families and staff will place in HSSIB’s processes and investigations, it is vital that Government is transparent to the public and parliamentarians regarding the performance of the new body. That report will be key to ensuring such transparency and to helping to facilitate learning and improvements within HSSIB. I therefore commend the clauses to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As the Minister has anticipated, clause 113 troubles me somewhat. We have talked extensively about the importance of independence and the need for HSSIB to have the confidence of those with whom it interacts so that it is fully effective. Once again, in common with much else in the Bill, we see that the Secretary of State gets to hand himself extensive powers to interfere with HSSIB. Subsection (1) basically places judgment about the exercise of that power in the hands of the Secretary of State. It is his opinion that counts, and no attempt is required to evidence-proof a failing. HSSIB is apparently unable to challenge that judgment. Subsection (5) states that that failure only has to be a failure to exercise its functions properly. That is qualified a little by subsection (1)(b), which says that the failure has to be significant, but unfortunately that is what the Secretary of State considers significant, nobody else. With all that together, the Secretary of State has pretty much a blank cheque to step in and interfere any time he likes, so long as he considers that there has been a significant failure.

However, it gets worse. Subsection (2) allows the Secretary of State to direct HSSIB in whatever manner he determines, which I would have said is about as far away from independence as we can get—until I read subsection (4), which allows the Secretary of State to step into HSSIB’s shoes and do its job himself. I am sure he has other things in his diary at the moment, but the idea that he can come in and undertake the functions of what is meant to be an independent body is simply unacceptable. I can do no better than refer to the evidence that Keith Conradi gave to the Committee:

“Ultimately, we end up making recommendations to the Department of Health and Social Care, and in the future I would like to ensure that we have that complete freedom to be able to make recommendations wherever we think that they most fit.”––[Official Report, Health and Care Public Bill Committee, 7 September 2021; c. 60, Q78.]

The Secretary of State having the power to effectively step in and start running the body, either directly or indirectly, at a moment’s notice, will not help with that freedom. Why does that need to be in the Bill and hanging over the body the whole time?

There is a suggestion that the Health and Social Care Committee would be better placed to administer this function, or at the very least that the Secretary of State should require its agreement before exercising this function. I agree that that Committee might be better placed than one person to have oversight of HSSIB. Perhaps we should consider which group will be best placed to have oversight of HSSIB, to ensure that it is truly independent.

The Secretary of State is tasked with carrying out a review of HSSIB. I am pleased that any subsequent report would be laid before Parliament, but again it is the Secretary of State undertaking that review—his judgment alone. Clause 114 says that the report must be laid within four years of the Bill’s passage. Is there a particular reason why four years was chosen? I am sure the Minister anticipated that question, so I hope he will be able to answer. My reading of the clause is that a report is required after four years, and after that there is no further requirement. It seems rather remiss for there to be no ongoing commitment to review HSSIB.

On clause 113, there are concerns that the oversight of HSSIB will be carried out by the same person who appoints its members, can remove them at a whim, sets remuneration, directs investigations, sets the funding and consents to the criteria of processes. There appears to be a clear conflict of interest. While I accept that there is a role for the Secretary of State, it is not necessary for this role to be so far reaching and overbearing. HSSIB is meant to be an independent non-departmental public body, but the role given to the Secretary of State throughout the Bill suggests that that will not quite be the case. The Bill firmly situates its functions under the Health Secretary, which is far from the definition of a non-departmental public as separate body from the sponsoring Department. Non-departmental public bodies tend to be responsible to Parliament, rather than the Government. Placing scrutiny powers with Parliament and ensuring that a framework document is in place to inform the basis of performance monitoring, rather than placing all the power in the Secretary of State’s hands, would be the best way to achieve this.

I have to say that the fact that the Secretary of State can pretty much pick all the main players in HSSIB does not say much about his confidence in his own judgment about these decisions, if he needs these sweeping powers up his sleeve just in case. I suspect that he was not the person responsible for these appointments, but the point remains that there are still questions over whether this is needed. I know the Minister said that this power would hopefully not be used, but if that is the case, why does it need to be in the Bill?

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Edward Argar Portrait Edward Argar
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I am grateful to the shadow Minister for his comments. I semi-predicted where I thought he might be going with his challenges, and I hope I can offer him reassurance.

First, at the heart of this is the fact that with an NDPB, an executive agency or any other public body, ultimately the Secretary of State is accountable, quite rightly, to this place for the operation of that—not for the operational decisions, but that it functions as an effective public body. Therefore, we never know, but I suspect that there may be a day—not necessarily in the immediate or near future—when the hon. Gentleman is sitting in my office or the Secretary of State’s office, and he would want, quite rightly, where there is a significant failure of an organisation, to be able to take action to address that. That is what the clause provides for.

Those powers would be used only in extremis, and only where

“HSSIB is failing or has failed to exercise any of its functions, and…the failure is significant.”

These are terms of which there is a legal understanding. It is not carte blanche for the Secretary of State, as I think the hon. Gentleman suggested in a debate on a previous clause, to get up one morning and say, “Do you know what I feel like doing? I feel like exercising these powers.” It is not possible to do it in that way. These are understood terms that set a very high bar for interventions.

Secondly, these powers are analogous to similar powers that the Secretary of State has over other NDPBs, or the CQC, as I said in my opening remarks, and other organisations in this space.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am not suggesting that anyone might wake up in the morning and decide on a whim to do this, but the fact of the matter is that, as the clause is drafted, if the Secretary of State was minded to do that, there is nothing that would stop them being able to do it, is there?

Edward Argar Portrait Edward Argar
- Hansard - -

I come back to the point that I have just made to the hon. Gentleman. Terms such as “the failure is significant” are understood terms, and of course public law principles would apply to decisions made by the Secretary of State, such as reasonableness and proportionality. I do think that this is both analogous to powers that the Secretary of State has over similar bodies and also proportionate.

Similarity, I do not believe that the clause questions or brings into question the independence of HSSIB. We recognise that that is fundamental to its success, and that is why it would be used only if the body

“is failing or has failed…and…the failure is significant.”

I come back to those understood terms, and that is a very high bar that would be subject to public law principles.

On the report that the hon. Gentleman mentioned, why is it four years—why not three, two or five? We think that four years is an appropriate and reasonable length of time for the new body to become established and to show what is working and what is not, so that we can see a meaningful report on how it has functioned over a number of years. As he said, the House would have the ability to debate that report, if it chose to do so. The report would be laid before the House and he could call a debate, if he was still in the same role at that point. Given that he has served in his Front-Bench role even longer than I have served in mine, I suspect that, much though he enjoys doing so, he may be hoping for a change by then.

The other point is that, just because this is the only report that is formally specified, it does not mean that there would not be the opportunity for other reports or reviews to be undertaken regularly. As the hon. Gentleman knows, we do that with other public bodies from time to time. It is right that Governments of whichever complexion review the NDPB landscape. We talked about ALBs earlier in our consideration of the Bill, and about the ability to move functions around depending on whether they are best exercised by the existing body or elsewhere, which reflects the same point.

I hope that gives the hon. Gentleman some reassurance that there is no desire on the part of the Secretary of State or me to add to our current workload, or indeed, should the day come, to add to the hon. Gentleman’s workload, were he to occupy this office—or indeed to that of the hon. Member for Nottingham North, whom I would not wish to exclude. The words used and the public law principles that apply would mean that the provisions would be commensurate with the powers over other bodies, and proportionate. I commend the clause to the Committee.

Question put, That the clause stand part of the Bill.

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Edward Argar Portrait Edward Argar
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These clauses cover further detail regarding offences created in part 4 of the Bill and interpreting part 4 of the Bill more generally. Clause 115 specifies that when an offence created by part 4 is committed by a company, an officer of that company may also be liable for that offence. This would be the case where it could be proven that such an offence was committed with the consent or involvement of an officer of the company or that such an offence could be attributable to neglect by an officer of the company. Hence the officer and the company who commit the offence are both liable and can be punished accordingly. Company officers who are liable in such a way would include any person who would purport to act in that capacity, including any directors or managers in the company.

It is important that any offences set out in part 4 of the Bill are capable of being fully enforced, and this means ensuring that the right actors are held to account and are therefore also deterred from committing such offences in the first place. Ensuring that both an individual and an organisation can be held to account shows clearly the commitment to maintaining a high standard of investigation and information protection, and to protecting the principles of safe spaces more widely.

Clause 116 specifies that when an offence created by part 4 of the Bill is committed by a partnership, a partner may also be liable for that offence. This would be relevant in an instance where, for example, a GP partnership commits an offence. The clause allows proceedings to be brought in the name of the partnership as well as the individual partners. Similarly to clause 115, where an offence is committed by an partnership and it can be proven that such an offence was committed with the consent or involvement of a partner or could be attributable to neglect by a partner, the partner and the partnership that commit the offence are both liable and can be punished accordingly. The clause also provides that where a fine is imposed on the partnership, it must be paid out of partnership assets. However, should a fine be imposed on a partner, that fine would be paid by the partner as an individual.

The committing of offences set out in part 4 of the Bill would reduce trust in HSSIB’s investigatory processes, and therefore it is important that the right actors are held to account should such offences be committed. Ensuring that both the partnership and individual partners can be so held to account is important for the same reasons I have discussed in relation to company officers under clause 115. The corporate structure itself should not make any difference: we want to ensure that the investigatory process and the principles of safe space are always upheld and protected. Both clause 115 and 116 are common provisions in relation to offences. They ensure that the appropriate actors are covered, but also add a further deterrent effect that can help avoid offences being committed in the first place.

Clause 118 inserts schedule 15 into the Bill. Schedule 15 makes the relevant consequential amendments to other Acts of Parliament to ensure that HSSIB, as a new non-departmental public body, is referenced in relevant legislation. This includes relevant public body, health, employment and equalities legislation and means that HSSIB must comply with the relevant legislation, such as the Freedom of Information Act.

Finally, clause 119 sets out the defined terms used in part 4 of the Bill. The clause is crucial to ensuring that the HSSIB provisions are correctly interpreted and provides the necessary clarity on key terms. I therefore commend these clauses and this schedule to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am not going to spend an awful lot of time on these clauses and this schedule, because the Minister has set them out very well, but I want to come back to his reference to clause 110 and the obligations on those who hold senior positions in NHS bodies. Regarding offences committed, the Minister said that there would not be the same need for punishments to follow failure to co-operate. I wonder whether that is consistent. Could he set out how offences committed by officers of a body corporate could be equated to offences committed by those who are running NHS bodies, or whether there is any discrepancy there that he would like to address?

Edward Argar Portrait Edward Argar
- Hansard - -

I will also endeavour not to detain the Committee for too long. I do not believe there is any discrepancy; I believe there is consistency there. The shadow Minister has highlighted what is essentially a technical point in the read-across between the two, and over the next couple of hours I will quickly check on that to make sure that I am right. I do not think there is any inconsistency there, but he has raised an interesting technical point, and I will review it. I hope he will forgive me if I do not give a technical answer right now, but I may shoehorn it in somehow this afternoon, keeping it in order by relating it to a clause that we will discuss subsequently. That will be a challenge, because we are about to finish the HSSIB clauses, but if there is anything to add to what I have just said, I will endeavour to work it in later this afternoon.

Question put and agreed to.

Clause 115 accordingly ordered to stand part of the Bill.

Clauses 116 to 118 ordered to stand part of the Bill.

Schedule 15 agreed to.

Clause 119 ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned.(Steve Double.)

Health and Care Bill (Fourteenth sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to you, Ms Elliott, and I challenge colleagues to remember what I was saying just before the Division.

On amendment 130, having the non-executive members remove one of their own members—essentially, their colleague—could very likely create a conflict between board members, because I would not expect that to be an easy decision for any of them. Of course, we want an effective, cohesive and united board with the Secretary of State stepping in only when a real issue needs to be addressed.

We would not expect those powers to be used very often, and ideally they would never need to be used. However, it is important to have those safeguards, which would allow action to be taken quickly should there be concerns about a non-executive member of the board.

Finally, I will speak about amendments 129 and 132 to 135, which look to mandate the creation and role of a chief finance officer for HSSIB. If I have understood the wording of amendment 129 correctly, the intention is to ensure that the chief finance officer of HSSIB is one of the executive members. As HSSIB is an independent NDPB, the recruitment of the executive members will be led by the non-executive members. It will be for them to take decisions about the composition of the executive members of the board, taking into account the balance of skills and experience required to lead the organisation in its vital work.

If the non-executive members were of the view that a chief financial officer’s skills would help the board’s work and complement the knowledge, skills and experience held by the existing non-executive and executive members, this would be a board role. There is nothing in the Bill, as it is currently drafted, to prevent the non-executive members from doing that.

It will be important for HSSIB, as an independent body, to be fully on top of finance and accounting decisions, and that is already reflected in the Bill. The constitution, which is set out in part 1 of schedule 13, includes a number of requirements in relation to funding and finance to ensure that that is managed correctly by HSSIB. For example, paragraph 12(1) of schedule 13 expressly states that HSSIB must exercise its functions economically, as well as effectively and efficiently. Paragraph 16 relates to the use of income from charges, and paragraphs 18 and 19 relate to the accounts of HSSIB. It is for HSSIB to decide how best to ensure it fulfils these duties, but I hope it is reassuring that the constitution underlines the importance of running HSSIB economically and the requirements for annual accounts, as would be expected of a public body.

Amendments 132 to 135 look to remove from the Secretary of State the responsibility to set the remuneration for non-executive members of HSSIB, and to give that power to the chief finance officer instead. The amendments present some challenges, which I will outline here.

