Health and Care Bill (Seventh sitting)

Justin Madders Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Alex Norris]

I am grateful for the contribution from my hon. Friend the Member for Bristol South. I completely agree that where we will see the worst practices across footprints, each and every one will be secretive and not invite scrutiny, so it is very important that we set arrangements to ensure that that cannot happen.

I am grateful for the clarification that the 1960 Act will apply, which assuages my first concern. On the second, relating to the notice of board papers, the Minister has essentially said that local footprints will have to set that element of the constitution themselves, but that the safeguards and schedules will mean that NHS England has to sign them off. In that sense, there cannot be wide divergence, because the centre would not permit it. I reiterate that there should be commonality. I cannot see why it would be seven days in one place and five days in another. I do not know how we could explain that, so I hope that in those conversations the Minister stresses the need for uniformity. Perhaps the guidance might include strong encouragement on that. On the basis of the agreement that we have in principle, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I beg to move amendment 43, in schedule 2, page 123, line 2, at end insert—

“(5) An integrated care board must apply all relevant collective agreements for staff pay, conditions and pensions.

(6) An integrated care board must ensure that all relevant collective agreements for staff pay, conditions and pensions are applied throughout the area for which it is responsible.

(7) Any integrated care board which wishes to employ anyone directly on an annual salary greater than £161,401 must receive approval from their integrated care partnership before confirming the appointment.”

This amendment puts into primary legislation the current practice that NHS bodies honour collective agreements over staff pay and conditions and gives the integrated care board a role in ensuring this remains the case.

It is a pleasure to see you in the Chair, Mrs Murray. I would like to say that it is a pleasure to see the Minister, although when I saw the headline that two Ministers from the Department had been promoted to the Cabinet, I had expected that he would be among them—alas, not on this occasion. I am sure it is only a matter of time. Of course, if the Minister and other Members on the Government side want to keep their phones on in case a call comes through, we will not be offended if they have to pop out for a couple of minutes. I hope the Minister’s rush of blood and damascene conversion to the perils of privatisation at the end of the sitting on Tuesday have not blotted his copybook too much.

I turn to amendment 43, which plays into several points that have come up in the evidence sessions, particularly the anxiety that was mentioned by Sarah Gorton of Unison in her evidence to the Committee last week. She said that she wanted to see in the legislation confirmation of assurances that have been given verbally and in guidance. She referred to conversations that she had had—I am not sure with whom, but I assume with officials in the Department. Those conversations were to the effect that there was

“no intention for any new parts of the system to undermine the collective arrangements”.––[Official Report, Health and Care Public Bill Committee, 9 September 2021; c. 96, Q129.]

and that the “Agenda for Change” agreement would continue to apply across the board and, indeed, to ICB staff. That is an important matter to seek assurance on. Anyone who has been involved in “Agenda for Change” will know that years of hard, torturous work were involved in getting that agreed. Certainly, on this side, we know the value of the staff and their trade union representatives, and the importance that collective agreements have in bringing issues to the fore and ensuring a universality in treatment and a common understanding of the basis on which the employer and employee move forward.

Of course, whatever the collective agreements say, the staff would like to be offered increases that actually keep pace with the cost of living, rather than the real-terms cuts that we have seen in the last decade. However, as an overall framework for ensuring staff are treated fairly and consistently, it is certainly not something that we want to be chipped away at.

I will not try to persuade the Minister of the benefits of collective agreements across other sectors—it would be well outside the scope of the Bill—but it is worth pointing out that there is plenty of evidence from across the world showing that where workforces have negotiated terms and conditions within sectors and across whole industries, they tend to enjoy better terms and conditions and, crucially, better rates of workplace satisfaction and staff retention. As highlighted in the report recently published by the Health and Social Care Committee, the NHS faces an enormous challenge in retaining its workforce.

We do not want anything to undermine “Agenda for Change”. Sadly, though, we have seen attempts to do that in recent years, with the creation of wholly-owned subsidiary companies. I will not return to the argument about whether those are a good thing, because we have said that they are not, but let us examine for a moment why trusts sometimes seem eager to set these companies up.

