NHS Dentistry: Recovery and Reform

Hywel Williams Excerpts

Wednesday 7th February 2024 Commons Chamber

[Hywel Williams (Arfon) (PC)]

Is the £200 million additional, in the sense of being diverted from other parts of the NHS in England, or is it new money from the Treasury that would attract the Barnett consequentials for Wales, Scotland and Northern Ireland? Which is it?

[Victoria Atkins]

We have finite resources. As I have said, this is additional money. I have prioritised dentistry across the board, but this is £200 million of additional money—in addition to the £3 billion that we spend in England.

Smokefree 2030 Target

Hywel Williams Excerpts

Tuesday 20th June 2023 Westminster Hall

[Hywel Williams (Arfon) (PC)]

I congratulate the hon. Member for Harrow East (Bob Blackman) on securing the debate. I must confess to some trepidation about taking part, because it is on an England-only topic: health is devolved, as the hon. Member for Strangford (Jim Shannon) pointed out. However, smoking is of specific and acute importance to young people, and many young people from Arfon work, live, love and play in England, so it has relevance.

I am a former smoker. I smoked until my 30s, when a friend pointed out the folly of rolling dried leaves up in paper and setting fire to them in my mouth—that eventually persuaded me. More relevantly, as long ago as 2005 I was a supporter of the Smoking in Public Places (Wales) Bill, a private Member’s Bill promoted by Julie Morgan, the then Labour MP for Cardiff North, that would have devolved power to the Welsh Assembly to ban smoking in public places. Unfortunately, the then UK Labour Government did not provide time for that Bill, and by the time an England and Wales Bill had become law, more people employed in bars, hotels and restaurants in Wales had contracted fatal smoking-related diseases. I am not being too dramatic about this: the lack of devolution in that instance actually cost lives.

In Wales, as in England, smoking is the largest single cause of preventable and premature death. Poverty is an issue. Wales is a poor country: when we were in the European Union, parts of Wales qualified for regional aid on the same basis as the most poverty-stricken parts of the former Soviet bloc in eastern Europe. That is how bad it was and, tragically, that is how bad it remains.

Smoking is responsible for half the difference in life expectancy between rich and poor. Smoking hits us hard in Wales: our smoking rates are some of the highest among vulnerable populations. The Welsh Government’s tobacco control plan, published in July 2022, sets a target for Wales to become smoke free by 2030. Meanwhile, England’s tobacco control plan has expired, and the promised updates have been delayed time and again.

As I said, this is an England-only matter because health is devolved. Health policy has diverged between Wales and England, not least in that the wellbeing approach adopted in Wales is markedly different from the illness policy introduced elsewhere. Reducing smoking is an urgent element of that wellbeing approach. However, many of the key policy interventions in Wales that require legislation are reserved and must be voted through in this Parliament. The Welsh Government do not have the power to put warnings on individual cigarettes, put inserts in tobacco packs or strengthen the regulation of e-cigarettes—by the way, if they did, I suspect that those warnings would be in both our languages, but that is a matter for another day. The Welsh Government have even been told that they do not have the power to raise the age of sale for tobacco to 21.

Those were all key measures that were recommended in the Khan review and are supported by the people of Wales, but they cannot be taken forward because of a lack of devolution and powers. By being so slow, the UK Government are undermining the ability of the Welsh Government to achieve their Smokefree 2030 ambition. That ambition is supported by seven out of 10 people in Wales, a figure that rises to eight out of 10 among those who voted for my party, Plaid Cymru, at the last election.

The “polluter pays” levy is vital for Wales, as it is for England. I was pleased to put my name, on behalf of Plaid, to the amendments to the Health and Care Bill that the hon. Member for City of Durham (Mary Kelly Foy) tabled on Report, and particularly to the amendment that called for a consultation on a levy on tobacco manufacturers to pay for measures needed to deliver a smoke-free future. If the Government had adopted that amendment, we would now be much closer to achieving the target. A UK-wide levy would have raised as much as £700 million per year, which would have been sufficient to fund the programme both in England and Wales.

There are many other regulations that would benefit Wales but that need action from Westminster. Because of the time available, let me just say that those measures include: warnings on cigarettes; a ban on all tobacco flavours; prohibition of free distribution of vapes to children; a ban on sweet names, bright colours and cartoon characters on vapes, which are all so appealing to children; and a requirement that tobacco packs have inserts. These are all measures that the Government have refused to adopt in the past and are still slow to adopt today. Announcements on pack inserts and free vape distribution are urgent, so that both Parliaments have clarity. Will the Minister confirm the dates for the launch of the consultation on the pack insert regulations that was announced in April, and at the very least to reassure us that it will take place before the summer recess?

[Mr Virendra Sharma (in the Chair)]

I hope that the Front Benchers and the Minister will spare about a minute or two for Bob Blackman to wind up at the end of the debate.

Smokefree 2030

Hywel Williams Excerpts

Tuesday 26th April 2022 Westminster Hall

[Hywel Williams (Arfon) (PC)]

I congratulate the hon. Member for Harrow East (Bob Blackman) on securing this important debate and on his very persuasive speech.

I will start with some context. Hon. Members might wonder why a Welsh MP, and a Plaid one at that, is speaking in a health-related debate when health is a devolved matter. I have a long-term interest in the negative effects of smoking. Many years ago, I supported Julie Morgan, then the MP for Cardiff North, when she tried to bring in a ban on smoking in public places in Wales. Unfortunately, we were unsuccessful. The Welsh Assembly was very anxious to bring in the ban at that time, which was some years before it was actually brought in in England and Wales. We had to wait.

I am no statistician, and certainly no epidemiologist—I cannot even say the word—but I did a back-of-the-envelope sum at the time and I reckoned that, because of the delay in bringing in the ban in Wales, between 15 and 20 people such as bar staff would have contracted smoking-related illnesses that would eventually killed them. That is the argument that we made at the time: the lack of devolution cost lives.