In respect of public appointments, the governance code for public appointments states that

“Ministers must be consulted before a competition opens to agree the job description for the role, the length of tenure and remuneration.”

A number of non-departmental public bodies follow this code, such as the Care Quality Commission, the Human Tissue Authority and the Human Fertilisation and Embryology Authority, to name a few. There is no reason why the arrangements for HSSIB should differ from those of other non-departmental public bodies.

We wish to ensure the independence of HSSIB’s board, and I know that hon. Members feel strongly about that, too. Giving a chief finance officer control over the remuneration of non-executive members means that the Secretary of State and, via the Secretary of State, Parliament would not have full oversight of how public money is spent. Although I am sure that the non-executive board members would act with the utmost integrity, we must ensure that the legislation supports them to do so as far as possible, and that we do not deviate from standard practice in public appointments. For those reasons, I ask hon. Members not to press their amendments, and I commend this clause and schedule to the Committee.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

It is a pleasure to see you in the Chair this afternoon, Ms Elliot. I am grateful to the Minister for setting out the Department’s position on the clause and the accompanying schedule. The proposed amendments relate to the establishment of HSSIB. As he has said, it builds on the work carried out by the Healthcare Safety Investigation Branch, which was established without statutory basis in 2016 and became operational in April 2017.

The Public Administration and Constitutional Affairs Committee identified in April 2016—more than five and a half years ago—that this legislation was necessary, and I am pleased to see that it is finally being brought forward. The Health Service Safety Investigations Bill, which was introduced in the House of Lords in 2019, did not proceed because of the calling of a general election, on which the Opposition do not wish to linger.

As other members of the Committee may have done, I have raised with the Healthcare Safety Investigation Branch both system-wide issues and individual matters on behalf of constituents. My experience has suggested that there are wider issues that need investigating, so we welcome this opportunity to discuss and set out in legislation the powers and remit of the body.

Unfortunately, some details are lacking from part 4 of the Bill, which we think represents a missed opportunity to set them out a bit more precisely. We should not miss the opportunity to ensure that this body can truly improve healthcare, as we will demonstrate with our amendments, notwithstanding what the Minster has said. We are trying to do our utmost to ensure that HSSIB has the independence, the resources and the influence it requires to operate at its maximum potential. Lessons must be learned from the experience of the Healthcare Safety Investigation Branch, which has undoubtedly had some impact. However, in many ways, its work has not had the impact it might have had, because its reach has been limited for a variety of reasons that are entirely out of its control.

Keith Conradi, the chief investigator of the Healthcare Safety Investigation Branch, touched on that during the second sitting of this Committee, when he commented on how the branch had been operating in shadow form, without any real powers. We have discussed the powers of HSSIB, especially in terms of access to information and compelling people to co-operate with investigations. However, it is what happens after the final report, and ensuring that those recommendations are acted on, that will have the largest impact on patient safety and driving through improvements.

A recent example of the work of the Healthcare Safety Investigation Branch is its investigation into wrong site surgery, through the wrong patients being identified in outpatient departments. The reference for the investigation was evidence from the NHS national reporting and learning system that the incorrect identification of patients is a contributing factor in patients receiving the wrong procedure. The safety recommendation to NHS England was to lead a review of risks relating to patient identification in out-patient settings, and to assess the feasibility to enhance or implement systematic controls such as technological options or the use of the NHS unique identification number. NHS England responded by stating that the work would require an understanding of the true scale and impact of the risks through observational study, which would be resource heavy. It said that, without evidence of the risk, that would did not justify the cost. Hence, the recommendation was considered but not acted on.

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Edward Argar Portrait Edward Argar
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This clause sets out what HSSIB will be doing. Its remit will be to investigate qualifying incidents in England occurring in the NHS and also in the independent sector. Its aim is to improve learning from events of harm and reduce the risk of reoccurrence for future patients across the whole health system. The Bill defines qualifying incidents as incidents that occur in England during the provision of healthcare services and that have or may have implications for the safety of patients. Based on its findings, it will be for HSSIB to recommend improvements to systems and practices.

I want to come on to an important point about the role of investigations. The aim of the investigations will not be to apportion blame but to foster a strong learning culture and make sure that, ultimately, patients get the best care they rightly deserve, wherever they are patients. For that reason, we have specified that HSSIB’s investigative function is not for the purposes of assessing or determining blame, civil or criminal liability or action to be taken by a professional regulator in respect of an individual. That important point is reflected throughout the HSSIB provisions, including in respect of the requirements and admissibility of HSSIB reports. I will expand on those points when we reach those specific provisions. I hope that being clear on those points in legislation will foster a culture of openness and continuous improvement and learning, so that the whole of society benefits.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

As we have heard, the clause covers investigations of incidents with safety implications, confirming that qualifying incidents must take place in England during the provision of healthcare services, with the investigations identifying and addressing risks by

“facilitating the improvement of systems and practices”.

I do not know whether the Minister can neatly sum up what “facilitating” actually means in this context, but as we will cover in other clauses, there are certainly some concerns about how exactly improvements will be delivered—some have been touched on already.

Keith Conradi confirmed during his appearance before the Committee that currently, recommendations are monitored “informally” by NHS Improvement, and he suggested that a “pan-regulation-type body” might be needed to consider

“whether the outcome…mitigated the patient safety risk.”––[Official Report, Health and Care Public Bill Committee, 7 September 2021; c. 61, Q79.]

That sounds like a suggestion that needs consideration, because it would ensure that recommendations made by HSSIB and the responses from NHS England, or whichever appropriate body is required to respond, are acted on and assessed.

If we are to improve patient safety, it seems unusual not to have any provision or mechanism to follow up on recommendations. Earlier, I referred to the recent investigation into the identification of outpatients, where, sadly, the recommendation was not acted on, largely because of the cost of complying with it. The Bill does nothing to clarify how funding will be made available to act on recommendations from HSSIB on improving patient safety. What mechanism will be in place for when recommendations are not followed, or for when they are followed but do not have the desired effect?

We must avoid the scenario in which HSSIB is essentially a toothless body whose well-intentioned recommendations are simply kicked into the long grass. In response to the Select Committee’s investigation into the safety of maternity services in England, the Healthcare Safety Investigation Branch stated that

“for various reasons, some trusts have struggled to recognise the information we are presenting to them or to prioritise the actions necessary to address the risks. We understand the many pressures on trusts and that maternity services are a product of systems not all within the full control of individual organisations; sometimes solutions do not appear easily achievable.”

In a nutshell, the Bill fails to set out how that very real problem will be addressed under HSSIB, which demonstrates why we have been arguing for further consideration of how monitoring and assessment of recommendations is to be delivered.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 101, in clause 95, page 86, line 37, at end insert—

“(10) Following any direction under subsection (2) the HSSIB may—

(a) request additional funding in order to carry out the investigation; and

(b) at the discretion of the chief investigator, decline to carry out the investigation.

(11) Following any direction under subsection (2) the Secretary of State—

(a) must have no further involvement with how the investigation is pursued;

(b) may not give a direction which directs the outcome of an investigation; and

(c) must have no involvement in the formulation of the investigation’s recommendations.”.

This amendment would ensure that HSSIB would maintain its independence following any direction from the Secretary of State to carry out an investigation and can request additional funding in order to carry out the investigation.

I hope my voice holds out, although I hope I will not be speaking for quite as long on this amendment. It addresses a familiar theme. It seeks to preserve the independence of HSSIB’s decision making, with particular reference to clause 95 (2), which gives the Secretary of State the power to direct HSSIB to carry out investigations.

The Joint Committee on the Draft Health Service Safety Investigations Bill raised concerns about the role of the Secretary of State in making representations about investigating an incident. The Government agreed to remove the mention of the Secretary of State to make it clear that the role would not amount to a direction by a Minister. In that light, it is difficult to understand why the Government have now decided to install a power on the Secretary of State to direct investigations. It is questionable whether such a power is even needed, if HSSIB falls into line with the practice of the Healthcare Safety Investigation Branch, which can accept referrals from anyone. If the Secretary of State has concerns relating to patients, he should surely be able to put those matters to HSSIB anyway, as anyone who has safety concerns can. HSSIB can then reach a decision based on the criteria that it has set out on whether to investigate, which we will return to later.

If HSSIB becomes the investigatory body for the Secretary of State, depending on how often the power is used, that could downgrade other safety concerns and also erode public, patient and staff confidence that HSSIB is a truly independent body. The Joint Committee on the Draft Health Service Safety Investigations Bill commented:

“Our witnesses were united in stating that HSSIB will be neither trusted nor effective unless it is, and is seen to be, independent of both health service bodies…and the Department of Health and Social Care. Only this will provide confidence that HSSIB will neither cover up failures by clinicians and trusts nor conceal issues that might cause political embarrassment.”

By allowing the Secretary of State the power to direct the investigations, trust in HSSIB is brought into question. The amendment would make it clear that if the power is needed—the Minister can try to convince us that it is—HSSIB could request additional funding in order to carry out that investigation, and the chief investigator would have the power to decline to carry out the investigation. It would also ensure that if the investigation does proceed, the Secretary of State has no further role once it has started. If this power is needed, we think the amendment would create sufficient safeguards to ensure the independence of HSSIB, by ensuring that the chief investigator cannot have its own judgment and decisions superseded by the Secretary of State.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister for bringing this discussion before the Committee today. [Interruption.] I will talk for a little while to allow him enough time to have a glass of water to try to preserve his voice and mine for another few hours at least. As he set out, the amendment seeks to ensure that HSSIB would be able to make its own decision on whether to pursue an investigation requested by the Secretary of State and ask for funding; it would also ensure that if an investigation went ahead, the Secretary of State would have no influence on the detail of that investigation.

I reassure the hon. Gentleman that, as I said earlier, we remain fully committed to the independence of HSSIB, which is of course the reason why we want to establish it as a non-departmental public body with its own statutory powers. Under our approach, the Secretary of State would be able to direct HSSIB to carry out an investigation, but only if there has been an incident that has caused particular concern. The power to direct at subsection (2) is only in relation to carrying out an investigation; it is not about directing the outcome for an individual. That is an important distinction—we can ask them to do it, but it is not about directing the outcome. I believe that is right for the Secretary of State with responsibility for the health of the nation to have a power to direct the carrying-out of an investigation, so that he is able to respond to emergent or ongoing safety priorities or issues of concern, asking that they be considered.

The measure will ensure effective and proportionate accountability between the Department and its arm’s-length bodies, and between the Department and the House and the other place. However, while the Secretary of State may request an investigation, as I have said, he cannot direct the body on how to conduct any particular investigation and will have no role in it, as he does not have any such power. I hope that offers some reassurance to the shadow Minister. The measure therefore does not encroach on the independence of HSSIB’s findings, which are one of the key concerns that the amendments seek to draw out or shine a light on, so I hope I have provided some reassurance.

In addition, should HSSIB wish to discontinue an investigation, it may determine to do so, setting out the reason why it will not be investigating an incident. That would include any investigation, including one requested by the Secretary of State. HSSIB could discontinue an investigation, but would have to explain its thinking, which is not an unreasonable balance to seek to strike.

To turn to the question of funding, the amendment seeks to ensure that, in the case of a request by the Secretary of State to carry out an investigation, HSSIB may ask for additional funding. We have estimated, in our current analysis of workloads, HSSIB is likely to carry out up to 30 investigations a year, which allows sufficient flexibility to ensure that in the event that an investigation requested by the Secretary of State goes ahead, adequate resources remain.

On the process for the Secretary of State requesting an investigation, the limitations on the Secretary of State’s ability to be involved in the investigation, and the ability of HSSIB to determine whether it will pursue an investigation further, I hope that I have offered sufficient reassurance to the Committee. Therefore, I hope that the shadow Minister will consider withdrawing his amendment.

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Edward Argar Portrait Edward Argar
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I take the hon. Lady’s point. That is not the intention, to prejudge or predetermine. It is what is sought with the investigation. I take the point about the language, which is important. The measure in essence requires HSSIB to notify the public that it is looking into a particular circumstance or complaint. I think “issues” still works, but I take her point that we cannot prejudge, and nor should HSSIB, where its investigation is going, which rabbit hole it will take it down, what it might find, but that is a point of language. I hope that I have reassured her, but I accept that we always need to be careful about the language.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful for the Minister’s investigation, but I am still not clear why an additional power needs to be set out in the Bill. My understanding is that anyone can make a referral anyway, so why this has to be set out in black and white is a mystery to me. Despite what the Minister has said, it is important to have the amendment in the Bill, because it will give patients and the public confidence that there will not be interference or challenges that undermine the notion of independence. We will press the amendment to a vote.

Question put, That the amendment be made.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 122, in clause 95, page 86, line 37, at end insert—

‘(10) The Secretary of State must by regulations lay out a process to challenge a decision made by HSSIB not to investigate a qualifying incident.”

This amendment would require the Secretary of State to put in place a mechanism through which any decision by HSSIB not to investigate a qualifying incident could be challenged.

We have had some discussion about the matters that may be chosen by HSSIB to be investigated, but it is probably more pertinent for the purposes of considering this amendment that we discuss what happens when HSSIB decides not to investigate. Amendment 122 would require a mechanism to be put in place so that any decision by HSSIB not to investigate a qualifying incident could be challenged. If the independence of the body and faith in its purpose are to be protected, it is essential that there is a mechanism whereby HSSIB decision making can be challenged. That is especially true when we consider the role of families in the investigation process.

My experience with HSSIB came when a patient safety concern was raised by a constituent, and after that concern was not investigated it brought home to me the distress and feeling of being let down by a refusal to investigate. Without a mechanism to challenge such a refusal, faith in HSSIB could be damaged by effectively creating a dead end to further inquiries.

