Health and Care Bill

Jonathan Ashworth Excerpts

2nd reading
Wednesday 14th July 2021 Commons Chamber

[Sajid Javid]

The right hon. Gentleman has raised an important matter. There are issues surrounding the cosmetic surgery industry, and I know that he has spoken eloquently about them in the House before. I do not necessarily agree that this Bill has to be the vehicle for any change, but if he wishes to discuss the matter further, I should be happy to meet him in due course, because it is important and it does require a fresh look.

Whenever the NHS is subject to change, it is tempting for some, who should actually know better, to claim that it is the beginning of the end of public provision. We know that that is complete nonsense, and they know it is nonsense, but they say it anyway. So let me very clear: our integrated care boards will be made up of public sector bodies and those with a social purpose. They will not be driven by any private interests, and will constantly make use of the most innovative potential of non-NHS bodies.

The spirit of this Bill is about holding on to what is best about the NHS and removing what is holding it back. That is something that we all want, and I am looking forward to a mature debate—[Laughter.] Perhaps that is too much to ask in this Chamber with this Opposition Front Bench, but I hope for, and I think the public expect, a mature debate on the Bill and on how we can achieve these sensible changes together.

In that spirit, the second theme of the Bill is cutting bureaucracy. As we have been tested during these past months, we have looked at the rules and regulations through new eyes. It has become increasingly clear which of them are the cornerstone of safe, high-quality care, and which are stifling innovation and damaging morale. It is that second group of rules and regulations that the Bill strips away, removing the existing procurement regime and improving the way in which healthcare services are arranged. Yes, this is about how we deliver better value for the taxpayer, but fundamentally it is about how we can free up NHS colleagues to deliver better care. We know that patients are better served when experts are free to innovate unencumbered by unnecessary bureaucratic processes. That is why the Bill will repeal section 75 of the Health and Social Care Act 2012, giving the NHS the flexibility for which it has been asking. I know that this is a point of agreement with the Labour party—

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

We said it 10 years ago.

[Sajid Javid]

The Labour party said it not just 10 years ago but in 2015, 2017 and 2019—in all those manifestos—so I am sure that its members agree with this direction. [Interruption.]

--- Later in debate ---

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I beg to move an amendment, to leave out from “That” to the end of the Question and add:

“this House declines to give a Second Reading to the Health and Care Bill, notwithstanding the need for a plan for greater integration between health services and social care services and for restrictions on junk food advertising to improve population health outcomes, because the Bill represents a top down reorganisation in a pandemic leading to a loss of local accountability, fails to reform social care, allows further outsourcing permitting the private sector to sit on local boards and fails to reinstate the NHS as the default provider, fails to introduce a plan to bring down waiting lists for routine NHS treatment or tackle the growing backlog of care, fails to put forward plans to increase the size of the NHS workforce and see them better supported, and fails to put forward a plan that would give the NHS the resources it needs to invest in modern equipment, repair the crumbling NHS estate or ensure comprehensive, quality healthcare.”

Well, the Secretary of State talked a lot, but he did not say very much. Look at the context of where we are. Yesterday, we recorded 36,000 covid infections. Hospital admissions have increased to over 500 a day, up 50% in a week. Waiting lists are at the highest level on record, currently at 5.3 million. Some 336,733 people have been waiting over a year for treatment, over 76,583 people are waiting over 18 months, and over 7,000 people are waiting over two years. Some 25,889 people are waiting more than two weeks from urgent referral to a first consultant appointment for cancer. Emergency care is grappling with some of the highest summer demands ever seen. Two hundred and fifty thousand people are waiting for social care. NHS staff are exhausted, facing burnout. We went into this pandemic with 100,000 vacancies across the NHS and a further 112,000 vacancies across social care.

The answer from the Secretary of State is to embark on a top-down reorganisation when we are not even through the pandemic—a reorganisation that will not deliver the integration needed, because reforms to social care are delayed again; a reorganisation that will not deliver more care but in fact, in periods of stretched health funding, could well deliver less care; and a reorganisation that is, in effect, a Trojan horse to hide a power grab by the Secretary of State.

Let us be clear why this reorganisation is taking place. The Government have come forward with this Bill because of the mess of the last reorganisation—the mess that the Secretary of State supported and voted for, and the mess that he spoke out for in this House, saying that it would modernise the NHS and that the

“concept of GP commissioning has been widely supported by politicians from all parties for many years. May I urge my right hon. Friend to keep putting patients first by increasing GP involvement in the NHS?”—[Official Report, 4 April 2011; Vol. 526, c. 773.]

Why, if he believed that then, has he U-turned now? And it was a mess that we warned of. My hon. Friend the Member for Leicester West (Liz Kendall), who opposed that Bill in this House, warned the Government that it would increase bureaucracy and increase the fragmentation that the Secretary of State has just complained about from the Dispatch Box.