The second point to contextualise my interest in this matter is that, some years ago, I asked Alan Milburn, the then Secretary of State for Health, about nurses’ pay. His reply, which I remember distinctly, was that it was one of the abiding

“joys of my life that I am not responsible for all things Welsh”.—[Official Report, 22 January 2002; Vol. 378, c. 739.]

Actually, health was devolved, but nurses’ pay was not. The point I am making—apart from the fact that he was wrong—is that devolution is not always particularly clearcut. In the short-term, more devolution is not really the day-to-day issue; the issue is policy divergence, not devolution.

In Wales, we see that in our early adoption of the wellbeing approach to health, which is one of the landmark policies that the Welsh Labour Government have brought in, supported by my party. In some ways, this answers the point made by the hon. Member for Harrow East about there not being cash available; this is not a cash issue—it is a policy and attitudinal issue. In Wales, we have a health—not an illness—policy, but without control over illness-creating factors such as tobacco and alcohol.

Unsurprisingly, my answer is to have fuller devolution in the short term and full powers in the long term, but if I were to pursue that point now, I am sure Ms Nokes would pull me up. For now, I will just say that the Welsh Government have the goal of being smokefree by 2030, as is the case in England. The impact on public health in Wales is frightening, as it is elsewhere—smoking is the largest single cause of avoidable early death. In 2018, around 5,600 deaths in people aged 35 or over in Wales were attributable to smoking, 16.5% of all deaths in that age group. The cost to the Welsh NHS is around £300 million per year, which is, to my mind, of itself a completely persuasive point.

The aim for England to be smokefree by 2030 was announced two years before we got around to it in Wales. However, in the meantime, Wales has taken a lead on action, having published its draft strategy and delivery plan last November. Interested hon. Members from England are still waiting for England’s tobacco control plan, and I share their concern at this delay. I would also say that this is undermining the Welsh Government’s ability to achieve their own targets, because under the current devolution settlement there are many policies that Wales cannot implement. These policies include the trailed “polluter pays” levy on tobacco manufacturers to fund tobacco control. The key tobacco controls are not devolved; they are reserved. Everything from tobacco taxes to packaging, labelling, product regulation to raising the age of sale are policies that we cannot change in Wales.

During the passage of the Health and Care Bill, I added my name to the amendment tabled by the Member for City of Durham (Mary Kelly Foy) that would have introduced tougher regulations on smoking and would certainly have benefited people in Wales. However, these measures cannot be brought in. I would formally like to state my support for raising the age of sale to 21 and putting warnings on cigarettes, advice to quit inside packs and the rest of it.

Those measures would reduce inequalities and smoking uptake. A sensible point—for me at least—is that this is not only a health issue. It is also a class issue. Clearly, it affects people on lower incomes. It is also an age issue. To conclude, I would like to ensure that the Minister is aware of all of these matters, and I ask her to commit to meeting her opposite number in Cardiff regularly to discuss how these measures can be implemented.

Health and Care Bill

Hywel Williams Excerpts

Report stage
Monday 22nd November 2021 Commons Chamber

[Mary Kelly Foy]

Most of my new clauses are indeed intended to prevent young people from starting to smoke in the first place.

[Hywel Williams (Arfon) (PC)]

The hon. Lady has said that these measures apply to England, but they will of course have an effect throughout the United Kingdom—and rightly so—contributing to our aim to bring about a smoke-free Wales as well.

[Mary Kelly Foy]

Again, I could not agree more.

In Committee, the Minister said that the Department could already legislate under the Children and Families Act 2014 to require the insertion of such information messages. In that case, why do the Government not commit themselves to doing so now?

New clauses 4 to 6 address loopholes in current legislation. Now that those loopholes have been identified to the Government, they should be fixed without delay, and today we have the opportunity to do so. New clause 4 would give the Secretary of State powers to remove child-friendly branding elements from nicotine products. There are e-liquids on the market that are given sweet names, such as “gummy bears”, and that have branding that is in garish colours and features cartoon characters. Surely more evidence is not necessary to prove that such branding risks attracting children.

--- Later in debate ---

[Dr Whitford]

There is no question but that, after public health moved into local government—we can absolutely defend that because, as I have said, health is often delivered by things that are nothing to do with the NHS—the problem was that the budget was then cut, so the potential benefit of putting public health into local government was lost due to the cuts to services.

On alcohol not being classed as a less healthy food, with this Government I find it hard not to ask: why not, and what or who may have influenced that decision? I certainly support amendments 11 to 13 from the hon. Member for Liverpool, Walton (Dan Carden), which would include alcohol, particularly the medium and high-strength alcohols, under less healthy foods, so that alcohol is covered by advertising regulations. I also support his new clause 15, which would mandate much clearer labelling of alcohol units, or whatever measure, on labels. It is no good just saying “Drink aware” or “Drink Responsibly” when the consumer has not actually been given the tools on the product to make a proper choice, such as by asking, “How much is in this?” Why not agree to use a simple, straightforward approach? A lot of public health advice is in units, so why not actually use them? People would then learn to be aware and ask, “How many units have I already drunk today?” or “How many units have I already drunk this week?”

New clause 17 calls on the UK Government to follow Scotland, and now Wales, by introducing a minimum unit price for alcohol. The UK Government have the advantage in that they can do that by setting alcohol duty based on unit, instead of on classes of drink. In every Budget we hear about a penny on a pint of beer, or so much on spirits, but why not do it by unit? It is much more accurate, and it would still allow the raising of taxation to help fund alcohol services, as well as those public services most hit by alcohol abuse, such as healthcare and policing. Under devolution the Scottish Government, and now the Welsh Government, did not have that power.

Over the past year and a half of the pandemic we have, unfortunately, seen a big increase in both smoking and alcohol consumption, as people struggled to cope with the loneliness and boredom associated with lockdowns and pandemic restrictions. However, the initial valuation of minimum unit pricing in Scotland showed that alcohol sales fell, for the first time in many years, by more than 7% in Scotland, compared with a continued rise in England and Wales. It was not possible to demonstrate a reduction in overall alcohol-associated admissions to hospital, which may include car accidents, violence and so on, but there was a drop in admissions due to alcoholic liver disease, suggesting that the policy was working. More evaluation after the pandemic will be required, but an immediate impact was an almost three-quarters drop in the sales of cheap white cider. That product is cheaper than soft drinks, and predominantly used by young—indeed, often under-age—drinkers, who purchase it, or get someone else to purchase it, so that they can drink it at home. However, that sector is literally disappearing overnight.