I should point out that in the particular circumstances that I have just referred to HSSIB agreed to a meeting and it set out in more detail its reasons for not investigating, but that might not be possible in all situations. That meeting aided my constituent’s understanding of why their request was refused, but it did not actually mean that they agreed with HSSIB’s decision. Consequently, our view is that there needs to be some sort of process—we do not intend to set out today what it should be—set out in regulations to ensure that those who make a referral have the opportunity to articulate their concerns if that referral should not go on to be investigated. In conclusion, if the purpose of HSSIB is to improve patient safety, we should ensure that collaborative approaches are enshrined in legislation, and we believe that a mechanism along the lines of what we have set out in the amendment would go some way towards achieving that.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister for setting out the background to his amendment, with which he seeks to ensure that a process is set out in regulations to allow the challenging of a decision by HSSIB when it has decided not to investigate a qualifying incident. However, I have to say that I do not think that this measure would necessarily be proportionate. The Bill already sets out, in clause 95 (8) and (9), that where HSSIB makes a decision not to pursue an investigation, it may explain the reasons behind that decision and communicate those reasons to those people with an interest.

It may be that the Government or others want to understand more about how HSSIB reached a decision, but setting out within regulations a fixed process to challenge HSSIB’s decisions would again risk being disproportionate. If HSSIB discontinues an investigation that it has started, then it must publish a statement that reports that it has discontinued the investigation and give its reasons for doing so. I believe that gives a high level of transparency in that circumstance.

I do not believe that it would be proportionate to take the same approach when an investigation has not even been commenced. The key theme running through these discussions, which we have heard about in our consideration of previous clauses, is the independence of HSSIB, and its ability to determine these matters and make its decisions in an independent way. I fear that this amendment sits slightly uneasily with that principle.

As I said, we intend HSSIB to carry out an estimated 30 investigations a year, so there is not the intention, even at the outset, that HSSIB should investigate all qualifying incidents. It is for HSSIB to determine that, so I do not think it would be the best use of HSSIB and its expertise to go through a formal process to explain why it has determined not to investigate incidents. We want HSSIB’s resource to go into investigating the qualifying incidents that it has determined to investigate.

I suspect we will return to this theme again in the course of our discussions, but I believe it is important that, as the expert body, HSSIB is given the autonomy to make its own decisions about what to investigate. Any such decision would of course need to stand up to scrutiny, and of course, as part of our own arrangements, we will need to ensure consistency, while at the same time ensuring that HSSIB’s autonomy is respected as it should be. That is a difficult balance, but it is one we need to ensure we strike. I therefore encourage the shadow Minister to not press his amendment to a Division.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

During our debate on amendments 101 and 122, we discussed a number of the key themes that run through clause 95. This clause sets out that, as an independent body, HSSIB will be able to decide its own priorities and determine which qualifying incidents it investigates. We would expect this to be the result of referrals it receives, but also its own intelligence. The clause also gives the Secretary of State powers to direct HSSIB to carry out an investigation when, for example, there has been an incident that has caused a particular concern, and it allows the Secretary of State to request a report to be produced by a specified date.

I appreciate that, as we have heard today, some could argue that the clause could be perceived to encroach on the independence of HSSIB. I hope I set out in my earlier remarks why I do not take that view, and why I believe it is right that the Secretary of State, who has responsibility for the health of the nation, has such a power and is able to respond to emerging, ongoing safety priorities or issues of concern. I believe that this measure strikes the right balance, providing the Secretary of State with that flexibility while ensuring effective and proportionate accountability. HSSIB is not bound to follow the instruction, but it is bound to explain why it deems it unnecessary, or why it has determined it should not pursue a particular investigation request.

Edward Argar Portrait Edward Argar
- Hansard - -

I am very grateful to my hon. Friend for making that point, and I put on record my gratitude—our gratitude—to him for his work, which he alluded to. He is right: one of the key things we would hope HSSIB would seek to do, where it was supported by the evidence, is to join the dots where there is a systemic issue—not just in an individual trust, for example, but an underlying issue for the Department or the NHS as a whole—and be able to reflect that in its decisions on what to work on and how to broaden the scope if it deemed that to be necessary.

Clause 95 provides that whenever HSSIB decides to undertake an investigation, it is required to make a public announcement, setting out briefly what it will be investigating and what it expects to consider during the investigation. I take the point made by the hon. Member for Central Ayrshire: that announcement should give the public an indication of the fact that something is being looked at, but it should not limit which leads—for want of a better way of putting it—HSSIB decides are worthy of investigation and of following. HSSIB will also be able to get in contact in advance with anyone who it thinks may be affected by the investigation. This may, for example, include patients, families or any individual who has referred the incidents to HSSIB, a trust or other healthcare provider.

Finally, there may be occasions when HSSIB decides not to investigate an issue or to discontinue with an investigation. Clause 95 covers those scenarios. If HSSIB decides to discontinue the investigation of an issue, we have set out that it should make a public statement explaining the reasons for doing so. If HSSIB decides not to investigate a qualifying incident, it will be able to give notice of the decision to those who it considers might be affected by it and to explain the reasons to those who have an interest in it.

I hope colleagues on the Committee will agree that the provisions are necessary for HSSIB to be in control of the qualifying incidents and to investigate and to ensure transparency about what investigations are being carried out or discontinued by the agency. We expect that the Secretary of State’s power of direction will be exercised extremely sparingly but it can ensure that crucial patient safety issues can always be focused on where appropriate. I therefore commend the clause to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

These processes will be critical if HSSIB is to function properly. The Minister has had three or four attempts to explain why the Secretary the State needs the power to direct when he can make referrals anyway, but we are still to understand why that power needs to be there. If the Secretary of State asked HSSIB to undertake an investigation, it would jolly well get on and do it. That aside, we will not be voting against the clause.

Question put and agreed to.  

Clause 95 accordingly ordered to stand part of the Bill. 

Clause 96

Criteria, Principles and Processes

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Edward Argar Portrait Edward Argar
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Clause 96 outlines that HSSIB must determine and publish certain criteria, principles and processes, including the criteria that it will use when deciding which qualifying incidents to investigate. The hon. Gentleman’s amendment would require HSSIB specifically to consult trade unions and patients when considering or reviewing criteria, principles and processes. I am not convinced that that is the most appropriate approach.

The clause, which I suspect we will turn to immediately after the debate, includes a number of references to “patients and their families”. HSSIB will need to set out how it will involve them in investigations as far as is reasonably practicable. It will also need to ensure that such processes are easily accessible and understood by families and patients.

I am sure that families and patients will be very much part of HSSIB’s considerations, as they are for the current Healthcare Safety Investigation Branch. However, the decision about who is consulted is best left to HSSIB, which will be best placed to determine who is appropriate. Again, that goes to the point of independence and flexibility to follow the evidence and determine where it thinks is the most appropriate place to go.

Similarly, on trade unions, as I have said in the Committee, while on occasion I suspect I may not agree with them, I recognise the vital role that they play in our country’s democracy. Again, it is important that HSSIB can judge when or whether to consult with them, depending on the issue involved. An approach where some groups are specified in legislation as needing to be consulted but not others may give the impression that some organisations or groups carry greater weight. It is important that, as HSSIB looks at each qualifying incident, it can judge what is the most appropriate balance for consultation.

The amendment would also mean that specific groups would always need to be consulted when it may not be appropriate in each case, dependent on the circumstances under consideration. I therefore think it is right that it will be for HSSIB to make decisions as to who it considers appropriate to consult. I hope that, in the spirit of striking the right balance in preserving HSSIB’s independence, the hon. Gentleman might consider withdrawing his amendment.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

The Minister is right; it should be up to HSSIB to decide who it consults. That is why it is seems superfluous to have a requirement in the clause that it must consult the Secretary of State. However, I cannot imagine a circumstance in which HSSIB would not want to consult him or her. Indeed, I cannot imagine patient groups and trade unions not being part of the conversation in most circumstances. We think we will need to keep an eye on this as matters progress. However, we have made our point and will not press the amendment to a vote, so I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

Clause 96 provides that HSSIB determines and publishes the criteria it will use when deciding which qualifying incidents to investigate, as well as the timescales by which investigations will be completed. The clause therefore ensures that HSSIB will be transparent in how it will work and will have the flexibility to determine the most appropriate investigation methods depending on the type of inquiry. The current body, the Healthcare Safety Investigation Branch, has a wealth of experience and has been conducting investigations since 2017, so it already has a solid base to build on to inform the criteria, principles and processes for its future investigations.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 124, in clause 97, page 88, line 15, leave out subsection (7) and insert—

“(7) The final report must be sent to the Secretary of State.

(8) Within 12 months of each final report being sent to the Secretary of State under subsection (7), a report must be laid before Parliament setting out the steps the Secretary of State has taken as a result.”.

The amendment seeks to ensure that each investigation report produced by the HSSIB is sent to the Secretary of State, who must report to Parliament on what steps have been taken as a result.

The clause deals with the final reports of HSSIB, which essentially will be about the manner in which improvements to systems and practices can be facilitated by the body. While the provision requires a final report to be published, only in subsection (7) is there a requirement for the report to be sent to the Secretary of State, and only in those cases where a direction has been given by the Secretary of State to investigate. Given the role of HSSIB, and to ensure that its functions are met, the amendment would require all final reports to be sent to the Secretary of State, who must present them to Parliament within 12 months outlining what steps had been taken. That would offer a safeguard and ensure some oversight from Parliament in considering HSSIB’s effectiveness and the improvements being made on patient safety.

As the Joint Committee on the Draft Health Service Safety Investigations Bill commented:

“There was widespread agreement among our witnesses that there would be more confidence in HSSIB’s independence were it to be accountable to Parliament rather than to the Secretary of State. When asked whether accountability to Parliament might not also be seen as political influence, Professor Toft responded that accountability through a cross-party committee was more likely to inspire confidence than to a single Minister, and that a committee was more likely to scrutinise and not to give directions.”

If there is to be faith in HSSIB, we must heed the Joint Committee’s warnings and ensure that the reporting mechanism is sufficient to ensure confidence in the body and to prevent reports from simply being filed away without scrutiny. I hope that the Minister will agree that confidence in HSSIB and its effectiveness to improve patient safety are integral and that he will support the amendment. There has been a little concern about placing requirements on the Secretary of State throughout proceedings on the Bill, so I hope that a requirement for him to present a report once every 12 months would not be too onerous but will be considered an appropriate and acceptable measure.

Edward Argar Portrait Edward Argar
- Hansard - -

Clause 97 deals with HSSIB’s final report following an investigation and sets out what a report should include, such as the overall findings, with analysis of what has happened. If the report concerns an investigation that the Secretary of State directed HSSIB to undertake, HSSIB will be required to send a copy of the report to the Secretary of State. I understand that the purpose of amendment 124 is to require the Secretary of State to consider the report and then report to Parliament within 12 months on what action has been taken as a result. Although I can certainly see that the purpose of the amendment is to ensure transparency, accountability and follow-up, I am not convinced that it is the right way to achieve that understandable and legitimate aim.

We expect HSSIB to conduct about 30 investigations a year, which means that the Secretary of State would need to report on 30 separate reports. I worry that that would be unnecessarily burdensome without delivering significant improvements in patient safety. The final HSSIB report will be published, and we expect that the recommendations will most likely be directed at and actioned by others. Organisations are required to respond to HSSIB’s recommendations, and HSSIB may publish those responses. Therefore, it is not necessary for the Secretary of State to publish an additional report, particularly if there is no action for the Secretary of State to take following HSSIB’s recommendations.

Parliament will be able to use its normal routes to hold Ministers to account and ask what progress has been made following these reports, which of course will be published by HSSIB and open to public scrutiny. I do not consider it necessary for HSSIB to send the Secretary of State a copy of the report, as this will be available to everybody without that additional step. I will therefore encourage the shadow Minister to consider withdrawing his amendment.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

The Minister makes some fair points, and we are aware that there are other channels to pursue these matters. However, it did seem a bit incongruous that the Secretary of State would have certain requirements on him if he directed a report but not otherwise. Again, we will see, as the body moves forward over the next few years, whether the scrutiny arrangements in place are indeed effective, so we will not press the amendment to a vote. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

Clause 97 deals with HSSIB’s final report following an investigation. It sets out that a report should include the overall findings, with analysis of what has happened. It is important that the emphasis of any such report is put on identifying risks to the safety of patients and addressing those risks by facilitating the improvement of systems and practices in the provision of NHS services or other healthcare services in England. Therefore, HSSIB should include recommendations about how any risks should be addressed. If an investigation has been commissioned by the Secretary of State, HSSIB will be required to send a copy of the report to the Secretary of State.

As I have mentioned previously, we are clear that the purpose of any investigation is to address issues so that we improve patient safety. We want to ensure that the NHS gains as much as it can from all investigations, even if they may not always relate to the NHS. The clause therefore sets out that if the investigation relates to an incident that has not occurred during the provision of NHS services, HSSIB must consider whether the systems and practices in the provision of NHS services could be improved.

The clause also sets out that there should be no assessment of blame, civil or criminal liability, or whether regulatory action should be taken against an individual in the report. That is not the role of HSSIB investigations, and any such assessment would discourage individuals from speaking candidly to HSSIB and could result in lessons not being learned. HSSIB plays a complementary but very different role from the police and regulators. Finally, the clause allows HSSIB to release protected material as part of the report if certain criteria are met.

The purpose of this clause is to set out the expectations on reporting from HSSIB following an investigation. I therefore commend it to the Committee.

Question put and agreed to.

Clause 97 accordingly ordered to stand part of the Bill.