There are, of course, huge financial pressures on trusts. I will not rehearse the arguments on that, but they are always looking at ways to reduce their costs, and potentially with these subcos to boost their income. The VAT advantages have been a big part of that, but one of the big concerns—cash-pressed trusts may see this as a big opportunity—is that the subcos potentially have the ability to move away from “Agenda for Change”. That is the heart of it; it is not that the trusts have a major objection to “Agenda for Change”, but moving away from it allows them to set their own terms and conditions, which is really a euphemism for saving money and cutting pay. We think that that kind of approach is a false economy and, ultimately, self-defeating.

There are other examples of where the private sector will step in. We saw the news this week that King’s College Hospital Foundation Trust will transfer staff at its urgent treatment centre in Denmark Hill to Greenbrook Healthcare under a three-year contract, starting in October. Of course, staff will expect TUPE to apply, but, as we know, it is not a panacea. It does not protect terms and conditions for ever more, so it is little wonder that the news of that change has led the workforce to raise concerns.

Unison’s written evidence sought clarification from the Minister that

“it’s not the intention that ICBs depart from Agenda for Change”,

which the Minister gave on Second Reading. The written evidence also states that

“UNISON would support amendments to ensure that ICBs will apply the relevant collective agreements for staff pay, conditions and pensions, and be responsible for ensuring that these are applied within the wider system. In addition, further reassurances should be sought that nothing in the Bill will compromise the assurances already given in the Employment Commitment, the terms of which should endure beyond the point of staff transfer.”

The evidence continues:

“Recently published guidance lists 10 ‘outcome-based people functions’”—

perhaps that phrase could be translated into plain English at some point—

“that ICSs will be expected to deliver from April 2022… In addition, the guidance suggests that the responsibility for engaging with trade unions will rest with the regional teams of NHS England / Improvement rather than with ICBs”.

That runs the risk of depriving unions of access to those who might be making strategic decisions in their area—or perhaps it just speaks to a larger truth about where power will lie in all this. We have covered those concerns in our amendment to some extent, but we would like reassurance from the Minister on some of the points we have raised about how this will all work in practice.

In particular, we need reassurance that the system will not undermine existing provider responsibilities on engaging with trade unions. As hon. Members will know, the vast majority of NHS staff will not be employed in commissioning bodies such as ICBs. The strong relationships with individual provider organisations should be a supplement to existing national and regional partnership forums. The concern is that the new kids on the block, the ICBs, will in some way disrupt those arrangements.

If, as we are told, the new ICSs—to use the correct terminology—will be system leaders themselves, it is not impossible that some of those leaders will want to set their own path in tweaking employment matters. We might see circumstances in which some agreement about staff mobility within ICSs comes to the fore, particularly for those whose duties cross organisational boundaries. In principle, that is no problem, as long as no ICB thinks that, as a result, it can move outside existing collective agreements. Our amendment would rule that out.

It is essential that ICBs have a positive role in all this and that they follow existing practice by referring to collective agreements. We would not want a re-emergence of what we saw some five years ago, with certain trusts trying to undermine collective terms and conditions. Those attempts failed, but we never know when that might re-emerge. We also believe that the ICB should honour national agreements for the staff it employs.

That should not need to be said—as we have heard, assurances have been given—but it needs to be made explicit in the Bill to give us the cast-iron lock that both we and Unison would like. We would certainly like some further assurances about whether the ICBs have the potential to circumvent or destabilise existing arrangements, should they seek to forge their own path at some point. We see this amendment as bolstering the commitment to “Agenda for Change”—I hope that the Minister will confirm that commitment when he responds —so that ICBs’ broad powers are not seen as an attempt to undermine or conflict with the hard-won terms and conditions that have been collectively agreed.

Turning to sub-paragraph (7) in the amendment, which relates to pay limits, hon. Members will have seen headlines in the paper, on Tuesday, I think, about the highest-paid NHS managers being “cleared out”; I think that was the term that was used. I am not quite sure what that means, other than redundancy. The story refers to a Government-inspired audit, which was—at least on Tuesday—going to be led by the then Chief Secretary to the Treasury, the right hon. Member for North East Cambridgeshire (Steve Barclay), who has since moved on to other matters. That is a shame, because he used to hold the same role as the Minister does now, and he would know exactly where to look if there were indeed examples of unnecessary management and bureaucracy in the NHS.