It will be important to review and maintain the pressure of the unit price on a regular basis, because young drinkers also drink many other products—this is the same issue as young smokers; more people are being recruited, often into problem drinking and problem products. Minimum unit pricing does not affect good wine, high-end spirits, or what is sold in a pub, but it does affect what someone can buy in a small shop to then hang out with their mates in their bedroom. Some of those products are not affected by the 50p unit price, and that must be kept under review.

I was disappointed that new clause 30, which is listed for discussion tomorrow, was not included in this group. It calls on the Government to reform the out-of-date Misuse of Drugs Act 1971, and to devolve it so to allow the devolved nations to take a public health approach to tackling drug addiction, in the same way as we take a public health approach to dealing with alcohol. Such an approach has already been demonstrated in many countries across the world, yet the Government keep sticking their head in the sand.

[Hywel Williams]

I am grateful to the hon. Lady for mentioning new clause 30, which I still hope against hope we might be able to discuss tomorrow. I am sure she will agree that problematic drug abuse is an illness and a social ill, not a crime, and our emphasis must be on harm reduction, treatment, and support for the problematic drug user.

[Dr Whitford]

That is the policy of the Scottish Government, and we would absolutely support the new clause if it is voted on tomorrow.

As Opposition Members have said, key to improving public health would be restoring the non-covid related public health budget in England. We cannot hide behind covid funding, because that is used up by the pandemic and does not help us with smoking, alcohol, or drug addiction. The biggest contribution the Government could make would be to abandon their plans for yet another decade of austerity. We hear the slogan all the time—levelling up—but it rings hollow after taking away £1,000 a year from the poorest families and most vulnerable households. Over the past decade, cuts to social security have caused a rise in poverty among pensioners, disabled people, and particularly children. Sir Michael Marmot was mentioned earlier, and his research was clear: poverty is the biggest single driver of ill health, and the biggest driver of poverty is Tory austerity.

Endometriosis and Polycystic Ovary Syndrome

Hywel Williams Excerpts

Monday 1st November 2021 Westminster Hall

[Hywel Williams (Arfon) (PC)]

It is a pleasure to serve under your chairmanship, Mr Mundell, and I congratulate the hon. Member for Coventry North West (Taiwo Owatemi) on opening the debate so ably. As she noted, on average, it takes eight years for a diagnosis of endometriosis to be made. Unfortunately, in Wales it now takes nine years on average, compounding the suffering of people who suffer from marginalisation and poverty in their communities in many parts of Wales. It is essential that that be addressed as soon as possible by the Welsh Government.

I also thank my constituent Kate Laska, who for a number of years has been a tireless campaigner for greater support for those who suffer from this condition in Wales. She has shown remarkable determination and has been working essentially alone on this matter. As part of her campaign, Kate has pushed for menstrual products to include labels that list their ingredients. Men and women—everyone—deserve to be empowered with vital information about the products they use, and to be assured of their safety; menstrual products are no different. Is the Minister aware of any ongoing discussions on that issue with the Office for Product Safety and Standards? I am not drawing attention to the issue to raise undue concerns, but my constituents would certainly be glad to be reassured that it is receiving proper attention.

Caseworkers also highlighted the lack of specialist support available in north Wales, which means that lots of patients have to travel across the border, to the excellent Liverpool Women’s Hospital, to have attention. The long distance to travel is, of course, a further burden. There is also, I am afraid, an almost complete lack of service through the medium of Welsh. The ability to discuss a condition of this nature in the patient’s language of choice is a particular issue, and not only in Wales but throughout the UK. I do not know how much attention that matter has had, but I draw it to the attention of the Minister.

Endometriosis is not just a health issue for those with the condition. It is debilitating, there is a lack of support and, as hon. Members have mentioned, statutory sick pay is available to an employee for a maximum of only three years. That penalises those with chronic long-term conditions such as endometriosis and others. Many of those severely affected have struggled to access personal independence payment and universal credit. Clearly, we need more understanding and education—specifically, more research. I end by quoting Kate Laska, who told me:

“Women with endometriosis suffer in silence and very often alone because no one around them can imagine their pain.”

Health and Care Bill (Seventeenth sitting)

Hywel Williams Excerpts

Committee stage
Tuesday 26th October 2021 Public Bill Committees

[Dr Whitford]

I beg to move amendment 112, in clause 123, page 105, line 13, at end insert—

“(f) after subsection (3) insert—

“(3A) An Order in Council under this section—

(a) which affects Scotland may only be made with the consent of the Scottish Ministers;

(b) which affects Wales may only be made with the consent of the Welsh Ministers;

(c) which affects Northern Ireland may only be made with the consent of the Northern Ireland Ministers.””

This amendment would require the appropriate authority to obtain the consent of devolved governments before orders under section 60 of the Health Act 1999 affecting the relevant territory could be made.

Obviously, we are discussing the regulation of healthcare and associated professions. I am concerned that what we see written is that the Secretary of State will have the power to abolish certain regulatory bodies, deregulate certain professions and specifically deregulate social care workers. Most registration and regulatory bodies for healthcare are UK-wide, but it must be recognised that people work and move between the four nations, so anything that happens at that level will have an impact on the devolved health services.

During the debate on the United Kingdom Internal Market Bill, Members raised the issue that professional qualifications gained in any of the four nations must be recognised across all four. That makes absolute sense, but the debate was about teachers, and in England Teach First allows a degree holder to become a teacher within a matter of a couple of months whereas in Scotland and Wales, a postgraduate teaching qualification is required. That did not go ahead, but it highlights the issue.