Clause 98

Interim reports

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

These clauses continue on the same theme as clause 97 and focus on HSSIB’s reports. I turn first to clause 98, which essentially allows HSSIB to publish an interim report with findings, recommendations and conclusions before the final report. The aim of the interim report is to address urgent risks to the safety of patients or issues that are known early in an investigation, so that swift action can be taken and lessons can be learned across healthcare systems as findings emerge.

Clause 99 requires HSSIB to share a draft of an interim report or a final report with those who are likely to be adversely affected by it, and to seek their comments—that might be NHS staff or other participants. HSSIB may also share a draft report with any other person who they believe should be sent a copy, which might include patients and families. That is to ensure that the interim and final reports are robust and an accurate reflection of what has happened, adding to the rigour of the investigation. It also gives individuals an opportunity to respond to adverse findings in advance of publication of the report.

Clause 100 describes what needs to happen once an interim report or a final report is published by HSSIB. It requires the addressees of the report to provide a response to the recommendations within the timeframe specified by HSSIB, and HSSIB may publish the response. The clause will ensure that it is clear and transparent what actions will be taken to address the recommendations. The clause is drafted to ensure that it does not encroach on the devolved competence of Wales. For example, the duty to respond to recommendations would not apply to any body that is or could be established by the Welsh Parliament. HSSIB may still make recommendations to persons in Wales, and certain types of organisations would be required to respond—for example, a private sector organisation in the health sector. The clause will ensure that there is follow-up to the recommendations in the report from HSSIB.

Finally, clause 101 sets out that unless the High Court makes an order to the contrary, final and interim reports prepared by HSSIB following an investigation, including drafts of the reports, are not admissible in proceedings to determine civil or criminal liability, proceedings before any employment tribunal, proceedings before a regulatory body—including proceedings for the purpose of investigating an allegation—and proceedings to determine an appeal against a decision made in any of the above types of proceedings. That is a demonstration of our commitment, as mentioned before, that we want the investigations to provide useful learning and foster a continuous improvement mindset for the benefit of all patients, rather than apportion blame.

There may be circumstances whereby a person involved in the above proceedings applies to the High Court for the report to be admissible. In that case, it will be for the High Court to determine whether it is in the interests of justice for such information to be made admissible, using the test set out in the Bill: whether the interests of justice are served by admitting the report and outweigh any adverse impact on investigations by deterring people from giving information to inform an investigation and any adverse impact on securing the improvement of the safety of healthcare services provided to patients in England. I suspect this is a theme that we will explore when we debate subsequent clauses and amendments. I know that the hon. Member for Central Ayrshire will wish to explore it further when we reach those clauses.

Clause 101 clarifies the circumstances under which a report can be used in legal proceedings. It is an important element of ensuring that safe space works in the way we intend, strikes an appropriate balance and encourages individuals to speak to HSSIB in a candid way. However, we rightly also provide the High Court order safeguard, so that the interests of justice can also be taken into account where appropriate. We believe that strikes an appropriate balance in this particular context, and that these clauses set out important provisions regarding HSSIB’s reports. I therefore commend the clauses to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful to the Minister for setting out the provisions here, and the ability to produce interim reports under clause 98 is welcome. We can all envisage circumstances in which such action would be of benefit. I note that the requirement to circulate the report to all interested parties in draft form also applies to interim reports. On clause 99, which is about draft reports, I agree that it is right that HSSIB should be able to judge for itself to whom it is appropriate for the draft report to be made available. Under clause 99(4), however, is there a need for comments that are not accepted in the draft stage to be published alongside HSSIB’s response, explaining why those comments have not been accepted at the same time as the final report is published? I do not think that is something that needs to be prescribed in legislation, but it may be something that HSSIB considers doing in some form, and I would be grateful for the Minister’s comments on the desirability or otherwise of such a move.

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Edward Argar Portrait Edward Argar
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I take the hon. Lady’s point. As I set out in response to earlier amendments and preceding clauses, I believe that we have struck the right balance on the obligation to respond and act, but I acknowledge, as I frequently do in these Committees, her expertise, particularly in this area, having sat on the Committee that previously considered the matter. I think that we have struck the right balance, but I am always happy to reflect further.

I can give the hon. Member for Ellesmere Port and Neston, within bounds, the reassurance, or agreement with what he is saying, that he seeks, with a caveat: I would hope that transparency and publication should be at the fore, but in doing that, and determining the other points that he raised, as he acknowledged that is for HSSIB to reflect on and consider within the context of its independence. I would hope, and expect, that it would consider extremely carefully exactly such points as those that he made, because they sounded like sensible points, as is often the case with him.

Question put and agreed to.

Clause 98 accordingly ordered to stand part of the Bill.

Clauses 99 to 101 ordered to stand part of the Bill.

Clause 102

Powers of entry, inspection and seizure

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 125, in clause 102, page 90, line 21, leave out subsection (6).

Oral Answers to Questions

Debate between Edward Argar and Justin Madders
Tuesday 19th October 2021

(2 years, 6 months ago)

Commons Chamber
Read Full debate Read Hansard Text Read Debate Ministerial Extracts
Edward Argar Portrait Edward Argar
- Parliament Live - Hansard - -

The short answer is that it looks as though I may be going on tour in the coming months, and I am delighted to accept my hon. Friend’s kind invitation.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Parliament Live - Hansard - - - Excerpts

With a £9 billion maintenance backlog, examples of which we have heard this morning, it is truly mind-boggling that the Department’s priority has been to try to change the definition of what a new hospital is, so let us cut out the spin on 48 new hospitals. Can the Minister tell us, of those 48—if we take out all the projects under way before the announcement was made, and those that are new wings, extensions or refurbishments of existing buildings—exactly how many new hospitals will be built by 2030? It is not 48, is it?

Edward Argar Portrait Edward Argar
- Parliament Live - Hansard - -

I am grateful, I think, to the shadow Minister. We have a very clear definition of a new hospital, which I believe is shared by the public. It also leans on VAT notice 708 and its definition of what constitutes a new build or a refurbishment. To his specific question, we are committed to our manifesto commitment of 40 new hospitals by 2030—we build, the Opposition complain.

Health and Care Bill (Twelfth sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
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I will be brief because we covered key aspects of clause 68 in debates on the amendments. The clause inserts proposed new section 12ZB into the NHS Act 2006. Section 12ZB allows the Secretary of State to make regulations setting out the regulatory framework for the procurement of healthcare services, to better meet the needs of the NHS.

Section 12ZB provides further information about the content of those regulations. They may contain provision in relation to the objectives of procurement, and they may contain provisions ensuring transparency, fairness and effective management of conflicts of interest, as well as provision for the purpose of verifying compliance with the regime. The new section also allows for NHS England to publish guidance about compliance with the new procurement requirements to which relevant authorities, as defined in the section, must have regard.

The NHS has sent us a clear message that the current regime for arranging healthcare services is not working. It is confusing, overly bureaucratic and does not fully support the integration and efficient arrangement of services and collaboration in the best interest of patients, which, of course, run through the Bill like a golden thread. Through the clause, we will develop a new provider selection regime for the NHS and public health—a bespoke NHS regime that will give the NHS and local government more discretion over how they arrange healthcare services. Informed by the consultation run by NHS England earlier this year, it will aim to enable collaboration and collective decision-making—recognising that competition is not the only way of driving service improvement. It will aim to reduce bureaucracy on commissioners and providers alike, and to remove the need for competitive tendering where it adds limited or no value.

We recognise that in many cases competition can be beneficial for procurement. Where a competitive tender is the best way for an NHS commissioning body to secure value and quality in its healthcare provision, it will be used. However, it will no longer be the default that contracts in the NHS are automatically put out to tender. All decisions about provider selection will continue to be made in an open and transparent way, considering key criteria and applying them to decision making, in the best interests of patients and the taxpayer. I commend the clause to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I will not repeat all my comments from earlier, to save the Committee’s time. I have two remaining specific questions, which I hope the Minister can address. The clause says that regulations “may” be produced. Can he state for the record that there will be regulations? Can he also give us some indication of when they are likely to be made and when they are likely to take effect?

Edward Argar Portrait Edward Argar
- Hansard - -

I can reassure the hon. Gentleman that “may” is the technical language used in drafting such legislation, but we intend that they will be made. I am afraid I will disappoint him on the second part of his question, because I would not presume to say exactly when; that will be down to the passage of this legislation and then the usual wait and the discussions through the usual channels on securing an appropriate slot for the regulations. I hope I have given the hon. Gentleman a modicum of reassurance.

Question put and agreed to.

Clause 68 accordingly ordered to stand part of the Bill.

Clause 69

Procurement and patient choice: consequential amendments etc

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I beg to move amendment 97, in clause 69, page 62, line 26, at end insert—

“(1A) In the National Health Service Act 2006, in section 272(6), after paragraph (za), insert the following paragraph—

‘(zaa) regulations under section 12ZB,’”.

This amendment would require a draft of procurement regulations under new section 12ZB of the National Health Service Act (inserted by clause 68) to be laid before, and subject to approval by resolution of, each House of Parliament.

I will not detain the Committee long on this amendment. Following on neatly from our previous discussion, it requires that the regulations, which I am now assured will be produced, are subject to a resolution of approval by both Houses. I do enjoy spending time in Delegated Legislation Committees with the Minister, and I hope we will be able to do that again as a result of this amendment’s being accepted.

Edward Argar Portrait Edward Argar
- Hansard - -

I am, as ever, grateful to the hon. Gentleman. The amendment would require a draft of procurement regulations under new section 12ZB of the National Health Service Act to be laid before, and subject to approval by resolution of, each House of Parliament. As set out in our delegated powers memorandum, the powers created by clause 68 amend the NHS Act 2006. In line with the vast majority of regulations made under that Act, these powers will be subject to the negative procedure in section 272(4) of that Act.

As demonstrated by the passage of the Health and Social Care Act 2012, there is significant parliamentary interest, both in this House and the other place, in the rules for determining how healthcare services are arranged. However, it is vital that we strike the right balance between democratic scrutiny and operational flexibility. The negative procedure provides that balance, ensuring transparency and scrutiny, while also providing sufficient flexibility to ensure that the regulations continue to drive high-quality services and value for money.

We have consulted extensively on the proposals for these regulations to ensure that we are delivering the flexibility, transparency and integrated approach that the NHS has asked for. The engagement exercise undertaken in early 2019 collected views from across the health sector, and the proposals put forward by NHS England around procurement gained widespread support, with 79% of respondents agreeing or strongly agreeing with the proposals.

Earlier this year NHS England consulted on further detail of the proposed regime that should apply when healthcare services are arranged in future, following removal of the current requirements. NHS England received a range of responses from NHS national and representative bodies. In addition to written feedback, it met NHS colleagues and external stakeholders. We have been and continue to be as transparent as possible in our approach to these proposals. Therefore, I suggest that the hon. Gentleman amendment’s is unnecessary.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

In the light of the Minister’s comments, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

I will be very brief. The clause will remove the specific healthcare procurement rules that currently apply to NHS commissioners when arranging clinical healthcare services. Specifically, it will repeal sections 75 to 78 and schedule 9 to the Health and Social Care Act 2012 and revoke the National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013. It also makes other minor, consequential amendments in relation to these changes and the introduction of the power to make a new provider selection regime for procurement of healthcare services under clause 68.

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Edward Argar Portrait Edward Argar
- Hansard - -

I will try to be as brief as I can, while giving the Committee the information it wishes to have.

This package of measures is aimed at promoting collaboration in the NHS, reflecting a shift towards integration between commissioners, providers and other partners as a way of improving the healthcare people receive. Clause 70 allows for the removal of Monitor and the Competition and Markets Authority’s duties to co-operate in the exercise of their functions as concurrent competition regulators. Instead, they are replaced with a duty on NHS England to share regulatory information with, and provide assistance to, the CMA where the CMA requires it to exercise its functions.

Clause 71 removes the Competition and Markets Authority’s role in reviewing mergers solely involving NHS foundation trusts, NHS trusts or a combination of both. The CMA has led a number of investigations into NHS provider mergers or acquisitions in recent years. Although it has approved all but one merger, the investigations have been costly and time-consuming for the organisations involved.

We recognise the CMA’s important role in investigating alleged infringements of competition law and particular markets if it sees issues for consumers with reducing competition. However, as has been alluded to, the NHS is not a true market, and it has become clear that the CMA is not the right body to review NHS mergers. Instead, NHS England will continue to review all NHS provider mergers to ensure they have clear benefits for patients and the taxpayer. The CMA will retain its merger control powers in relation to the private healthcare and pharmaceutical industries, where competition plays a greater role. The NHS should be able to make decisions about provider mergers itself. Without this clause, NHS provider mergers will still be subject to costly, time-consuming investigations.

Building on the experience of the last few years, the Bill will clarify the central role of collaboration in driving performance and quality in the system. As part of that, under clause 72, we are looking to remove Monitor’s role as a concurrent competition regulator. However, although we are removing Monitor’s competition regulation functions, it is right that NHS England should continue to share regulatory information with and provide assistance to the CMA so that the CMA can carry out its functions. The clause will ensure that the CMA has the information and assistance it needs to do that in respect of its competition functions to prevent anti-competitive behaviour in the wider sector. That will ensure that the CMA can continue to make sure that the healthcare sector works for consumers, patients and the taxpayer.

The clause removes Monitor’s competition functions, which it exercises concurrently with the CMA. It also inserts schedule 12, which makes consequential amendments in relation to the removal of Monitor’s competition functions. The Health and Social Care Act 2012 allowed Monitor to exercise some of the functions that the CMA holds under the Competition Act 1998 and the Enterprise Act 2002, but solely in relation to the provision of healthcare services in England. Those included powers to take action on anti-competitive agreements and conduct in the sector and powers in relation to mergers in the sector.