Ministers said that that reorganisation under Lord Lansley would reduce bureaucracy, and Back Benchers told us that it would reduce bureaucracy, but what ended up happening? Billions were wasted and thousands of NHS staff were made redundant. That was the Government’s priority then, and now they are asking us to clean up their mess today. They also told us that that reorganisation would improve cancer survival rates, and where are we today? We are still lagging behind other countries on cancer survival rates. Perhaps the Secretary of State could have come to the Dispatch Box and apologised for that Lansley reorganisation and 10 wasted years.

The Secretary of State talked about NHS leaders, but the truth is that NHS leaders asked for a simple Bill to get rid of the worst of the Lansley restructuring and instead re-embed a sense of equity, collaboration and social justice in our NHS structures. That is not what this Bill is. Of course, the Secretary of State secretly agrees with me. According to The Times, he wrote to the Prime Minister saying that there were “significant areas of contention” that were yet to be resolved with the Bill, and that he wanted to delay it. The Secretary of State was only back five minutes and already Downing Street was overruling him. When it overrules him on his choice of spin doctors, he walks; when it overrules him on the future of the NHS, he puts his career first and stays in the Cabinet.

I listened carefully to the case made by the Secretary of State. He talked of the need for greater integration between health and social care and the need to provide better co-ordinated care, and he referred to an ageing population.

To be frank, that was a speech that Health Secretaries and their predecessor Social Services Secretaries have been making more or less since 1968, when Richard Crossman proposed the first set of NHS reorganisations. Indeed, there were echoes of the Secretary of State’s speech in that made by his predecessor Keith Joseph, when he came to this House in 1972 to set up the area health authorities, bringing together hospitals and community care and working more closely with local authorities because we needed seamless care. Those authorities were of such a size that, within a year, they were rearranged again into district health authorities. Given the size of some of the integrated care systems that the Secretary of State is proposing, I suspect that the seeds of the next reorganisation are being sown today.

Yesterday, the Secretary of State told the House that his

“three pressing priorities for these critical…months”

were

“getting us…out of this pandemic…busting the backlog”

of non-covid care, and

“putting social care on a sustainable footing for the future.”—[Official Report, 13 July 2021; Vol. 699, c. 163.]

But absent from his speech was any credible explanation of how this reorganisation will meet his objectives that he outlined to the House yesterday. In fact, in the last 30 years, we have seen around 20 reorganisations of the NHS. Have any of them delivered the outcomes that Health Secretaries have promised from the Dispatch Box? Well, not according to analysis in The BMJ, which observes:

“Past reorganisations have delivered little benefit”.

Why should this one be any different?

The question for me is: how will the 85-year-old with multiple care needs experience better whole-person care as a result of the restructuring that the Secretary of State is embarking upon? How will waiting times for elective surgery for cancer and mental health be improved by this reorganisation? How will health inequalities that have widened and life expectancy advances that have stalled be corrected by this reorganisation? To those questions, the Secretary of State had no answer today: the Bill fails those tests because it is a badly drafted Bill and could in fact even worsen health outcomes.

Let me outline our specific concerns. On the proposed integrated care boards, the Bill collapses the remaining 100 or so clinical commissioning groups into 32 integrated care systems differing in geographical size and with some covering populations up to 3 million or 4 million. In some parts of the country, the ICSs are not based on the NHS agreed boundaries, but currently on centrally drawn-up boundaries for political reasons. We know that Cheshire will be combined with Merseyside. Glossop is cut off from Greater Manchester and allocated to Derbyshire. Frimley is split up, leading the former Prime Minister, the right hon. Member for Maidenhead (Mrs May), to complain in an Adjournment debate recently:

“Do not break up Frimley ICS. Just for once, let common sense prevail.”—[Official Report, 29 June 2021; Vol. 698, c. 238.]

These boundaries and the way in which they were proposed by the previous Secretary of State, the right hon. Member for West Suffolk (Matt Hancock), prompted NHS Providers to warn that the disruption could lead to

“a worsening of patient care”.

And then, of course, we have the design of the integrated care system, split across two committees—a partnership board containing people from local authorities, the third sector and others, and then an NHS board responsible for spending the money, for commissioning. The Secretary of State has moved away from GP commissioning, of course; he wants the NHS board to commission now. Those two boards will probably have different chairs, but the NHS board only has to have “regard” to the partnership board strategy. Nor is it clear how local authority seats—the one local authority seat—will be decided when they cover more than one council and possibly even councils of different political persuasions, so we will see how a consensus can be built then.