That news follows the headlines we saw last week about some ICB executives potentially receiving salaries of £270,000. Let us be clear what we are talking about here: that is the pay of 10 nurses. It seems that someone somewhere in Government is exercised about the number of managers in the NHS, but according to the King’s Fund, the actual figure is somewhere below 5%, and many of those managers hold dual clinical roles. If the Government think there is a problem here, I am not entirely clear what they think the scale of it is, or what the consequences would be if thousands of managers in the NHS were made redundant. I am sure that was not covered in the impact assessment, but we have the benefit of that now.

To be clear, the amendment is not about bashing managers at all. Every organisation needs managers if it is to be effective, and they play an important role in enabling clinicians to get on and do their jobs on the frontline. I am sure the Minister would not want to leave managers in the NHS with the impression that has unfortunately been left by some of the headlines this week, namely that there is no role for managers in the NHS. One could be forgiven for concluding that from Tuesday’s headlines. If the Government think layers of management, bureaucracy or management costs have got out of control, we can do something about it.

--- Later in debate ---

[Edward Argar]

I am grateful to the shadow Minister, the hon. Member for Ellesmere Port and Neston, for his remarks on the amendment. I echo some of his comments, which we covered on Tuesday in Committee in response to the intervention by the hon. Member for Bristol South. Members on both sides of the Committee made clear our recognition of the value we place on those who work in the NHS, irrespective of whether they are managers, in clinical roles or in any other role. In our exchanges, we recognised the centrality of having good, high-calibre managers for what we all know is a huge system.

Amendment 43 would have two effects. First, it would require ICBs to apply to their staff all relevant collectively agreed terms on pay, conditions and pensions. Secondly, it introduces new rules for oversight of pay for the most senior ICB staff. The Government and the NHS remain committed to the principle of “Agenda for Change”. If it gives the hon. Member for Ellesmere Port and Neston further reassurance, I am happy to write to him, because this is a detailed point and I suspect he may wish to have something in black and white that sets out exactly our position on this. We recognise—he alluded to this—that there is a need for a degree of flexibility in some circumstances. He talked about people moving between roles, secondments and so on. I will turn to that in a moment before turning to the point about pay.

There is already a commitment in the ICS HR framework technical guidance that staff transferring into ICBs will transfer across on their current terms and conditions, in line with the “NHS Terms and Conditions of Service Handbook” requirements. The commitment states that NHS pension rights will be preserved, as the individual will continue to be employed within the NHS, ensuring that staff transferring into ICBs will benefit from that protection and will not see any change to their existing conditions. Furthermore, we would expect ICBs to use the nationally agreed pay and conditions framework for the overwhelming majority of the time.

The hon. Gentleman referred to some flexibility, and he was right to do so. There may be circumstances in which an ICB needs flexibility to recruit staff, to attract staff with very unusual or valuable skills, or to reflect local circumstances and the availability of certain staff. Therefore, an ICB may need to vary the terms and conditions in order to make a post attractive if the marketplace is very competitive. Equally, the Bill provides valuable flexibility—for example, in order to allow ICBs to employ on secondment staff who have previously been employed by a foundation trust or local authority. Given the emphasis that the Bill places on systems working collectively and sharing staff, that is a useful flexibility. I would argue that such flexibilities are not unique, because NHS foundation trusts also have a degree of discretion in adopting such conditions, although they overwhelmingly choose to honour and keep the existing terms and conditions.

If I recall correctly, the hon. Gentleman asked specifically about the view on the involvement of unions and staff where there was divergence or flexibility. I would hope that where there was any divergence or a need for flexibility, that would be addressed collaboratively. Ideally, there should be consent from those working in the organisation as well.