We see new health professions developing—new grades, physicians and associates—and the devolved nations will have their own view on whether they would use such staff, how they think those staff should be regulated and registered, and where they would fit in their health services. We face the potential of new grades or qualifications being created that the devolved health services would have no option other than to recognise and accept, yet they would have minimal input, so we are back to the issue of genuine consultation with and consent from Health Ministers.

Earlier, when we were talking about the need to professionalise social care, I was surprised to hear the deregulation of social care workers mentioned. In Scotland, we are moving forward with the registration of care staff as the first step in that professionalisation, and we would not want to see it undermined. That is the same theme, unfortunately, that I have repeatedly put before the Committee. However, it is important to recognise that while the delivery of health and social care is devolved, some of the issues that we are debating would have a significant impact on the three devolved services, and it would be wrong for their Ministers to have these decisions forced on them by the Secretary of State with no significant input or consent as to how to take things forward.

[Hywel Williams (Arfon) (PC)]

I shall be brief. I support my hon. Friend on this matter. Clearly, systems vary from one country to another. Indeed, a long time ago, I was involved in teaching social care staff, and we were ambitious to register all staff whereas, as I remember it, 10% of staff in England were going to be registered at that time. Across the UK, there are different approaches to health provision. As I have said before in the Committee, the Labour Government in Wales have adopted a wellbeing approach for many years, and I think the requirements of implementing such a wellbeing approach might vary from one country to another.

I restate my support for my hon. Friend on this matter and look forward to hearing what the Minister has to say about it.

[Edward Argar]

Amendment 112 would place on the Secretary of State a duty to obtain consent from the devolved Administrations prior to legislating using section 60 of the Health Act 1999, where such legislation would affect the devolved Administrations. Before I turn to the substance of the amendment, I will set out the benefits of regulating health and care professionals on a UK-wide basis. It is important that we have UK-wide standards to ensure the same level of public protection across the UK and to allow healthcare professionals the flexibility to work across the whole of the UK. We value and will continue to work collaboratively with our devolved Administration partners on the regulation of health and care professionals.

Each devolved legislature, as has been alluded to, has its own devolved arrangements in respect of professional regulation, which are a mix of reserved and devolved or transferred powers. In practice, any use of section 60 affecting professionals in Northern Ireland is exercised only with the agreement of the Northern Ireland Executive. In Scotland, consent is required in relation to legislation concerning healthcare professionals brought into regulation post the Scotland Act 1998. In the case of Wales, the regulation of healthcare professionals is a reserved matter, so consent is not sought.

In practice, the UK Government always seek the agreement of the NI Executive when making changes to the regulation of healthcare professionals, and the Scottish Parliament’s consent is required in the circumstances that I set out previously. The amendment would add to that by requiring consent in relation to any changes to the regulation of healthcare professionals affecting the devolved Administrations. In addition, legislation requires that section 60 can be used only following public consultation and the affirmative parliamentary procedure.

The purpose of the professional regulation system is to protect the public. Regulating health and care professionals on a UK-wide basis helps to provide consistency across the four nations and ensures that we continue to work together with the devolved legislatures to align workforce policy. For those reasons, although I appreciate the point underlying the amendment, I ask the hon. Member for Central Ayrshire to withdraw it.

--- Later in debate ---

The Government’s response states that the extent of a platform’s liability for unlawful advertising generally would be considered as part of its online advertising programme, and that it would be for the regulators to determine whether an online platform should be treated as an advertiser. That is where the ambiguity lies. There is a chance to make those expectations clearer through primary legislation or in regulation. What we do not want is for the intent of the measures not to be reflected in the actions of those types of platforms. We are also setting a precedent for the way that we will engage with the online world, and how we protect children, whether from advertising or even more sinister parts of the internet, which are still unregulated for many children. If the legislation is to do what we want it to, how will some of that start to be pulled together in a way that demonstrates that there is a level playing field, and that those who are ultimately responsible for the content that children have pushed in their direction online will play their part or face the consequences of not doing so?

[Hywel Williams]

I will not repeat the points that my hon. Friend the Member for Central Ayrshire made about what is sometimes called the jagged edge of devolution—in this respect, that public health is devolved, but the regulation of broadcasting is not. I am not contesting that this afternoon, but I seek assurance that the Welsh Government, along with the Scottish Government, will be properly consulted, and their views listened to.

I will make two points on schedule 16. On the point that the hon. Member raised about small and medium-sized enterprises, in Wales, particularly rural Wales, food and drink businesses are overwhelmingly microbusinesses employing one, two or three people. It would be unusual indeed to have such a company employ more than 250 people, which I think is the definition of an SME. I therefore assume that those small producers will not be affected by the schedule, and will be exempt.

A point that has been made to me—perhaps the Minister could give me an answer to this—is that there are umbrella bodies that promote certain foods. The one that springs to my mind is Hybu Cig Cymru—the red meat authority in Wales—which promotes lamb and beef. It promotes red meats extensively, and advertises, particularly on S4C, the Welsh language channel, which I think helpfully has lower advertising rates. Would that particular umbrella or trade body, and others, be affected by the legislation?

[Edward Argar]

This is an important clause and set of amendments, so I fear I may detain the Committee on them for a little while. However, it is important that we air a number of points. I am grateful to my hon. Friend the Member for Eddisbury, the hon. Member for Ellesmere Port and Neston and others, because when we talk about digital platforms, including in other pieces of legislation and, indeed, in democracies around the world, we are essentially grappling with whether they are platforms or publishers responsible for content. I think it is fair to say that that debate continues in legislatures around the world, which presents a fundamental challenge.

I will pick up on a few questions while they are fresh in my head, and I suspect that I will cover the others in my prepared remarks. The hon. Member for Ellesmere Port and Neston asked why there is no watershed equivalent online, and how that might operate. The short answer is that it reflects the nature of online media: it is on demand, rather than linear, as with a terrestrial or satellite broadcast, though we see slight changes to that now, with Sky boxes—other online platforms are available for TV—the ability to record things, catch up, and so on. The situation is changing, and is not quite as binary as it used to be, but that is the primary reason.