The Bill will enhance collaboration between different NHS commissioners, providers and local authorities. We therefore expect that NHS England’s primary role, following its merger with Monitor, will be to support commissioners and providers to deliver safe, effective and efficient care, rather than to act as an economic or competition regulator.

While competition will continue to play an important role, including through patient choice and the new provider selection regime, it is right that the duties and role of the merged NHS England give greater weight to fostering collaboration and integration rather than enforcing competition, and that competition regulation is left to the CMA. The concurrent competition duties and functions of Monitor should therefore be removed. Schedule 12, inserted by clause 72, makes the necessary consequential amendments to take account of the removal of Monitor’s competition functions. The clause allows NHS England to work collaboratively with organisations to deliver the best possible services to patients.

Finally, clause 73 removes the CMA’s role in reviewing contested licence conditions. The licence conditions have not changed substantially since they were first agreed in 2013. However, NHS England and NHS Improvement’s oversight of the NHS has changed significantly. Their primary role is to support the delivery of safe, efficient and effective care. The merged NHS England, as provided for under this Bill, should be able to set its own licence conditions for providers and regulate providers of NHS services without needing to refer matters to an external competition regulator such as the CMA.

NHS England will remain under duties to consult with local organisations on revised licence conditions. That, alongside the removal of the CMA’s review functions, ensures that any decisions remain in the interests of the NHS as a whole. In addition, NHS England’s accountability arrangements to the Secretary of State and Parliament offer a further safeguard against disproportionate changes to licence conditions. Sufficient safeguards, such as those that I have mentioned, ensure that providers have input into any proposed changes, without the need for oversight from a third party.

We therefore believe that these measures deliver the changes that the NHS has been asking for to help it deliver the long-term plan and recover from the pandemic. I therefore commend them to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I will not detain the Committee long, but perhaps we need a minute to pause, because, as my hon. Friend the Member for Bristol South said on Tuesday, this marks the end of an era. Monitor is gone, competition is no more, and procurement is gone—I think—and become bespoke, to be determined in more detail in the regulations. Perhaps even more stark is the fact that ICBs now have providers on the board, having jettisoned the GPs, and that NHS England is now both an actual commissioner and a systems manager for both commissioners and providers. It feels like we are going back to the future.

As the Minister said, these clauses end the role of the Competition and Markets Authority. This is the final nail; it is perhaps the final recognition that the wild promises made about the 2012 Act have failed to achieve what they said they would. The expectations that Lansley set out back then have failed to produce any desirable results. I do not know whether Government Members wish to shed a tear at this point for the end of these measures, but, for Opposition Members, health is not a commodity; it is a right. Health is not a product, and the NHS is not—and never can be—a market.

As we see the end of the ideological attempt to create a market, Opposition Members cheer the bidding into history of this failed experiment, which should never have occurred. Turning to the actual substance of the clauses, as the Minister set out, they do what is necessary to achieve that aim.

Question put and agreed to. 

Clause 70 accordingly ordered to stand part of the Bill. 

Clauses 71 and 72 ordered to stand part of the Bill.

Schedule 12 agreed to.

Clause 73 ordered to stand part of the Bill.

Clause 74

Special Health Authorities: removal of 3 year limit

Question proposed, That the clause stand part of the Bill.

None Portrait The Chair
- Hansard -

With this it will be convenient to discuss clauses 75 and 76 stand part.

Edward Argar Portrait Edward Argar
- Hansard - -

Clauses 74, 75 and 76 repeal the three-year time limit on special health authorities, restate the requirements for special health authorities and NHS trusts to keep proper accounts and records, and repeal the powers of the Secretary of State to make a property or staff transfer scheme.

Together, along with the provisions in the Bill to merge NHS England and NHS Improvement and the powers we will discuss in part 3 of the Bill in a few weeks’ time, these technical changes will help ensure that we have flexibility in the arm’s length body landscape to support the delivery of a world-class healthcare system.

Clause 74 repeals legislative provisions that currently impose a three-year time limit on any newly established special health authority. When the three-year time limit was initially imposed under the Health and Social Care Act 2012, it was envisaged that any future special health authority would have time-limited functions and therefore be temporary in nature. This has not proved to be the case.

The NHS Counter Fraud Authority is the only special health authority created since the time limit was introduced. The Government consider it unnecessary for the NHS Counter Fraud Authority, or any other special health authorities that are established in future, to undergo the process of extending their lifespan every three years. As well as repealing the time limit, the clause sets out changes to the statutory instrument used to create the NHS Counter Fraud Authority, to reflect the fact that there is no longer an abolition date.

Clause 75 simply tidies up provisions in the current legislation in respect of requirements to keep accounts. It restates the requirements for special health authorities and NHS trusts to keep proper accounts and records. It also restates a number of requirements in relation to the auditing and publication of accounts. This clause does not create any change in existing arrangements.

Finally, clause 76 abolishes powers taken in the Health and Social Care Act 2012 to transfer property, rights and liabilities from bodies abolished or modified by that Act. Those powers are now spent, so we are removing the clause to ensure neatness of the statute book, especially as a number of bodies in the 2012 Act are being abolished by this Bill. However, we have retained the ability to make transfer schemes in respect of previously transferred property and rights.

The Bill allows property, rights and liabilities that have been transferred previously under section 300(1), to subsequently be transferred to a Minister of the Crown, NHS England, an integrated care board, an NHS trust or foundation trust, or a qualifying company. That will ensure clarity that rights, property and liabilities are properly allocated and maintained, and not lost to the NHS.

These technical changes will support the wider intentions of the Bill to have a flexible and responsive national architecture for managing the healthcare system. I therefore propose that these clauses stand part of the Bill.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I will not detain the Committee for long. We are enjoying the Minister’s conversion as regards the folly of the 2012 Act, this being another example of things not turning out as originally envisaged. As he said, these clauses are necessary and we will not oppose them.

Question put and agreed to.

Clause 74 accordingly ordered to stand part of the Bill.

Clauses 75 and 76 ordered to stand part of the Bill.

Clause 77

Abolition of Local Education and Training Boards

Question proposed, That the clause stand part of the Bill.

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Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I have a couple of questions for the Minister. We would more accurately describe this as a reflection of the reality on the ground, and how local education and training boards have not really been the vehicle for change that they might have been. Their original rationale was to

“build a system that is responsive to the needs of employers, the public and the service at local level.”

It seems odd that this is happening, given that the thrust of the rest of the Bill is to increase local autonomy, but I understand that the regional people boards will be taking up the majority of the slack. It raises the question of how exactly the undoubted variation in recruitment and training needs within ICBs and regions will be addressed, and how ICBs will interact. I would like to hear from the Minister about that. There is also a concern from the British Medical Association that this could mean the loss of dedicated local support systems for GP trainees, and there is some need for clarity on how that function will be met.

Edward Argar Portrait Edward Argar
- Hansard - -

The shadow Minister is right in surmising that once LETBs are abolished, their functions will be discharged by HEE directly in the manner he has set out. On his specific questions, HEE will continue to have responsibility for workforce planning and will engage with regional people boards, integrated care boards and the regional directorates of NHS England to carry out this function. Those responsibilities will be set out in a report that we will publish describing the system for assessing and meeting the workforce needs of the health service in England, as debated in relation to clause 33—to which we may yet return, either on the Floor of the House or in the other place.

We are not removing local or regional workforce planning from the statute, as the hon. Gentleman suggested; HEE will continue to have responsibility for that workforce planning. The LETBs were sub-committees of HEE and reported to the HEE board in any case, so clause 77 just removes some of the rigidity in respect of how HEE had to operate. As is the theme throughout this legislation, this clause seeks to give a greater degree of flexibility and permissiveness to allow the system to adapt to changing needs. On that basis, I ask that it stand part of the Bill.

Question put and agreed to.

Clause 77 accordingly ordered to stand part of the Bill.

Clause 78

Hospital patients with care and support needs: repeals etc

Health and Care Bill (Eleventh sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait The Minister for Health (Edward Argar)
- Hansard - -

It is a pleasure to serve under your chairmanship once again, Mrs Murray. With your indulgence, I will speak to each of the clauses in turn.

Clause 51 amends section 88 of the Health and Social Care Act 2012. Section 88 requires that Monitor—or, in future, NHS England—treats an NHS trust that has become an NHS foundation trust as having made an application and met the criteria for a licence. The clause will require NHS England to apply that provision when that queue of NHS trusts waiting to become foundation trusts do so—[Laughter.] I hope the Committee will forgive my gentle reference to what the shadow Minister said last time. On a more serious note, the clause will also require NHS England to apply it when a foundation trust is created as a result of the merger of an existing foundation trust with an NHS trust or another foundation trust, or the separation of one foundation trust into two or more new foundation trusts.

Clause 51 clarifies the situation when new foundation trusts are created, merged or separated and ensures there is no unnecessary bureaucracy as a result. It is an important clarification for NHS England on how to exercise its licensing powers in such situations, should they arise.

We are investing record levels of capital expenditure into the NHS to help it build back better after the pandemic. We intend to set capital expenditure budgets at integrated care board level, and we expect providers to work with ICB partners to agree capital expenditure, in line with the ICB capital plan. To ensure that the interests of the wider system are taken into account at individual provider level, clause 52 provides a new power to allow NHS England to make an order imposing capital expenditure limits for NHS foundation trusts.

That narrow and reserved power will ensure that a limit can be set only for an individually named foundation trust for a specified period, and would automatically cease at the end of that period. The power relates solely to capital expenditure and not to revenue expenditure. NHS England must also consult the foundation trust before making the order. There will be clear transparency, as the order will be published.

In applying to an individual foundation trust in particular circumstances, the power stands in contrast to the capital limits that apply to all NHS trusts. The power is likely to be used where there is a clear risk of an ICB breaching its system capital envelope as a result of non-co-operation by that foundation trust, and when other ways of resolution have been unsuccessful.

NHS England must set out in guidance the circumstances in which it is likely to set a capital limit and how it will calculate it. NHS England intends to work closely with foundation trusts to develop that guidance. I want to make it clear to the Committee that the clauses are not intended in any way as an erosion of the autonomy enjoyed by foundation trusts. Unlike NHS trusts, foundation trusts will continue to have additional financial freedoms, such as the ability to borrow money from commercial lenders. However, the clause is crucial for managing NHS capital expenditure across a system and to ensure that all NHS providers operate within the ICB capital limits. Without that control, other NHS providers may have to reduce their capital spending to ensure that the NHS lives within its allotted capital resources and that resources are spent in a way that best delivers for patients and the taxpayer.

The provisions in clause 53 are largely a consequence of the merger of NHS England and Monitor, in this case reflecting Monitor’s oversight role in relation to foundation trusts. Subsection (1) gives foundation trusts greater flexibility in their forward plans. Paragraph (a) removes requirements currently in the National Health Service Act 2006 concerning the content of the forward plan. Paragraph (b) removes the requirements for the forward plan to be prepared by the foundation trust’s directors and for the directors to have regard to the views of the foundation trust’s governors when preparing the forward plan.

Foundation trusts will no longer be mandated to set out information in the forward planning documentation around non-health service activity and income. The clause also removes the requirement for governors to be mandated to determine whether the foundation trust’s forward plan interferes with the trust’s health service activity.

As the Committee will know by now, and as a consequence of the abolition of Monitor and its merger with NHS England, NHS England will formally become responsible for the support and oversight of foundation trusts, which includes taking on Monitor’s regulatory and intervention powers. That change will enable improved oversight and greater flexibility across the system. Provisions elsewhere in the Bill make the detailed changes, including formally giving NHS England responsibility for giving directions in relation to the content and form of foundation trust accounts. That includes specifying information to be included in the annual reports and accounts of foundation trusts.

The clause is simply part of transitioning the provider-based functions of Monitor into NHS England, ensuring continuity of oversight of foundation trusts’ accounting and forward planning. NHS England will be able to provide fundamental advice and guidance to foundation trusts in the exercise of their functions. Provisions elsewhere in the Bill will formally allow NHS England to monitor the performance of foundation trusts and to take steps to intervene where necessary, which may take the form of advice and support. As we discussed on a previous occasion, however, it may also involve NHS England requesting the trust to take action to remedy emerging issues. At the same time, the clause makes the requirements on annual plans more flexible, to reflect the direction of travel towards system-wide, rather than organisation-specific, planning.

I turn now to clause 54, which inserts proposed new section 47A into the National Health Service Act 2006 and allows an NHS FT to carry out its functions jointly with another person, should the foundation trust consider such arrangements to be appropriate. That would allow a foundation trust to exercise its healthcare delivery functions jointly with another foundation trust as part of a provider collaborative. The clause will make it easier for FTs to work with partners across the health system to develop integrated, seamless services in the best interests of patients.

Clause 55 amends sections 56, 56A and 56B of the 2006 Act, which relate to the merger, acquisition, separation and dissolution of NHS foundation trusts and NHS trusts. It removes the requirement that an application to acquire or merge an NHS FT with another NHS FT or an English NHS trust be supported by the Secretary of State if one of the parties is an NHS trust. NHS England will now consider each application, but the Secretary of State’s role has been strengthened, as he must now approve such applications. However, NHS England will consider the applications and provide advice. That is in keeping with the policy intention that the Secretary of State should have a strengthened accountability role for NHS foundation trusts, in the light of the transfer of Monitor and NHS Trust Development Authority functions to NHS England. NHS England replaces Monitor in the relevant sections of the NHS Act 2006.