I turn to the proposals for very senior managers. I believe that procedures are already in place to ensure that the most senior staff within the NHS are appointed with fair and equitable salaries, and proposals to pay very senior staff more than £150,000 a year must follow benchmarks or be subject to ministerial oversight. Ministerial oversight of salaries higher than £150,000 a year has been effective in managing the risk of salary escalations, and it provides for a national outlook across the public sector.

The hon. Gentleman referred to the former Chief Secretary to the Treasury, my right hon. Friend the Member for North East Cambridgeshire, who is now the Minister for the Cabinet Office. I do not think there is any inconsistency in what my right hon. Friend envisaged with the review. That should not be interpreted as a criticism or an attack on hard-working staff, but given the amount of money that is spent in our NHS on salaries at all levels, it is right that from time to time the Government look at that, review it and reassure themselves that the appropriate balance is being struck between fair remuneration for the work that is being done and value for taxpayers. I do not think I would read any more than that into it; it is simply the Government and Treasury being responsible with public money.

The hon. Member for Ellesmere Port and Neston will be aware that the Government are in the process of finalising the system for pay oversight that will apply to ICBs. Although the specifics may differ, the effect and intention will be the same: to afford ICBs a degree of agency and flexibility, so that we can continue to attract the most senior and experienced leaders, while also ensuring that we put adequate checks and balances in place to ensure that public money is well spent. Therefore, I would argue that the amendment is unnecessary. Once again, I gently encourage the hon. Gentleman to consider not pressing the amendment to a Division.

[Justin Madders]

I am grateful to the Minister for his comments, but I fear that I will disappoint him on this occasion. He mentioned the flexibilities that already exist, which we do not seek to change. I do not see anything in the amendment that would alter those. We have had a very clear commitment, and he has mentioned the guidance. Indeed, he may write to me—

[Edward Argar]

As I do regularly.

[Justin Madders]

As he does regularly. I write to him regularly, too. He mentioned the importance of having this in black and white, and that is where we agree. We do need this in black and white, and the place for that to be is in the Bill, so we will press the amendment to a Division. I understand what he has said about ministerial oversight of ICB salaries, but if these bodies are to be locally run and accountable, we think the amendment would be entirely consistent with that aim.

Question proposed, That the amendment be made.

--- Later in debate ---

I made a throwaway comment about what a hospital is, the 40 or 48 and what they are, but the Government have got themselves into a bit of a mess about this now. All hon. Members will have examples from our own constituencies that we can raise. LIFT is a way to manage some of these issues, and it does not go through the same process of capital. What is the further investment? How can I ensure that Bristol gets its dividend back from the LIFT scheme? That might be beyond the Minister’s wit now. But on a serious note, the people providing the bulk of our health services in community and primary care deserve to understand how they can have better estates over the coming years.

[Justin Madders]

Particularly in light of the changes that have been made with covid, one thing that has cropped up locally is that a lot of GP practices—they are basically converted houses—simply are not designed with the ventilation or space to ensure there is a safe distance between people. That points to the importance of this issue and the need for clarity on how we get these estates into a state that is fit to deal with covid.

[Karin Smyth]

I agree, and we will probably all have examples through the primary care networks of practices that were not in old houses but that had perhaps had a LIFT scheme or another new development. In my constituency, the Bridge View Medical practice was able to have a flow through the building and move patients downstairs because it had a large, fairly new building. The pandemic has shown that in an emergency we need to make sure that the community-based estate is brought together in some way. Actually, that applies not just to the health service, but to ex-local authority or even Ministry of Defence or other Government Department estates. The place-based aspect of the Bill should be encouraging people to do that locally. Because estates are not part of it, they will struggle to deliver on the service intent of the Bill.

--- Later in debate ---

The schedule confers all the necessary powers and requirements to enable the ICB to discharge its general functions. I hope that the Committee will agree that it is therefore crucial to the establishment of ICBs and will ensure consistency in the arrangements across England. I therefore commend the schedule to the Committee.

[Justin Madders]

We will not divide the Committee on the schedule but as we have batted quite a lot of this about for a couple of days, it is worth reiterating some of our concerns in relation to how ICBs will actually work in practice.