If it is agreeable to you, Mr McCabe, I will discuss the amendments first, then turn to clause 125 and schedule 16. I hope that, with my extensive notes, I will be able to mop up and scoop up a number of the questions asked. If I do not, I will ask my officials to have a scan of Hansard, and I will endeavour to write to hon. Members prior to Report to cover any points that I omit. I will then address new clause 55, which relates to the clause and schedule.

I am grateful for the opportunity to discuss amendment 113, which would require the Secretary of State for Health and Social Care to obtain the consent of the DAs before any of the regulation-making powers granted by schedule 16 of the clause were exercised. As I am sure members of the Committee will be aware, the provisions in clause 125 and schedule 16 on advertising less healthy food and drink will extend to the whole of the United Kingdom.

We consider the provisions in this part of the Bill to be primarily focused on online services and broadcast restrictions, which are not devolved realms of responsibility. I appreciate that the hon. Member for Central Ayrshire and her colleagues in the Scottish Government might have a different interpretation of the same point—it is in the nature of the constitutional settlement that such discussions occur—but telecommunications and internet services remain reserved matters under the devolution settlement. The UK Government have made it clear that the primary purpose of the provision on the advertising of less healthy food and drink on TV and internet services is to regulate content on reserved media, internet and broadcasting. On that basis, we hold to the view that it is reserved. The purpose is not incidental—hence our argument that it does not fall within the devolved provisions and the devolved remit—but I suspect that we may return to this debate in the coming months.

Health and Care Bill (Sixteenth sitting)

Hywel Williams Excerpts

Committee stage
Tuesday 26th October 2021 Public Bill Committees

[Hywel Williams (Arfon) (PC)]

I want to ask some questions about clause 112. I have practical questions that the Minister might answer today, or he might wish to write to me. I welcome the clause as a continuation and an improvement, hopefully, on current arrangements. Who might ask HSSIB to carry out an investigation in Wales? Would it be the individual health board or the Welsh Government? Has a mechanism been established yet? Secondly, how involved would the Welsh Government be in any investigation? Would the Senedd, for example, have access to information in an ongoing investigation?

Thirdly, in respect of challenging who would be responsible for paying, would it be the Welsh Government or the individual health board? Fourthly, the Healthcare Safety Investigation Branch has noted that the Bill could be strengthened by the Secretary of State giving a clear mandate for HSSIB to monitor the progress of the response to recommendations. Does the Minister envisage the Welsh Government having a role in monitoring progress, or would it be a matter for HSSIB or the health board?

On clause 107, which has already been debated, I have reservations about extending further exemptions. Would the Welsh Government be able to request or even authorise exemptions where HSSIB carries out investigations in Wales, or is it a matter specifically for the Secretary of State, although health is almost entirely devolved, of course? Finally, will the Minister outline what discussions he has had with the Welsh Government about these provisions? I appreciate that those are detailed questions and he might want to reply to me in writing.

[Edward Argar]

A number of questions were asked that I will seek to address. If I cannot answer the specific points raised, I will write to clarify them.

The hon. Member for Ellesmere Port and Neston asked about sanctions, and the hon. Member for Bristol South asked about a list of bodies and whether there are any not included—essentially, who was in and who was out. There are two, which I am sure the hon. Gentleman will have noticed, not included in the list of bodies: the Medicines and Healthcare products Regulatory Agency and the National Institute for Health and Care Excellence. I suspect that is the genesis of his asking the question. We recognise the strategically important role that both bodies play in patient safety. Not listing them does not mean that HSSIB cannot co-operate with them. Co-operation across different bodies is something that we encourage. In fact, we would expect HSSIB to develop memoranda of understanding with those organisations, but we focused on specific ones on the list where there is likely to be day-to-day co-operation, particularly with health trusts and others.

On sanctions, we focused on what HSSIB is doing and its being able to progress its investigations. Ultimately, as we have debated, it has the power to seize documents and require information. I very much hope that that will not be needed and that co-operation and memoranda of understanding will be an effective way of moving forward, as it appears to be at the moment, but we have those powers in the legislation, were they to be needed in extremis.

The hon. Member for Arfon mentioned several issues relating specifically to Wales and engagement with the Welsh Government. As I briefly alluded to in my speech, the inclusion of powers to allow the Welsh Government to request the involvement of HSSIB was done at the request of the Welsh Government. We have discussed the issue with them, and I think their request reflects their view that HSSIB involvement could add value in Wales.

The hon. Gentleman sought to understand how the arrangement would work in practice and asked a number of questions about what the fees would be, who would pay them and whether that would be the responsibility of a trust or the Welsh Government. We are still working through those practical matters with the Welsh Government, but we were keen to include the power while we had the opportunity, because the original request came from the Welsh Government. It is a similar case with the Northern Ireland Government. Scotland, to which the hon. Member for Central Ayrshire alluded, has its own well established approach, which works, and therefore a different option was taken in its respect.

Conversations with the Welsh Government have not progressed to the extent that I can give the hon. Member Arfon detailed answers to all his questions, but I will write to him if there is any more that I can add.

Question put and agreed to.

Clause 110 accordingly ordered to stand part of the Bill.

Clauses 111 and 112 ordered to stand part of the Bill.

Clause 113

Failure to exercise functions

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

Health and Care Bill (Ninth sitting)

Hywel Williams Excerpts

Committee stage
Tuesday 21st September 2021 Public Bill Committees

Division 11

Ayes: 5

---

Labour: 4
Plaid Cymru: 1

Noes: 9

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Conservative: 9

[Hywel Williams (Arfon) (PC)]

I beg to move amendment 85, in clause 33, page 40, line 11, at end insert—

‘(3) The Secretary of State must consult the Welsh Ministers before the functions in this section are exercised.”

This amendment would require the Secretary of State for Health and Social Care to consult the Welsh Government before the functions on workforce assessments in this clause are exercised.