Other important voices are left out. Mental illness accounts for roughly a quarter of the total burden of illness, yet there is no guarantee that mental health providers will get the seats on these boards, when we know that mental health services are under pressure and the Secretary of State tells us that the mental health backlog is one of his personal priorities. The pandemic has also reminded us that the health and wellbeing of our community is not just in the hands of large hospitals or general practice. It is also in the hands of our directors of public health, who have shown exceptional local leadership throughout this crisis, standing on the shoulders of their forebears, who in the past confronted diseases such as cholera, smallpox and diphtheria. Test and Trace would have been far safer in their hands from the outset, by the way, and what is their reward? They are sidelined. Public health, again, should be properly represented on the NHS boards and we will table amendments to that effect.

[Mr Kevan Jones]

Does my right hon. Friend agree that it is not just about their being sidelined; it is actually about the budgets for public health, which have been pushed off into the autumn? If the consultation paper that went out last year is anything to go by, County Durham would lose 19% of its budget. How can we effect these changes without its being divorced from what will be provided in terms of cash?

[Jonathan Ashworth]

My right hon. Friend is absolutely right. I will come to the financial flows in a few moments. But how on earth can we have a triple aim of trying to improve health outcomes for a population and not even give public health a voice and a seat on the decision-making body that decides health plans for an area?

The Secretary of State talks about integrating health and social care. There is no seat for directors of adult social services on these committees, either. And what about patients? Patients were not mentioned very often by the Secretary of State in his speech. Patients will always come first for the Opposition. They have no mandated institutional representation, either—no guaranteed patient voice—so we have yet another reorganisation of the NHS whereby patients are treated like ghosts in the machine. It is utterly unacceptable. This is fragmentation, not integration, with a continued sidelining of social care.

There is a loss of local accountability as well, because there is no explicit requirement that the boards meet in public or publish their board papers. Although NHS England has stated that that is its preference, it is not required; nor is there any commitment, despite the wide geographical spread of some ICSs, for meetings to be made accessible online. But, of course, the White Paper did indicate that the independent sector could have a seat on an ICS, and the explanatory notes to the Bill state that

“local areas will have the flexibility to determine any further representation.”

[Kevin Hollinrake]

The right hon. Gentleman talks about solutions to social care. Will he come on to his own solutions to social care? Will they potentially include the recommendations of the Select Committees about that German-style social care premium—recommendations made by members of his own party who were elected by his party to serve on those Committees? Is that something that he is now willing to explore? He has ruled it out time and again on the Floor of the House.

[Jonathan Ashworth]

I have. The hon. Gentleman is a dogged advocate for that proposal for social care, and he is quite right: he always raises it with me. I am unpersuaded but I am more than happy to sit down with the Secretary of State and with my hon. Friend the Member for Leicester West to discuss a solution to social care. We keep being told that there are going to be cross-party talks, but I think I missed the Zoom link, because they have not happened so far.

As I was saying, these committees do permit a seat, if the committees want it, for the independent sector. In Bath, in Somerset, we have seen Virgin Care get a seat on the shadow ICS. The Opposition think that is unacceptable and we shall table amendments to prohibit it.

I welcome the removal of the section 75 competition and procurement rules, finally scraping the remnants of the Lansley competition rules off the boots of the NHS. We did warn him and others that this compulsory competitive tendering would lead to billions going to the private sector, would be wasteful and bureaucratic, and would be distracting—and it even led to the NHS getting sued by Virgin Care when it did not win a contract. But this is not the end of contracting with the private sector. Without clauses to make the NHS the default provider, it would be possible for ICBs to award and extend contracts for healthcare services of unlimited value without advertising, including to private companies. Given the past year, when huge multibillion-pound contracts have been handed out for duff personal protective equipment and testing, we naturally have concerns about that and will seek safeguards in Committee. We are worried about further cronyism.

We are particularly concerned about the Bill because of the power grab clauses for the Secretary of State. He is creating 138 new powers, including seven allowing him in effect to rewrite the law through secondary legislation, to transfer functions between arm’s length bodies without any proper scrutiny. He has not explained why he needs these powers or given any guidance on how he expects to use them. These powers also include a requirement that Ministers be informed of every single service change, every single reconfiguration, and the Secretary of State will then decide whether or not to call them in for ministerial decision. Are you sure you want that power, Secretary of State?

The Government have gone from wanting to liberate the NHS under Lansley to now listening out for the clang of every dropped bedpan echoing through Whitehall. This is not a plan for service modernisation; it is a “Back to the Future” plan and it will mean more inertia. Instead of powers to interfere at every level, resetting the mandate for the NHS within years, we instead would want the duties on the Health Secretary, and therefore on the 42 ICSs to which he delegates those responsibilities, to continue the promotion in England of a comprehensive health service, as per the National Health Service Act 2006, to be fully reinstated and made explicit.

[Steve Brine (Winchester) (Con)]

As ever, I have listened carefully to the right hon. Gentleman. If this is the “Back to the Future” Bill, presumably it puts right what once went wrong. Does he support the clauses on foods that are high in fat, salt and sugar, and the watershed proposals for advertising?