Taking the Committee through the schedule, in paragraph 4 we have concerns about the chair having to be approved by the Secretary of State and, indeed, under paragraph 5 the chair can be removed by the Secretary of State, which could create tensions and speaks to the reality of how much autonomy these bodies will have. Paragraph 6(2) states:

“constitution must provide that a person is eligible to become or remain the chief executive only if the person is an employee of the integrated care board.”

That stands to reason, but the interim guidance on ICBs for the position of chief executive says that they must be employed or seconded to the ICB. Indeed, the chief finance officer, the director of nursing and the medical director can all be employed or seconded to the ICB, according to that guidance. We think that potentially represents a conflict of interest. It needs clarification, because what is in the Bill does not necessarily sit well with what is in the interim guidance. I wonder whether the Minister can clarify that.

Paragraph 7(1)(a) of the schedule talks about the constitution specifying who should be appointed as ordinary members. Again, the interim guidance helps in providing a list of suggestions regarding ordinary members. It is worth pointing out that, when we totted up all the people the guidance says are the minimum requirement for a board, it comes to 10 people. Although the Bill may say three, the reality is that the guidance says many more. Again, that speaks to the amendment that we tabled on Tuesday about the numbers on the board. The idea that the Bill is permissive is slightly betrayed by the detailed guidance. It depends on what is meant by “permissive”.

One particular mystery is in paragraph 7(3), which says:

“The constitution must set out the process for nominating the ordinary members”.

We know that ICBs will be able to set their own constitutions, approved by NHS England, but how the particular individuals on the boards will emerge still feels rather opaque. Of course, we hope that such things can be done by consensus and agreement. No doubt in the majority of cases they will be, but given the size of some of the areas it will be very difficult sometimes to get a geographical spread that represents the whole area and the various interest groups that constitute an ICB. Of course, diversity may also struggle to be accommodated within that. Such things are all fine and good in the Bill and in the guidance, but I think delivery on the ground will be slightly more difficult to achieve.

Paragraph 8 talks about qualification and tenure for membership of the board. I would be interested to hear the Minister’s comments on whether there is an optimal period of membership of a board. I think I saw two years somewhere in the guidance. I may be mistaken on that, but that seems a little short to me. I wonder whether he has a particular view on that. Paragraph 9 talks about constitutions being required to comply with any regulations that may come forward. Of course, the Bill has a lot of such clauses, where regulations will be produced in due course. I know this is slightly out of his control, but the Bill may not come back to us until much later in the year, if at all this year, depending on how the other place views it. That may mean that we are really down to the wire in terms of any enabling regulations that are needed under the Bill.

Paragraph 10 deals with the terms and conditions—a point that we discussed this morning. Paragraph 14 is quite interesting, because it talks about variation of the constitution, and how that should be done in consultation with NHS England. Indeed, NHS England will retain its own power to vary the constitution. It is important to put on the record that if such steps are taken to change the constitution, it is really important to involve stakeholders, the public, patients and workforce representatives. I hope that the Minister can fill me in on some of the details.

[Edward Argar]

I will try to address each of the shadow Minister’s points one by one, perhaps not in an entirely fluent way.

The hon. Gentleman asked about what he perceived to be an inconsistency between interim guidance and what is proposed in terms of secondees in similar employment. Actually, under paragraph 18(4) of schedule 2, the legislation allows for secondments to continue for those employed as chief executives. It specifies particular organisations, such as secondments from trusts, other parts of the NHS, such as NHS England, or indeed from the civil service. Given that specification, I do not believe that there is an inconsistency.

The hon. Gentleman touched on interim guidance and how that fits with what the Bill will look like once it is, as I hope, enacted. I would gently remind him that it is interim guidance—the key word being “interim”—to allow the continued evolution of ICSs at the moment, without pre-judging what the House may or may not do in terms of making them statutory. That guidance is there to allow them to continue on their path without having to sit and wait for the deliberations of the House on something that they are empowered to do and are already doing. I do not necessarily see the opacity to which the hon. Gentleman alludes but he may disagree.