I will be brief, given that much of what I would otherwise have said has been covered in the debate on the previous group of amendments. I will just say to those on the Front Benches, in their discussion of the genesis of the NHS, that success has many parents. Aneurin Bevan of Tredegar was the father of the NHS, based on his experience of the provision of health in that area, but it was also based on the foundation that was set up by my predecessor but three as Member for Caernarfon, David Lloyd George.

Having got that out of way, the amendment would place a duty to consult the Welsh Government on workforce assessments. Although the amendment is a probing one, I am concerned that the devolution settlement remains somewhat complicated and sometimes unclear, even in its current iteration. As a piece of history and a reference to how that settlement can cloud matters, I will mention a question I asked a former Labour Secretary of State for Health, Mr Alan Milburn, some years ago about nurses’ pay. His response, which I committed to my memory, was “It is one of the abiding joys of my life that I have no responsibility for things Welsh.” Unfortunately for both Wales and him, he actually had responsibility for nurses’ pay at that time. Even Secretaries of State are not perfect, let alone Ministers of State and others. That situation has now been resolved.

The danger is always that the remaining integration of parts of the Welsh health service and health service in England might be overlooked. I referred to that earlier in respect of services and people from Wales—and people from England, for that matter—accessing health services on the other side of the border. People in north Wales specifically will recognise the names of individual hospitals in England. I refer briefly to Alder Hey on the Wirral, which provides services to children with severe conditions. There is the Royal Liverpool; the Christie in Manchester, which provides specialist cancer treatment; and the hospital in Gobowen, which has for a long time provided orthopaedic services. Recently, severe casualties and people who have suffered road traffic accidents have been helicoptered to Stoke for specialist treatment. As I said the other day, around 13,500 Welsh people access GP services in England, and 21,000 or so people from England access GP services in Wales. Those are the 2019 figures.

The workforce-training and education aspects of cross-border arrangements must be considered because staff are mobile. People from Wales access training in England and then return to Wales, and it works the other way around as well. In my own constituency specifically, the school of nursing at Bangor University has for a number of years trained nurses from all over the UK and elsewhere. We are now establishing a medical school that will certainly be training doctors who will return to Scotland, England or Northern Ireland.

The other positive opportunity that proper workforce planning would present the health service throughout the UK is in the specialisms that we hope to develop in Wales—particularly in my area of north Wales. Those specialisms include, for example, treating injuries arising from accidents on our coasts and mountains, for which we already have some specialism. There are also particular issues around mental health and multilingualism, particularly in talking therapies and work with children and older people.

There are opportunities for people who might be trained in Wales before going over to England, and vice versa. For the reasons that I have outlined, I think it essential that those matters be taken into consideration in workforce planning.

[Alex Norris]

It is a pleasure to serve with you in the Chair once again, Mrs Murray, and to follow the thoughtful contribution by the hon. Member for Arfon.

The hon. Gentleman’s points about interdependency are important. Of course, we cherish and build on the devolved settlement, but we understand that we still have important relationships, not least at our borders. I thought that his point about specialised care was a thoughtful one, too: we know that as conditions or treatments become complex, there will be specialisations, and we would never want artificial barriers to get in the way of people accessing specialised care. His point about training was also good and jumped out to me.

Yesterday, I spoke to a surgeon in my community who took great pride in working in the hospital where he was born. In between, he had gone away; I am told that there are parts of the world other than Nottingham—I dispute that fact—and he wanted to go and see some of them. That will inevitably involve crossing borders, and it is important that that is reflected in the Bill. That will happen from nation to nation, but in the future it will happen from integrated care system to integrated care system. Where there is divergence, we need to be thoughtful of it.

The statement of values relating to cross-border care said:

“no treatment will be refused or delayed due to uncertainty or ambiguity as to which body is responsible for funding an individual’s healthcare provision.”

That is an important principle because it sets out that it is the job of the system rather than the individual to understand and navigate the separation between different bodies that may diverge but which work together in common purpose. That is easy to say, but hard to do at times. As I say, that is something that we will see between integrated care systems in time, too. That is true for patients, but also for staff, whether those staff work in Wales but live in England or vice versa, and for the important interrelationships between border integrated care systems on the Welsh border and the NHS in Wales.

There will be devolved and separate competencies between those bodies, but the human beings who make those systems go live side by side in communities, sometimes even next door to each other. A decision taken in one place, of course, impacts on everybody; we see that a lot in social care. Local authorities are under so much pressure at the moment, both in the resources that they have to fund social care and finding individuals to staff that care. There could be price wars at the borders that mean that individuals move between organisations more frequently than they would in a system that was better planned. We have to be mindful of that.

During the evidence sessions, we heard about the safe staffing legislation for nurses in Wales. That is the sort of thing that would already impact on border CCGs, and will do on integrated care systems in due course. That will only grow as the considerable workforce pressures that we discussed in the previous debate bite down even harder. Again, we must be mindful of that. It is crucial that there is a collective approach—a minimum approach—where the NHSs in neighbouring nations have due regard to each other. If the workforce becomes a zero-sum game, we will all lose in the long term.

I was heartened in those proceedings to hear about the contact between the Minister and his colleagues in Wales. I know that he takes matters seriously in Wales and across the United Kingdom, which is good. We might hear more about how that works with regard to the work- force. In the meantime, we support the inclusion of this measure in the Bill and the fact that it will be a priority.

--- Later in debate ---

For those reasons, I gently encourage the hon. Member for Arfon to consider not pressing his amendment to a Division.

[Hywel Williams]

I am not entirely reassured by the Minister’s words; possibly the best response is, “We shall see”.

I make one further point, if I may, in reference to his former Parliamentary Private Secretary: people from Ynys Môn are known in Welsh as people from “Gwlad y Medra”, which translates as “the land of I can do it”. Clearly, she can do health, and we look forward to seeing her performance at the Wales Office as well. I add my congratulations to her. 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]

Can I clarify, Mrs Murray, that we have a hard finish at 11.25 am?

Health and Care Bill (Eighth sitting)

Hywel Williams Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Hywel Williams (Arfon) (PC)]

It is a pleasure to serve under your chairmanship, Ms Elliott.