Like Monitor, NHS England has a duty to grant the application to merge, acquire or separate if it is satisfied that the necessary steps have been taken to prepare for an acquisition or the dissolution and establishment of new trusts. Additionally, the clause adds a further requirement to each of the sections, which provides that NHS England must refuse an application if the Secretary of State does not approve it. That strengthens the role of the Secretary of State in the process, and it will be for NHS England to take note of the Secretary of State’s comments in taking forward its plans. The clause provides for enhanced oversight and places strategic decision making in the health system in the hands of NHS England, while also conferring a commensurate and important role on Ministers, in line with the direction of accountability set out in the Bill.

Clause 56 relates to the transitioning of the provider-based functions of Monitor and the NHS TDA into NHS England. That will allow NHS England to grant an application by an NHS foundation trust for dissolution. The clause confers the powers that rested with Monitor to transfer or provide for the transfer of property of an NHS foundation trust on its dissolution. Previously, on the dissolution of an NHS FT, Monitor had the power to transfer the property of the NHS FT to the Secretary of State. The clause amends that power so that, when making an order to dissolve an NHS foundation trust, NHS England now has the power to make an order to transfer, or provide for the transfer of, property and liabilities to another NHS FT, an NHS trust or the Secretary of State. The clause also includes a new duty for NHS England to include the transfer of any employees of a dissolved NHS FT in the transfer order.

Taken together, these clauses ensure that foundation trusts are able to play a central role in a more integrated and collaborative healthcare system. As part of that, the clauses also provide NHS England with the powers it will need to help support NHS FTs. I therefore commend clauses 51 to 56 to the Committee and propose that they stand part of the Bill.

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

It is a pleasure to see you in the Chair this morning, Mrs Murray. I am glad you enjoyed Tuesday so much that you came back for another round. We will do our best to inform and entertain as we go along.

I am grateful to the Minister for setting out the Department’s position on the clauses. We really need to have another go, don’t we, at trying to understand the landscape for foundation trusts? I have already referred the Committee to the description of foundation trusts when they were first established, as vigorous, autonomous, business-like new organisations that would shake up the NHS and bring choice and competition into healthcare. As we know, there was no evidence that that model did any better than the previous standard trusts, once the high performers had been accounted for.

The Minister’s contention that the clauses do nothing to impinge on a foundation trust’s autonomy is quite the claim. The big change in the clauses is the stripping away of financial autonomy, as set out in clause 52, directly contradicting the many occasions when we have been told that the Bill is all about permissiveness, local decision making and accountability. In clause 55, we also see the Secretary of State giving himself yet more powers.

Clause 52(2) could, in effect, mean there was an indefinite block on foundation trusts using their own capital resources. Will there be any limitations on what is a broad power? I refer to the evidence from Dr Chaand Nagpaul, who touched on that:

“At the moment, we are seeing foundation trusts thinking about their budgets, community providers thinking about theirs, and general practice as well. There is not even collaboration between the community and the hospital. No foundation trust currently has the ability to say, for example, ‘We will go beyond our budget and invest in the community—it may actually reduce our hospital admissions.’ At the moment there is no structure or processes to enable collaboration even within the NHS.”—[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 93, Q120.]

Dr Nagpaul sets out very well the lack of clarity that we still have about how finances will work at a local level within an ICB, and clause 52 gives foundation trusts even less autonomy in that respect.

On that point, I noted with interest today yet another Health Service Journal article, which talked about how integrated care partnerships may not be up and running for some time after the ICB has been set up. That raises questions about what their role is going to be in helping to form those capital priorities for an integrated care system.

In other evidence, Richard Murray said:

“The bit that I think is really uncertain is how the big hospital schemes get picked. That is the bit that looks very different. Obviously, there is a manifesto commitment.”—

although we know that, in recent times, the Government have not been so keen to follow those commitments. He continued:

“There used to be a process by which it was determined whether providers could afford to repay—if they could do it through loans, or if there was a need system. That is now going off in a completely different place, and I think that is the bit that is not quite clear. How does that work within this system? Who gets to choose how those projects get picked, so to speak?”—[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 118, Q158.]

I appreciate that the point is slightly off-piste, but as we are talking about capital expenditure it is appropriate to raise it, and I am sure the Minister will take the opportunity in his response to set out that process in more detail. At the same time, can he set out in more detail what the guidance set out in proposed new section 42C would entail? Hopefully we will be able to set out some broad points in respect of that.

While we are on the Minister’s response, will he consider the broader point we made on Tuesday about foundation trusts’ focus on involvement of patients and the public and whether that needs to be strengthened across the board? He needs to think again about the whole question of accountability on ICBs.

To go back to the essential question, are foundation trusts now any different to plain, old-school NHS trusts? Is a foundation trust now a dodo? Is it extinct or on its way out? If an ambitious young chief executive of a trust were to approach the Minister and say they were thinking of putting in an application for foundation trust status, what would the Minister say to them about the benefits of such an application, both to their trust and to the wider healthcare system?

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Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister for his suggestion of a consolidation Act. I can tell just how much he enjoys the sessions we spend in Committee and how eager he is that, no sooner do we finish, than we are back in another Bill Committee together. In terms of his gentle gibe about reorganisation in another two years, there was roughly a two-year gap between the 1999, then the 2001, then the 2003 and then the 2006 reorganisations of the NHS under the previous Government. I fear this is something that affects Governments of all types.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Indeed, but the point that we would make is that there was such a mess to clear up after 18 years of Conservative Government that we had to do a lot of reorganisations. If the Minister can state for the record that there will be no reorganisations within a specified timescale, we would all be delighted to hear that.

Edward Argar Portrait Edward Argar
- Hansard - -

We must always retain flexibility so that the legislative framework reflects the evolving nature of healthcare provision in this country and we can we deliver what all our constituents want us to.

The hon. Gentleman touched on the importance of licensing. The licence applies to anyone providing NHS services, including the independent sector. With the system oversight framework, it provides a tool that helps to ensure quality across all types of providers in a consistent way, hence the importance that we still attach to it.

At the heart of the hon. Gentleman’s speech were his points about foundation trusts, a 2004 innovation. The reason we are introducing these changes is that we recognise not only the ability of foundation trusts to be autonomous, but the need for them to collaborate and integrate. The aim is to create a framework that allows for local flexibility but brings together local services, recognising the synergies that need to exist between all healthcare providers in an area. With the ICB holding the ring, we get local flexibility, but we look at it the local system level rather than the individual provider level. I alluded to it jokingly, but as I promised in our last session I can confirm to him that I was correct that there are no current applications from NHS trusts to become foundation trusts. I said that I was relying on my memory, but I can confirm for the record that my memory was accurate.

The hon. Gentleman talked about the new hospitals programme and capital more broadly. While slightly stretching the scope of the debate, I think that is probably relevant because he was talking about capital, so I am happy to accept that—subject to your judgment, of course, Mrs Murray—as being in scope. In terms of investment in new hospitals, the bottom line is that this is capital provided by the Treasury—by central Government —to build new hospitals where they are most needed. He will have seen the criteria and the approach set out for the next eight schemes, which are currently being considered. An expression of interest is the first stage of that process. A number of criteria are set out—for example, are there safety issues? Is there an urgent need? Will this facilitate transformation and improve patient experience? The criteria are set out publicly.

The next stage, which will take place next year, is the whittling down of the applications to a shortlist and further consideration. I believe it is entirely right that, guided by advice from officials and local NHS systems, Ministers make those decisions, because it is central Government money that is being invested directly in the schemes, rather than the normal capital allocations from NHS England to local NHS systems that are decided at local system level. This is additional, over and above the normal capital allocations.

The hon. Gentleman mentioned proposed new section 42C and asked what it is envisaged the guidance will say, what it will cover, and how it will work. Essentially, we envisage it setting out how and when NHS England and NHS Improvement will exercise the powers—for example, where a foundation trust’s plans potentially put at risk the broader ICB plans for capital, unduly divert resources, or skew the capital allocation in a particular direction. We do not envisage their being used with any regularity, and hope that, as now, broadly, there is a collaborative approach. It is more informal now than envisaged under the provisions, but there is a collaborative approach.

In his broader remarks about the balance between autonomy and freedoms, the hon. Gentleman asked what I would tell a keen and ambitious NHS trust chief executive who was considering taking advantage of the spaces in the queue to become a foundation trust the advantages in doing so are. Essentially, I would say that they should consider what best reflects the local needs for their local healthcare system, because foundation trusts will of course retain freedoms around commercial borrowing and other existing freedoms. The powers that we are introducing act as a safeguard should they be used against the wider interest of the system. There are still advantages, but each NHS chief executive in that situation should consider carefully their own local circumstances and what is most effective in providing for their patients and service users.

My two final points go to what the hon. Gentleman said about the fear that the powers are significant and should be used only as the last resort, and his second point about whether there should be a greater willingness to allow NHS providers to decide how they spend their surpluses, rather than a regulator or central Government deciding. I might be paraphrasing, but I think those were his two key concerns. On his first point, the powers act as a safeguard to allow national-level intervention when local negotiation cannot resolve disputes. I have alluded to what we would use the guidance for, which is to add a bit of flesh to the bones. We think that is best set out in guidance rather than on the face of statute, as circumstances change over time and applying a narrow statutory test could hinder the aims of the clause, which would ensure that NHS spending overall is in the best interests of the public.

To the second point about whether it should be down to NHS providers and systems to determine how they spend surpluses or moneys that they have saved each year for a particular purpose, the hon. Gentleman is right that NHS trusts and foundation trusts operate as autonomous organisations that are legally responsible for maintaining their estates and providing healthcare services. That will continue, but only where there is a clear risk of a trust acting against the wider interest of the NHS system locally and an ICB would the controls be considered for application.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

The Minister is setting out the aims, but I am a little unsure what a foundation trust acting against the wider interest of the ICB would look like. Can he give us examples of where that might have happened?

Edward Argar Portrait Edward Argar
- Hansard - -

The hon. Gentleman tempts me to give a specific example. The reason we chose the flexibility of using guidance is that we cannot envisage every eventuality, so we will set out in guidance the process and approach. I will try to give him an illustrative example rather than a specific one, if he will allow me. If we have an ICB making collective decisions about where capital investment is most needed at a system level, and if we have a foundation trust with resources deciding to prioritise huge investment in one particular area, that might not necessarily reflect the broadly agreed local priorities in the ICB plan and the ICP plan for that area. I envisage such matters being resolved at an ICB level. I have certainly seen in this job and in a past life, as I suspect the hon. Member for Bristol South has, where informal resolution of these things is often the most effective way, so I would not envisage these powers being used often, but it is important that we have the flexibility that they bring. On that basis, I commend the clauses to the Committee.

Question put and agreed to.

Clause 51 accordingly ordered to stand part of the Bill.

Clauses 52 to 57 ordered to stand part of the Bill.

Clause 58

Transfer schemes between trusts

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

As the Committee knows, one intention of the Bill is to create more flexibility, alongside the promotion of greater local integration. The clauses help to allow local bodies to work together in different ways to deliver effective health services.

Clause 60 enables NHS organisations, and any other bodies that may be prescribed in regulations, to commission and arrange services collaboratively, not only with other NHS organisations but with local authorities, combined authorities and other bodies that could be specified in regulations. Existing NHS legislative mechanisms make it difficult for the health and care system to work collaboratively and flexibly across different organisations, forcing local systems to adopt complex workarounds to be able to take joint decisions and pool budgets. In that context, back in the day, when I served in a local authority, we used section 75 of the 2006 Act as one mechanism for doing that with the local primary care trust.

In practice, however, those arrangements can sometimes be cumbersome and difficult to manage, and can delay making vital decisions. The new provisions inserted by the clause into the NHS Act 2006 will enable NHS organisations and any other bodies that may be prescribed in regulations to delegate functions to, or jointly exercise functions with, other NHS organisations, local authorities, combined authorities and other bodies as specified in regulations. Where functions are exercised jointly, the provisions will also enable those organisations to pool funds and form joint committees, facilitating partnership working and joint decision making at place and system level.

To ensure that delegation or joint exercise of functions does not lead to reduced accountability for delivering services, we have proposed appropriate safeguards in the clause. The Secretary of State will be able to set out in regulations which functions can and cannot be delegated, impose conditions in relation to delegation or joint exercise of functions, and specify the extent of such arrangements, for example. Furthermore, the parties will be able to agree terms as to the scope of the delegation arrangement. NHS England will have the ability to issue statutory guidance in relation to functions that are being delegated or jointly exercised under the provisions. The relevant body, as defined in the provision, must have regard to such guidance.

The provisions will replace those in existing sections 13Z, 13ZB and 14Z3 of the NHS Act 2006, which provide for the delegation of joint exercise of NHS England’s functions. The clause also amends section 75 of the 2006 Act, which I just alluded to. That section details arrangements between NHS bodies and local authorities so that where a combined authority, for example, exercises an NHS function as part of arrangements under the new provisions, it can be treated as an NHS body. That is in line with how combined authorities are treated for other, similar joint working arrangements.

Clause 61 and schedule 9 focus on the delegation of functions. Clause 61 inserts a new section into the NHS Act 2006 that makes express the assumption that a general reference in the Act to a person’s functions includes any functions that they are exercising on behalf of another person. That means, for example, that a reference in the Act to the functions of NHS England should cover any public health functions of the Secretary of State that NHS England may be exercising on their behalf under section 7A arrangements. The practical effect of this would be, for example, that any general duties that apply when NHS England is exercising its functions would also apply when it was exercising delegated functions. Until now, delegated functions have not been dealt with consistently in our health legislation. While it is not feasible, notwithstanding the suggestion of the shadow Minister, the hon. Member for Ellesmere Port and Neston, to remedy this issue across all health legislation in one consolidating Bill, this clause seeks to produce a more consistent approach.