The hon. Gentleman spoke about geography and the number of local authorities and other organisations involved. I suspect that he has got in mind his own particular geography of Cheshire and Merseyside and the size of the ICS there. That goes to the heart of why we are being permissive: we are setting out a minimum level, and therefore there is nothing to stop an ICS of that size, if it so chose, at ICB level to have a broader range of people sitting on it and a larger number. Each organisation will be able to judge what it thinks is the appropriate number of people to sit on its board to reflect the need for effective decision-making and effective local and organisational representation to reflect the broad geography of its remit.

The hon. Gentleman also asked about the optimal length of service on a board. I have to say in my experience, and I suspect in his from his days in local government, one sees a multitude of approaches in different public bodies. Some tenures are for two years or three years, or two years with a renewal presumed for another two years. I am not sure that there is a clear one size fits all, but there should be principles underpinning it, namely that one does not have someone who joins and never leaves the board, and one has to have the ability to refresh the board to bring in new skills. From my experience of sitting on various boards, including charity boards as a trustee or as a non-executive director, effective organisations need to conduct regular skills audits of their boards, to ask what has changed and what the organisation is lacking in the modern world. As time goes by, one needs different skills and different mixes of people. I would expect ICBs and ICPs to continue to look at what is needed to be at their most effective.

I hope that I have broadly addressed the main thrust of the hon. Gentleman’s points. The other points were those that he has quite rightly come back to, and which we debated at length when we considered his other amendments and those tabled by the hon. Member for Bristol South. On that basis, I encourage members of the Committee to support the schedule.

Question put and agreed to.

Schedule 2 accordingly agreed to.

Clause 14

People for whom integrated care boards have responsibility

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

[Edward Argar]

The clause requires NHS England to publish rules setting out which people each ICB is responsible for. We intend to recreate as closely as possible the arrangements that currently exist for clinical commissioning groups. However, CCG responsibility is based on a model of GP membership that will no longer exist under the new ICB arrangements.

The clause places a duty on NHS England to publish rules determining the responsibility of each ICB, subject to certain exceptions that may be created by secondary legislation. This is intended to replicate the ability to make exceptions to the responsibilities of CCGs by regulations in section 3(1D) of the National Health Service Act 2006. As with the existing regulations, the new regulations would be subject to the affirmative procedure of the House, which I hope offers some reassurance to the Opposition Front Bench in respect of the regulation-making powers. Therefore, there would continue to be strong parliamentary oversight of regulations under the clause.

Proposed new section 14Z31 ensures that no one slips through any gaps. The rules set by NHS England must ensure that everyone who accesses primary medical services, as well as anyone who is not registered with a GP but is resident in England, is allocated to a group of people for which an ICB is responsible. In practice, we expect NHS England’s rules to be framed in such a way that ICBs will be associated with certain GP practices, and responsible for patients registered with those specified GP practices. They will also be responsible for people who are not registered but are resident in the ICB geographical footprint.

Taking that approach is intended to ensure universality of coverage and to minimise the disruption of transitioning from CCGs to ICBs. The clause also provides a power to replace the duty on NHS England to publish rules dealing with ICB responsibility, with an alternative approach based simply on residency. If it is considered appropriate in the future, those new arrangements would mean that ICBs were responsible for those who usually reside within their specified geographical footprint. Regulations would be required in order to change that approach.

The clause provides the necessary certainty about which ICB is responsible for which people. Without it, there could be significant confusion about ICB responsibilities, difficulty in calculating financial allocations to ICBs based on those they are responsible for and uncertainty for providers about which people they are contracted to provide services to. The clause seeks to provide fluent continuity with the arrangements under CCGs, and explicitly does not allow people to fall through gaps. Ultimately, everyone will be the responsibility of an ICB and will be able to access care when they need it. I therefore commend the clause to the Committee.

[Justin Madders]

I will make some comments on clause 14. I think the Minister has anticipated to some extent what I might say. I may well drift into clause 15 as well, but I promise the Committee that I will not repeat those comments in the discussion on clause 15. There is clearly an overlap here. It really is about the issue that the Minister referred to: who is entitled to what within the comprehensive NHS? For some, this is a formality, repeating the language used before and the principles on which the NHS was founded. For others, every word change and new clause that appears in the legislation is an attempt to restrict access and allow an opening for cuts to services to be made in a time of immense financial pressure. We want, and I think the Minister has opened the door to this, to ensure that that is not what the Bill is about.