I have some questions for the Minister about the cross-border joint committees. I would, of course, be happy if he could answer them this afternoon, but he if wishes to have a period of further consideration I would be content for him to write to the Committee with the answers.

Clause 19 sets down the prescribed functions of an integrated care board that can be exercised jointly with the local health board in Wales. This is to be the responsibility of joint committees. The clause replaces the regulations in the National Health Service Act 2006, which provide that any prescribed functions of a clinical commissioning group can be exercised jointly with local health boards. The immediate questions for me are quite obvious—the who, what, why and how sort of questions—and I have not seen any details on this matter as yet, although I might have missed something.

As to my questions to the Minister, first, the why is quite clear: people from Wales access specialist services in England, as I am sure the hon. Member for Vale of Clwyd would point out if I did not. People from border areas, but also from the far north-west of Wales where I live, access services in Manchester and are very glad to do so. Indeed, people from England access services in Wales as well, although that is less remarked on. Cross-border traffic is usually couched in terms of dependency from Wales, but it might interest the Committee to know that in 2019, 13,500 people from Wales accessed GP services in England, while at the same time, 21,000 people from England accessed GP services in Wales. That might, of course, be something to do with the free prescriptions provided by the Labour Government in Wales—I could not possibly comment.

To be clear, as a Plaid Cymru Member and a nationalist, I think co-operation is not just desirable but essential to ensure that fair and effective cross-border arrangements are in place. There will, no doubt, be opportunities to compare and contrast and to learn from each other. As I said, however, I would like the Minister to address some of my questions. This is not an exhaustive list.

First, to what degree have the Welsh Government played a part in drawing up the arrangements for joint committees? I am sure there have been discussions. For example, how will the membership of joint committees be decided? There has been a good deal of concern in debates in this Committee about private providers having seats on ICBs, as we have already heard. Pertinently to this matter, the private sector has a lesser role in the provision of health and social care in Wales. We are not talking about identical services here. The private sector might have a greater prominence on the other side of the border. Has it been agreed with the Welsh Government that private providers are to have seats on joint committees or not? If so, what safeguards will be in place to prevent the conflicts of interest that were referred to on Tuesday?

What structures will be in place to ensure that there is national Welsh consistency in decision making between the joint committees along the border? Will there be a national framework, although perhaps that is the responsibility of the Welsh Government rather than the Government here in Westminster, for coming to agreements on the delivery of services, or will it be up to the local joint committees, with the danger of a postcode lottery? As I said, I think this might be a matter for the Welsh Government rather than the Government here in Westminster. It has been agreed, I hope, so I would like to know what was agreed.

Lastly, in respect of the detailed points, to whom will the joint committees be accountable: to their respective ICBs or health boards, to the Government, or to the ICB on one side and the Welsh Government on the other? How will that be done? Indeed, when consultation—wide consultation, I hope—is undertaken, will it happen across the border as well? Will Welsh patients be able to have their say? There are more questions that I will pursue, and more will surely arise as the joint committees begin their work. I hope the Minister appreciates that these matters need further explanation.

Finally, I have three broader points. Perhaps the Minister can clarify whether there have been discussions on these points and what has been decided about the services provided over the border. First, I am worried about divergence in health policy between Wales and England. There is a wellbeing approach to health in Wales, as I said in the debates on Tuesday. Might any difficulties arise from that? There might be some difference between what is available in Wales and what is available over the border.

Secondly—this is a particularly important matter where I live—has there been any discussion on whether services provided from England into Wales are consistent with the Welsh language requirements of the Welsh health service? I think there is a problem here, and some services provided into Wales from England are really aware of this. I think of the Robert Jones and Agnes Hunt Orthopaedic Hospital in Gobowen, which has Welsh-language services for people coming in from Wales. The hospital is just outside Oswestry, not far from the border. That is an issue to be examined, and perhaps to be answered by the Minister today or in a letter.

Lastly—this is more of a point in law, or possibly a philosophical point—can ICBs, which are ultimately the responsibility of the Government here in Westminster, be accountable to the Welsh Government, who have their power devolved from London? To put it more directly, can the Welsh Government peck up the pecking order towards bodies over in England? That has been a real question for services provided from outside Wales by Government bodies or agencies. Over many years, there has been quite a debate about bilingualism in the services provided into Wales by the Department for Work and Pensions. Again, that might not be a problem, but I would be grateful for the Minister’s views on this issue and on the other questions that I have raised.

[Edward Argar]

I am grateful, as ever, to my right hon. Friend the Member for Kingswood for his comments. I hope I can reassure him that the issues he raised, and the issues that he has aired in the Committee today, will continue to be reflected on carefully by officials and Ministers during the passage of the Bill.

I will try to address the specific points raised by the hon. Members for Ellesmere Port and Neston and for Arfon. The hon. Member for Ellesmere Port and Neston touched on the appointment of chief executives and the termination of appointments. That power is broadly akin to the current power that CCGs have, and we are simply moving across the power that NHS England has over CCGs to reflect the new environment of integrated care boards.

Health and Care Bill (Fifth sitting)

Hywel Williams Excerpts

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Karin Smyth]

I concur with the comments of the hon. Member for Central Ayrshire and my hon. Friend the Member for Nottingham North. The hon. Lady referenced the Black report, which first got me interested in working in the health service. I was shocked that, after all those years, the NHS had not improved the dreadful health inequalities that much of the population, including my own constituents, suffered. Here we are 40 years later, and we still have some really quite shocking health inequalities, even in the wealthy city of Bristol.

This is a really important point. We learned a lot in the pandemic, and hon. Members spoke about meeting their directors of public health recently. I have known my director of public health in Bristol for some 20 years because we have worked together over that period. I supported the movement of DPHs into local authorities. I think that was the right move, although the lack of funding that followed has made their job really difficult, and we have not made the improvements we should have made, as my hon. Friend the Member for Nottingham North outlined.