[Jonathan Ashworth]

Yes, although I am disappointed that they are in this particular Bill. I think they should be part of a stand-alone Bill. In my concluding remarks, I will make a point or two about other public health interventions, which I imagine and hope that the hon. Member, as a great champion of public health, would support.

It is crucial that the Secretary of State’s duty to provide comprehensive healthcare is reinstated, rather than the duty to meddle in the NHS at any time he wants, because there is a lack of clarity about how the funding flows work in this system. The talk is of moving to capitated budgets for an area to provide holistic care to meet the complicated care needs of individual. But when waiting lists are increasing at the current rate, and when cancer waits and mental health referrals are going up, how is an area going to fund the episodic care for each unit of extra care that is needed—often care that is expensive and more complicated because it needs to be done in the acute sector?

We have worries. Clauses 21 to 24 on the financial duties on ICS boards, NHS trusts and NHS foundation trusts are alarming, because they put in place a duty to ensure financial balance across the ICS area, but there is no clarification of how that balance should be achieved and enforced. Local health budgets have been stretched to breaking point after years of underfunding, so what does this duty mean for existing deficits? At the moment, trusts have a combined deficit of £910 million. King’s has a deficit of £111 million. Worcestershire has a deficit of £81 million. University Hospitals of Leicester NHS Trust has a deficit of £80 million. Will the ICBs need to fill this £900 million black hole before they are even up and running How exactly will trust and ICS board deficits be dealt with at the end of each financial year?

This could well be a return to the days that we saw in the ’80s, which some Members in the House may recall, when health authorities would close beds and put off paying bills from January onwards in order to hit financial balance. If health authorities have to hit this financial balance year by year, will it result in a postcode lottery of more rationing and an even longer list of treatments being removed from the NHS through the decisions of ICBs because they have to hit balance, effectively forcing patients either to go private or go without? I hope that the Minister, in summing up, can clarify what the situation will be.

If a set of providers, trusts and an ICB feel that the financial settlement they have been given by NHS England will not allow them to deliver the levels of care to bring down the waiting lists, which the Secretary of State said is one of his top priorities, or to improve mental health outcomes, which he has also said is one of his top priorities, what is their appeal process? How will the arbitration process work on an area’s financial settlement under the current plans to bring together NHS England and NHS Improvement, not split them out?

The Bill is spun as an attempt to integrate health and social care, but there is nothing in it actually to integrate health and social care, because there is nothing in it to fix social care. If it is about integrating health and social care, where is the long-promised Bill to reform social care? The Bill will repeal provisions in the Care Act 2014 that require patients to be assessed for their social care needs before they are discharged from hospital. Without long-term funding in place, that could mean a patient being sent home, left out without support and waiting for an assessment. Will the Secretary of State, or the Minister who responds to the debate, guarantee that that will not be the case? Will they put in place the necessary funding alongside the Bill?

A number of royal colleges and health bodies have said today that the biggest challenge facing the NHS is workforce. The Bill proposes a duty on the Secretary of State to report on workforce once every five years. That is simply not good enough. We need a solution to workforce now; we need a solution to recruitment now; staff need a fair pay rise now; we need more investment in training and professional development budgets now; and we need safe staffing legislation now. We will therefore look to amend the Bill, hopefully on a cross-party basis and perhaps working with others who put forward proposals to improve the workforce sections of the Bill.

As my hon. Friend the Member for York Central (Rachael Maskell) asked the Secretary of State, what does the Bill mean for “Agenda for Change”? The Bill suggests that an integrated care system will be able to change “Agenda for Change” terms; we disagree with that.

Finally, on public health, the Bill introduces restrictions on the advertising of less healthy food and drink. We welcome this step—it, too, was in our 2017 manifesto, which the Secretary of State has been reading—but we would go further. Why can we not have more restrictions on the advertising of unhealthy food around schools? Our public health crisis is about not just obesity but smoking and alcohol, so why are there no provisions in the Bill on smoking services and to ensure alcohol calorie labelling? We will table amendments on those issues in Committee.

This is the wrong Bill at the wrong time. Will the person with learning difficulties or the older person who needs social care experience improved care? No. Will social care be brought back in from the wilderness? No. Will the cancer backlog be tackled more effectively? No. Will health inequalities be narrowed? No. Will parity of esteem for mental health be delivered? No.

Instead of this being a simple Bill to end competition and foster local collaboration, NHS staff will be left trying to second-guess where the Secretary of State will interfere next in the safe running of their local NHS with his in-year changing mandate. The rules on funding could result in more rationing and cuts, so we cannot possibly support the Bill. We have championed integrated care for many years, but the Bill does not deliver it and we urge the House to accept our reasoned amendment.