Schedule 9 contains amendments to the NHS Act 2006 and other legislation to reflect the broader approach taken by clause 61 to delegated functions. Clause 61 also enables regulation to be made to create further exceptions where necessary to ensure that delegated functions are not covered by a provision where this would be inappropriate. Clause 61 addresses an important but technical legal issue in the Bill and is essential for enabling consistent and clear interpretation of our legislation.

These clauses are essential for ensuring that NHS organisations can collaborate effectively with each other as well as with other partners in the system. I therefore commend clauses 60 and 61 and schedule 9 to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

Members will be relieved to hear that I will not detain the Committee long on this. Clause 60 does what the NHS itself has decided it needs. Over the last six years, we have had various iterations of this integration process, joining things up around joint working, joint bodies and delegation. The provisions try to put all that in one place.

A recurring theme is clarity about the extent of crossovers between local authorities and the NHS. In that respect, proposed new section 65Z5 suggests that local authorities can carry out any function of an NHS body. Could the Minister say more about that? Does it mean that we could see local authorities commissioning—setting up GP surgeries in wellbeing centres? We are assuming that this is one-way and there is no reciprocal arrangement for the NHS to take on local authority functions, so that a foundation trust could not take on an arm’s length management organisation or some other local authority function as a tax-efficient way of avoiding certain liabilities. Could the Minister respond on that?

I also wonder about care trusts, which were the original integrated working teams with the NHS and local authorities. They are rarely mentioned and were largely regarded as unsuccessful. Is there any intention to favour such genuinely integrated bodies? They were used in one recent case by an integrated care provider to get around some of the prohibitions on new trusts. Can the Minister tell us anything about where care trusts now fit into the landscape?

Given the joint nature of the provision, I would like to know why the guidance was published only by NHS England. Should it not have been a joint effort by the NHS and the Local Government Association? Was the LGA consulted and involved in the preparation of the guidance? That perhaps exposes that this is really about the NHS, not about integration across the board. As we have heard today, the ICPs will roll up at some later point, perhaps exposing the reality that this is going to be an NHS-dominated process.

Finally, on the pooling of funds, is there any limit on that? Is that envisaged to be an occasional opportunity, or will it be a more significant step down a road of full funding? Will the Minister set out whether the direction of travel will be quite as dramatic as possibly suggested by the clause?

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the shadow Minister for his support for the clauses and for the, as ever, perfectly sensible questions he poses. I hope to reassure him that the intention behind the clauses is not to create tax-efficient organisations or anything like that; it is to create the most efficient organisations for the delivery of joined-up care. I alluded to section 75 of the 2006 Act, which is an example of what many local authorities are doing already.

On guidance, I hope to reassure the hon. Gentleman that, throughout the genesis of the legislation, we worked collaboratively with the Local Government Association, reflecting local authorities more broadly. As we develop guidance, I am clear that the NHS, NHS England and the Government will continue to work with the association to ensure that local government’s view is reflected in the drafting. A number of conversations have already taken place between officials and the LGA. Notwithstanding the debates we may have in this House or how the legislation emerges, I am clear that we will continue to work collaboratively throughout with all the partners involved, even in areas where we may disagree. We will always seek to work with them.

The hon. Gentleman expressed concerns—he will shake his head if I paraphrase him unfairly—about whether the legislation will allow for unlimited or unfettered delegation without checks and balances. Will we be able to transfer anything from an NHS trust to a local authority, or vice versa? The short answer is no. There will need to be a clear line of accountability between the body ultimately exercising the function and the delegating body. Safeguards ensure that any onward delegation is appropriate. That said, there may be circumstances in which a local authority would commission a particular healthcare service linked to other functions of the local authority delegated from the NHS. We would expect that clear accountability to be in place where that is done. We do not envisage the power being used regularly in that way, but there might be circumstances in which it would be.

Regulations may restrict what, where, when and how—and, indeed, to whom—delegations occur. The delegation agreement may also prevent further onward delegation of functions beyond a certain level. In addition—this goes back to the hon. Gentleman’s point about the LGA—NHS England will, I expect, issue statutory guidance on delegation and joint committees, which would include scenarios, case studies, model delegation agreements and similar to show how, in practice, we envisage this working. The guidance would be statutory, and I envisage it being developed in concert with local authorities, represented by the Local Government Association—that is probably the most effective way of doing that.

I hope that I have given the hon. Gentleman some reassurance that there is nothing sinister—for want of a better word—intended in the clauses; they are merely meant to make things easier for local NHS bodies and local authorities, in particular, to co-operate more. That goes back to the integration at the heart of—the thread that runs through—all the legislation.

Question put and agreed to.

Clause 60 accordingly ordered to stand part of the Bill.

Clause 61 ordered to stand part of the Bill.

Schedule 9 agreed to.

Clause 62 ordered to stand part of the Bill.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

Before I speak to clauses 63 and 64, I crave your indulgence, Mrs Murray: I should have said to the shadow Minister that the previous clauses were about delegation from the NHS to local authorities, not the other way around. I would just like to put that on the record for him, because he expressed a concern about that.

Clauses 63 and 64 have been included in the Bill to help support ICBs and ICPs and to enhance integration across the health and care system. Clause 63 allows NHS England to issue guidance about appointing an individual to roles simultaneously in NHS commissioners and NHS providers, or in relevant NHS bodies on the one hand, and local authorities or combined authorities on the other. We have seen a number of clinical commissioning group and local authority joint appointments that have supported integration and been successful, and we would be keen to see those continue.

The clause further sets a requirement for these NHS bodies to have regard to such guidance when considering making a joint appointment. Joint appointments between organisations can support aligned decision making, enhance leadership across organisations and improve the delivery of integrated care. However, we believe that greater clarity is required to support organisations in making appropriate joint appointments, to avoid conflicts of interest that can be difficult to manage. Before issuing any new or significantly revised guidance, NHS England would be required to consult with appropriate persons.

Clause 63 will allow NHS England to publish a clear set of criteria for organisations to consider when making joint appointments and ensure regard is given to such guidance. That will also provide a safeguard against any conflicts of interest that may arise in the process of making joint appointments.

Clause 64 amends sections 72 and 82 of the National Health Service Act 2006, which deal with the co-operation between NHS bodies and the co-operation between NHS bodies and local authorities respectively. The clause inserts a new power for the Secretary of State to make guidance related to the existing co-operation duties between NHS bodies and between NHS bodies and local authorities. While the existing co-operation duties in sections 72 and 82 relate to both English and Welsh NHS bodies and local authorities, the guidance relates only to England, and the requirement to have regard to guidance issued under this new power will apply only to English NHS bodies and English local authorities.

Our intention is not to produce a single piece of co-operation guidance, which would risk being too general or too wide-ranging to be effective. Rather, we are considering discrete pieces of guidance in specific areas such as delivery of alcohol and drugs services, sexual and reproductive health, or hospital discharge services, to encourage and facilitate co-operation and integration in their delivery.

The clause also amends section 96 of the Health and Social Care Act 2012, which concerns the setting of licensing conditions for providers of NHS services. The licence, as we touched on earlier today, was established in 2013 so that providers of NHS services must meet to help ensure that the health sector works for the benefit of patients. Currently, conditions can be set on co-operation, but these provisions can apply only in certain circumstances.

The clause goes further: it supports system integration, promotes greater co-operation by removing the limitation on setting licence conditions on co-operation, and expands the range of bodies with which co-operation can be required. That will strengthen and reinforce the requirements on providers to co-operate and further strengthens the ability for NHS providers to deliver the system plan.

Co-operation is central to the intentions and underpinnings of this Bill. New guidance and expanding the role co-operation plays in the licensing regime will give organisations greater clarity about the practical expectations for co-operation, help the NHS to build on the innovation, working relationships and positive behaviours that have been seen over the past year, and further embed these behaviours across the health and care system. I therefore commend these clauses to the Committee.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am sure the Minister will be unsurprised to learn that the Opposition are a little wary of the powers in clause 63. One person doing two jobs is never ideal. I make an honourable exception for the hon. Member for Vale of Clwyd, who, in his other role, plays an important part in contributing to the wellbeing of the nation. Such exceptions are rare, and we think that two jobs for one person is never a sustainable or long-term solution.

We draw a distinction between a secondment, which obviously means that the position is by definition time limited and allows the post-holder to return to their original position. It is often good for career development, and that kind of mobility and interchange between the NHS and local authorities may be a very positive development, particularly with ICBs. However, the idea that there can be a joint appointment of a commissioner and a provider sounds wholly contradictory. Although the Minister has tried to allay our concerns by referring to guidance, it is clear that an NHS body needs to only “have regard” to that guidance. The question remains: at what point does someone step in when there is a clear and detrimental conflict of interest? We will see what the Minister has to say, but it we may need to keep a very close eye on that.

Clause 64 is a rather less obvious power grab by the Secretary of State, but it is one all the same. Clearly, he is not satisfied with the extent of co-operation between NHS bodies, because the Secretary of State now wants to be able to tell them how to co-operate. The guidance is to be issued, and a duty is to be placed on NHS bodies to follow it, or else face the consequences. What of? It is good old-fashioned persuasion—the willingness to work together for the greater good. It is actually the case that the Secretary of State wants two goes at this, as there are further powers to issue guidance in respect of NHS bodies and local authorities, which currently have to co-operate in order to advance the health and wellbeing of people.

Surely it is the case that they are doing that already. I cannot think of any reason why they would not co-operate, but what would be the sanction if they do not? Can the Minister tell us who he thinks these errant councils are that are not co-operating? Between myself, my hon. Friend the Member for Nottingham North and the Minister himself, we must have over a quarter of a century of experience in local government, and I cannot think of any occasion when councils were anything other than co-operative with the NHS. That is my experience, but if the Minister can help fill in the gaps, I would be most obliged.

Edward Argar Portrait Edward Argar
- Hansard - -

The shadow Minister tempts me to name and shame. He may be tempting me in vain. He raised three key points. One was about one person doing two jobs. To paraphrase him, he asked how that would work and why it was appropriate. He also mentioned conflicts of interest and asked why it was necessary and appropriate for the Secretary of State should have these powers.

To his first point, the clause is about driving greater integration. During my time as a member of Westminster City Council many years ago, we had a joint appointment. Our director of public health, if I recall correctly, was also an NHS appointment and she sat in both organisations in the senior management structure. It was extremely effective. Conflicts of interest, as we would envisage here, were managed both within the system and in accordance with guidance and principles of appointments and appropriate governance. That worked extremely well. It was not so much one person doing two jobs, but where the job was needed and the job description fitted both organisations, it delivered a real synergy and better outcomes.

There are circumstances where it can work. I would not have envisaged it being used essentially so that one person has multiple roles and jobs, but there are occasions when there is a benefit from someone sitting jointly in two organisations to help drive that integration and shared understanding. We can create, as we are doing here, mechanisms and structures to help drive integration and co-operation, but as the hon. Member for Nottingham North will know, and as the hon. Member for Bristol South will know from her time in the NHS, we can have those structures, but ensuring that organisations work effectively often relies on individuals, personal relationships and the trust that builds up at that level.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Lady, but those joint appointments have always gone on—they have existed for many years. The example I referred to was in about 2008 or 2009, and it worked extremely well, as both organisations benefited from that individual being a part of both. Our clauses seek to ensure that those joint appointments work well and effectively.

The hon. Member for Ellesmere Port and Neston asked why the powers sit with the Secretary of State rather than with the local NHS or NHS England. I am afraid that he will not tempt me into naming any particular local authorities or otherwise. The NHS is a critical part of our health and care system, but integration and co-operation need to go beyond the NHS itself, encompassing the role of local authorities in this space, which we all recognise. I hope that that co-operation will be consensual and voluntary, as the hon. Gentleman said, but it is important that the Secretary of State, with his accountability to this place and to the public, sits above that system. I would argue that he is in the best position to offer guidance on how that system can co-operate, and to help to resolve matters.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

One of the things that we have been told consistently is that integration and joint working are already well under way on the ground, and that the Bill is, in part, just putting a legislative seal on that work. If that is correct, why does the Secretary of State need those additional powers?

Edward Argar Portrait Edward Argar
- Hansard - -

Because we wish to take the opportunity to further drive forward the integration. The system has evolved, but we want to be more ambitious. The powers reflect the fact that the Secretary of State is able to take that wide perspective to most effectively see those two organisations coming together at a macro level—at the national level. That does not mean that I am denigrating in any way the evolution that is already occurring voluntarily in a whole range of areas around the country.

I sense that the hon. Gentleman is still unconvinced by joint appointments, so I will say a little more about them before I conclude, although I might still leave him unconvinced. There are already very few prohibitions on joint appointments, and we see an increasing number of them. In some cases, however, there could be a perception, or a reality, of a potential conflict of interest that could be difficult to manage or could lead to a perception of bias. We recognise that, which is why we have proposed the power to issue guidance to help organisations make the right joint appointments and to help them understand what factors to consider when deciding whether to proceed down the route of a joint appointment. The new powers for NHS England to issue guidance will ensure that there is a clear set of criteria against which to judge joint appointments when considering whether to make one. Bodies will have to have due regard to that guidance. I believe that the powers are proportionate.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am grateful to the Minister for giving way again. One of the critiques that we have developed —I hope that he has noticed—is that the Secretary of State has given himself an awful lot of powers and abilities to intervene. It seems highly incongruous that in the specific example of joint appointments, where there would be a clear role for the Secretary of State to intervene, he has not availed himself of the opportunity to do so.