There is real enthusiasm among clinical and financial leaders for some of the movement in the Bill to bring organisations together in integrated care partnerships or ICSs—wherever we think the power will be—to look at population health. Financial directors I have talked to have said, “This is the direction we need to be going in. We need not to be looking just at our own institutions.” There is a will with the Government, but not including health inequalities is a major mistake. I appreciate that when they drafted this legislation, they were perhaps not thinking in that form, but a number of organisations have asked for that addition to be made.

The pandemic required us to talk closely to our clinical leaders, and it really educated people in individual specialties, who are not terribly knowledgeable about health inequalities—perhaps we think they should be. Even in terms of our understanding of where vaccines have been successful and unsuccessful, and how different communities receive information and engage with local health and care services, the pandemic has been a wake-up call and a good education for many of those leaders. We need to capitalise on that.

I know that drafters do not like to change things, but if we were to put addressing health inequalities in the Bill, as we seek to do, it would focus the Government’s drive on place-based commissioning and service delivery, and send a message to the powerful acute trusts—which at the end of the day run the money, and still will—that addressing health inequalities and looking at where and how their services are delivered to the most vulnerable will be a really positive outcome for the entire system. I therefore support the pursuance of the amendments.

[Hywel Williams (Arfon) (PC)]

To encourage the Minister to accept the amendment, I point out that addressing health inequalities would coincide with the Government’s stated aim of levelling up, so there is a happy coincidence there that might persuade him. Health inequalities are reflected geographically, and large parts of the country clearly suffer from them more than others. That pertains to England, but were I standing in the Senedd in Cardiff, I would say the same about Wales. That is slightly off the point, but there we are.

[Edward Argar]

I am grateful to the shadow Minister and all other hon. Members who have spoken for the expertise that they bring to this debate. It is one of the quirks of this House that lawyers are hon. and learned Members and members of the armed forces are hon. and gallant Members, but we do not have an equivalent for those who serve in the medical profession. Perhaps we should think about that.

I am very grateful to hon. Members for bringing this debate to the Committee by tabling these amendments, which relate to the important issue of health inequalities, in the context of the new triple aim duty set out in the Bill. Even though we may not reach the same conclusions about the best way to do it, it is right that we debate this crucial issue in Committee.

With your consent, Mrs Murray, and that of the Committee, I will start in reverse order with new clause 13, and then work my way through the amendments of the hon. Member for Nottingham North. The new clause would place an additional duty on the Secretary of State to produce a report setting targets on the improvement of the physical and mental health of the population and the reduction of health inequalities.

I appreciate and understand the intention behind the hon. Gentleman’s new clause. He is right: health is the nation’s greatest asset. Preventing ill health, improving people’s health and wellbeing, and tackling long-standing inequalities are all fundamental to the economic and social strength of our country. However, the creation of a new statutory duty to set the type of target identified in the new clause is not necessary, in the light of the existing duties on the Secretary of State around improving public health and seeking to reduce health inequalities, as provided for in the 2006 Act. I may not agree with everything in it, but I pay tribute, where it is due, to the Labour party. Labour Members will hear a number of references to what is in that Act and to the retention of what is in that Act in many areas.

Of course, ICBs, too, have duties to have regard to the need to reduce health inequalities whenever they are exercising their functions, to promote integration where it would reduce health inequalities and to set out how they will tackle health inequalities in their plans.

I hope I can reassure members of the Committee that the Government are already taking strong action in these areas and that there are already a number of targets relating to improving the population’s health that cannot be met without addressing those underlying inequalities. For example—I know that this is something that the hon. Member for Nottingham North feels very strongly about—we cannot achieve our existing commitment to a smoke-free generation by 2030 if we do not address as a priority the needs of those people and populations with the greatest levels of need and help people to give up smoking. He is right, and this involves the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Bury St Edmunds. I suspect that when we reach the latter parts of this legislation that are about public health more specifically, this issue may feature, rightly, in the Committee’s discussions again.

To support our strategy to improve the population’s health and reduce health inequalities, at the beginning of October we will launch the Office for Health Improvement and Disparities within the Department. We have also announced that we will create a cross-Government ministerial group with a remit specifically to identify and tackle the wider determinants of poor health. Our broader focus on levelling up, to which the hon. Gentleman alluded, recognises the wide range of factors such as good jobs, homes and local environments in which we can take pride, alongside a range of other factors, that all support and interact with our physical and mental health.

In contrast, I fear that the new clause, although I can see its intent, could make it more difficult for us to swiftly focus on ensuring that such inequalities are identified and acted on. Had we a fixed, five yearly set of targets to work towards, I fear that it would introduce more rigidity, rather than the agility and flexibility that we seek in meeting the changing assessments of what underlying health inequalities must be tackled as a priority. I hope that I can persuade members of the Committee, although perhaps not all of them, that a five-year fixed plan is potentially inflexible and is not necessary in the context of this legislation.

I turn now to the amendments that relate to the duty known as the triple aim. Amendments 21, 23 and 25 would add a fourth limb of tackling health inequalities for NHS England, ICBs and NHS trusts. As I have stressed, we do recognise the importance of tackling health inequalities, but again, we do not feel that the amendments, however well intentioned, are necessary. As we have discussed, there are existing statutory duties on bodies in this area, many of which relate specifically to health inequalities. NHS England and ICBs will have to have regard to such duties alongside the limbs of the triple aim. NHS England will also have to consider such duties when it produces the guidance on the triple aim.

The triple aim is compatible with and conducive to addressing health inequalities and furthering the delivery of these duties. Indeed, tackling health inequalities is a theme that runs throughout the duties. Having organisations consider the wider effects of their decisions will, we believe, encourage greater collaboration and engagement with communities on how best to meet their needs, which in turn will assist with tackling health inequalities nationally, but also flexibly at a local level.

The triple aim duty requires consideration of the health and wellbeing of the people of England. As the shadow Minister alluded to, that would also include consideration of the health and wellbeing of those who are not accessing health services. Similarly, it is a key element of the second limb of the triple aim—the improvement of the quality of services—to consider those areas where services are in most need of improvement. We expect guidance from NHS England to make clear how bodies can discharge the triple aim duty in a way that is fully commensurate with the reduction of health inequalities.