Health and Care Bill (Tenth sitting)

Debate between Edward Argar and Justin Madders
Edward Argar Portrait Edward Argar
- Hansard - -

The shadow Minister has made a number of serious points—I am not sure how one spins the wheels when the car is stalled, but none the less I took his point. First, at the heart of this Bill is the fact that we seek to strike the appropriate balance between what is clearly a national health service, accountable to the Secretary of State and Parliament, and local flexibilities and local integration. The debate we will have for the next two hours or so will probably be about whether we have struck that balance appropriately, but that is the core of what we are seeking to do here.

The hon. Gentleman rightly talked about the importance of local authorities in this space. He and I share a common view on that, and he is right: one of the few things in the 2012 Act that I suspect he would have agreed with was the recognition of the public health function of local authorities. We are not seeking to do anything in the Bill to undermine that function in any way. It will not surprise the hon. Gentleman to know that I believe that the Bill provides for multiple layers of integration. Within a local NHS system, at an ICB level and then at an integrated care partnership level, there will be increased integration with local authorities and others, laying the foundations for the ambitious programme that the Prime Minister set out when he spoke earlier in this Session about the health and care levy.

The hon. Gentleman spoke about combined authorities. My recollection—I may be wrong—is that they date to about 2016, rather than 2012, and my understanding of the power is that it does not go against what he was saying, but provides for the continued evolution of the system and enables that delegation to take place. In practical terms, I would envisage that, where local authorities combine and work together, they would have their own arrangements, and we are not seeking to cut across those local working arrangements.

The hon. Gentleman also talked about the ICBs, saying that they are NHS bodies and asking whether this is a threat to local authority delegation of public health functions. My reading of that is that, as I mentioned in my opening remarks on these clauses, there are some public health functions that are NHS and delegated through CCGs, such as GPs participating in child immunisation programmes—hence the reference to ICBs, because they will be replacing CCGs in the new world.

Understandably, the hon. Gentleman talked about funding for public health. On his comments about the bigger picture on funding and spending levels more broadly, I simply remind him of the note left by a previous Chief Secretary to the Treasury:

“I’m afraid there is no money.”

We cannot get away from that context in this space, but more broadly he is right to highlight the importance of public health. The past 18 months have shone a light on public health; under Governments of all political complexions, public health has not always enjoyed that prominence in public debate, external media and other commentary. One thing that I hope will follow on from the terrible events we have endured over the past 18 months is a greater understanding and appreciation of public health and its measures, and for public health to enjoy the support it needs to do its job. I think all Members would agree that one of the few positives has been the recognition of the value of public health and prevention.

I think that those were the main points that the hon. Gentleman raised. I see these clauses as permitting a further evolution of the system and a recognition of the need, ideally, where we can, to further delegate powers from the Secretary of State to lower down within the system. On that basis, I hope the hon. Gentleman and his colleagues will feel able to support the clauses.

Question put and agreed to.

Clause 34 accordingly ordered to stand part of the Bill.

Clause 35 ordered to stand part of the Bill.

Clause 36

Power of direction: investigation functions

Justin Madders Portrait Justin Madders (Ellesmere Port and Neston) (Lab)
- Hansard - - - Excerpts

I beg to move amendment 108, in clause 36, page 42, line 33, at end insert—

“(10) Nothing in subsection (2) supersedes Part 4 of the Health and Care Act 2021.”

This amendment will ensure nothing in new section 7D of the NHS Act 2006 about the Secretary of State’s powers to direct HSSIB supersedes what is in part 4 of the Bill.

It is a pleasure to see you in the Chair, Mr McCabe, and to see the Minister back again. We heard about his increased workload this morning; I also saw him on the Treasury Bench during the urgent question. I wonder where he finds the time—he should speak to his trade union rep if he feels there are too many demands being placed on his time. We will do our best to ensure that this afternoon is as stress-free for him as possible; if he accepts our amendments, that will go some way towards enabling that.

I will not speak for long on amendment 108 because we will be talking extensively about the Healthcare Safety Investigation Branch later on in the Bill. Concerns have been expressed in briefings received by the Committee and in evidence about some of the relevant provisions in the Bill, particularly on access to information. Clause 36 looks at the proposed power over bodies that have investigatory powers, which include HSSIB. It is difficult for us to accept the clause as it stands without having gone through all the details on HSSIB, because we cannot possibly know whether our concerns will be resolved about how it will operate in practice. That is why we have put forward amendment 108.

The amendment would ensure that the powers in clause 36 do not in any way impede the important principle that HSSIB will be an independent body established by the Bill. In conjunction with further amendments, which we will no doubt get to in part 4, we can all be confident that HSSIB’s independence is sacrosanct. That is important for not just us as parliamentarians, but everyone within the NHS who may have reason to come across HSSIB. It is also important for patients, of course, because they will ultimately be the judges of whether HSSIB has been a success. It would be helpful to understand what the approach will be in relation to maternity investigations. HSSIB has a potentially important role in identifying how providers can sustainably and systematically improve the quality of such investigations and then provide appropriate support. However, ensuring proper accountability, clarity and independence remain important, and this amendment seeks to ensure that those matters are enshrined on the face of the Bill.

Edward Argar Portrait Edward Argar
- Hansard - -

I am grateful to the hon. Gentleman; I made it in rather slower time down to the Chamber to listen to the statement. After one of our sittings last week, I think the hon. Member for Nottingham North was on his feet asking a question in the Chamber before I had even made it out of this room, which shows a certain speed that I can only seek to emulate.

I appreciate that the amendment is linked to the independence of the Health Services Safety Investigation Body. The Government are clear that HSSIB will be independent, which is why it is being set up as a non-departmental public body, with a chief executive—to be known as the chief investigator—and executive and non-executive members. I hope I can reassure hon. Members that clause 36 is a temporary measure to ensure that the current Healthcare Safety Investigation Branch can continue to exist in the interim phase before the new body is established.

As I am sure hon. Members are aware, the merger of NHS England and NHS Improvement means that the NHS Trust Development Authority, of which the Healthcare Safety Investigation Branch is a part, will be abolished. We need the important investigation function that the Healthcare Safety Investigation Branch provides to continue until HSSIB is fully operational which, subject to parliamentary approval, is planned for spring 2023.

The power set out in clause 36 is designed to enable the Secretary of State to direct NHS England, or another public body, to carry out the investigation function in the interim period. I reassure hon. Members that the HSSIB will be independent. Clause 36 is not designed to infringe upon its independence and cannot be used to direct the new HSSIB in how it exercises its functions; it is there simply to ensure the continuity of current investigations until the 2023 start date. For those reasons, I ask the hon. Member for Ellesmere Port and Neston to consider not pressing the amendment to a vote.

Justin Madders Portrait Justin Madders
- Hansard - - - Excerpts

I am reassured to some extent by the Minister’s words, but we have seen over the past 18 months that temporary powers do have a habit of becoming rather more permanent than was originally intended. I think it would be perfectly possible for the Government to include some sort of sunset clause to ensure that the intentions set out by the Minister are adhered to, but we may come back to that. As things stand, we maintain our criticisms, and it would be remiss of us not to push this matter to a vote.

Question put, That the amendment be made.

--- Later in debate ---
Edward Argar Portrait Edward Argar
- Hansard - -

If I may, I will turn to the amendments first and then the substantive clause. I am grateful to hon. Members for tabling the amendments. I said that the previous clause was coming to the main business of the afternoon, but I now suspect that was but an hors d’oeuvre to the discussion we may have on this clause and this set of amendments.

Amendments 102 and 103 would require the Secretary of State to consult all relevant health overview and scrutiny committees before making a decision on a reconfiguration. Amendment 103 would also require the Secretary of State to have regard to, and publish, clinical advice from the ICB’s medical director. It is of course vital that local views are represented in any reconfiguration. However, although I understand the rationale behind these amendments, I do not think they are strictly necessary. The new power will not replace the important role that local scrutiny and engagement plays in service change decisions; we expect the vast majority of reconfiguration decisions to continue to be managed by the local system, and system players will be encouraged to resolve matters locally where possible.

The Secretary of State will continue to be advised by the Independent Reconfiguration Panel, which is being retained. The focus of the IRP is and will continue to be the patient and quality of care in the context of safe, sustainable and accessible services for local people. It has also provided the system with advice based on its experience to date around critical success factors.

If I may go down a slight rabbit hole here, I would like to put on the record my appreciation for the work of the IRP. Certainly during my tenure in this post, I have consulted it and seen its advice on a number of occasions, and I am grateful for the work its staff do, the speed with which they do it and the benefit I have gained from that advice in making decisions or advising the Secretary of State on particular decisions.

In practice, the Secretary of State will always need to seek appropriate advice from clinicians, local leaders or other experts before making any decision, and all decisions made using the powers inserted by clause 38 and schedule 6 must be published. This will ensure transparency and allow for proper scrutiny of the way the power is being used.

Schedule 6 also includes the requirement for NHS commissioning bodies, including integrated care boards, to give the Secretary of State any information or other assistance required to carry out any functions under the schedule. It is envisioned that the Secretary of State will obtain information from NHS commissioning bodies when making reconfiguration decisions. This will include any representations that an HOSC, stakeholder, patient group or any other interested party have made, if applicable.

All decision making on reconfigurations, at both local and ministerial level, will continue to be guided by the four tests laid out in existing guidance that reconfiguration should be assured against: strong public and patient engagement; consistency with current and prospective need for patient choice; a clear clinical evidence base; and support for proposals from clinical commissioners.

As such, we believe that clause 38 and the guidance that the Secretary of State is required to produce under the powers in schedule 6 will provide sufficient safeguards to ensure that the Secretary of State receives appropriate advice before using the powers in this clause. As a result of not accepting amendment 103, we will also resist amendment 102, which is consequential on amendment 103.

Amendment 104 would require the Secretary of State to publish, alongside any decision they have made under this provision, a statement demonstrating that the decision is in the public interest. The Secretary of State is accountable to Parliament for all his or her decisions. Ministers are expected, as a core principle of the constitution, to act in the public interest, and this is reflected in the ministerial code. In addition, the Secretary of State’s scrutiny and direction-making process on this and any other matter must already take into account the public law decision-making principles, all relevant information and their legal duties, including the public sector equality duty, that adhere to such decisions.

The Secretary of State is also under a number of duties set out in the National Health Service Act 2006, including a duty to promote a comprehensive health service, to secure continuous improvement in quality of services, and to have regard to the NHS constitution. As I have already set out, the Secretary of State will continue to be advised by the IRP, and will seek appropriate advice from clinicians, local leaders or other experts.

As for paragraph 4 of schedule 6, the Secretary of State already has a duty to publish any decision they make on a reconfiguration and to notify the NHS commissioning body of the decision. For those reasons, I urge the hon. Member for Nottingham North to withdraw his amendment—I suspect that I will be unsuccessful in that plea, but I make it none the less.

I will now address clause 38 and schedule 6. The clause inserts proposed new section 68A and proposed new schedule 10A into the National Health Service Act 2006. It also introduces schedule 6, which includes a new intervention power to allow the Secretary of State to call in a reconfiguration of NHS services at any stage of the process, without the need for a referral from a local authority. A reconfiguration of NHS services is a change in service provision that has an impact on the manner in which a service is delivered at the point at which the service is received by the user, or the range of health services available to individuals. That could be, for example, a change in where a mental health in-patient unit is based, building a new stroke unit, or restructuring a whole hospital trust.

The new intervention power will enable the Secretary of State to act as a scrutineer and decision maker for reconfigurations, to intervene where, for example, they can see a critical benefit or cost to taking one or other course of action, or to take action where there is significant cause for public concern. We do not expect or intend to use the power with any regularity, and where it is used, it will be done so transparently. As I have emphasised, the Secretary of State must publish any decisions made about reconfigurations.

Schedule 6 sets out the scope of the reconfiguration powers as they pertain to NHS commissioning bodies, NHS services, NHS trusts and foundation trusts. It introduces a new duty for the relevant NHS bodies to notify the Secretary of State of any proposed or likely reconfiguration. The Secretary of State will be able to take any decision that could have been taken by the NHS commissioning body. That includes the ability for the Secretary of State to decide whether a proposal should proceed, the results the NHS commissioning body should achieve, and the procedural steps that should be taken. As I set out earlier, decision making will continue to be guided by the four reconfigurations tests. The new power will not replace the important role that local scrutiny and engagement play in service change decisions.

As the shadow Minister set out, the public expect Ministers to be accountable for the health service, which includes reconfigurations of it. The clause ensures that decisions made in the NHS that affect all our constituents are subject to democratic oversight. Without it, the Secretary of State’s ability to intervene and take decisions will remain limited, often coming at the end of a long local process. As now, he would not be alerted to a potential change in services until the change became an issue and he would remain powerless to intervene without a formal referral by a local authority.

I am conscious that that existing arrangement satisfies few in Parliament, including Opposition Members, on the occasions when they make representations about the process. However, it will be for this debate to see whether Members feel that the proposed new arrangement satisfies them—I will not prejudge that for a minute, looking at the faces of the Opposition Members. I therefore commend clause 38 and schedule 6 to the Committee.

Justin Madders Portrait Justin Madders
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I congratulate the Minister on his valiant attempts to defend the powers that he wishes the clause and schedule 6 to give his boss.

The Opposition are pretty realistic and do not think that the clause will survive the parliamentary process in its current form. It would save a lot of time if the Minister was to indicate now that he had taken note of the many concerns expressed and that things will change. However, as the clause remains on the face of the Bill, we will have to go through the long and important reasons why it will not be able to stand in its existing form. The Minister will continue to defend the indefensible until it no longer needs to be defended.

We have heard evidence as to why the powers in the clause are not needed and, indeed, why the Secretary of State would not want s