To be fair, there is a history of commissioners trying on occasions to restrict access. There was the Croydon list of some 20 years ago. Primary care trusts set out lists of services and said that the treatments had little or no value and should not be provided on the NHS. Of course, that led to huge debates between trusts and medical practitioners. It could be argued that people were defending their own particular practices and specialties, or they could be said to be champions of the NHS. Patients looked at it from both perspectives, but for the patients who relied on those services it was a very real debate and a very real source of anxiety.

A more recent argument on this came from the various attempts to apply NHS charges to certain people who it was argued were not eligible for free treatment. There is a very sinister echo of the phrase “no access to benefits”. The long-held consensus appeared to be under threat—the principle that emergency NHS care is open to all. When American tourists come over here and have to seek emergency treatment they are pleasantly surprised, and somewhat bemused, that they do not have to produce a credit card at the point of use. This is where the arguments begin to arise.

If a patient is moved from an emergency bed for elective care, they can be charged if they are ineligible for free NHS care. The usual test is whether they are ordinarily resident in the country. On principle, if someone qualifies for NHS treatment, they can get it anywhere in the country, while on holiday. Most of us have taken our breaks this year somewhere in this country. We do not have to go back to our own local A&E to get treatment. We could, in theory, get our elective operations anywhere in the country, should we wish. Pre-Lansley this did not matter as much, because it was always payment by results. Ambulances crossing borders may occasionally result in a cross-organisational internal charge. Maybe we will see an end to that kind of bureaucracy.

The other argument that emerged during the Lansley period was around who the responsible commissioner within a particular area or population was. That market approach required tying people to a GP practice. The GP register has been a central base from which decisions were made. Did that really affect things on the ground? It certainly caused a lot of debate. It would be helpful if the Minister provided clarity.

The issue of access is important, and clause 14 sets it out in subsections (1), (2)(a) and (2)(b) of proposed new section 14Z31 of the National Health Service Act 2006. According to the NHS, access is universal, but depending on their immigration status within the UK, a person may be charged for accessing certain services. However, certain services are free to everyone: treatment given in an A&E department, though this does not include further treatment following admission to hospital; treatment for certain infectious diseases, but for HIV/AIDS only the first diagnosis and counselling that follow are free; compulsory psychiatric treatment; and family planning services, but this does not include termination of pregnancy or infertility treatments. People ordinarily resident in the UK or who have an exemption from charging will not be charged for NHS treatment. I could go into what ordinarily resident means, but I will not detain the Committee by going through all of that. However, it is fairly clear that it can be a British citizen or someone naturalised or settled in the UK, usually known as having indefinite leave to remain.

The Bill does not cover any of this, but there is a point about it not necessarily being the same person paying for and receiving the treatment. There are questions about those seeking asylum and those who might be denied care because there are questions about where they live. There was the image of a paramedic stepping out of an ambulance and asking someone suffering a cardiac arrest whether they had some kind of identification to prove that they were ordinarily resident. The images are not common ones, but they raise concerns. When the 2012 Act was debated, these issues were discussed at great length. I do not think the fears that were expressed at the time have manifested themselves. Does the Minister believe that using “usually resident” is better than “ordinarily resident”? I also wonder whether under proposed new section 14Z31, the NHS will publish rules as referred to. Could we have clarification on that?

[Edward Argar]

I will respond very briefly. The shadow Minister raises two key bundles of points. I hope that I can reassure him that the approach adopted here is far from restricting access. It is designed to ensure that everyone has an ICB covering them, ensuring universality of coverage. Similarly, the clause does not alter in any way the ability of anyone to access emergency care when they need it, nor those ordinarily resident in the UK to use the NHS as they do.

The second bundle of points he made related to charging regulations and those who are eligible to be charged under current regulations. While he highlighted a number of points, I genuinely believe that the charging regulations in place are appropriately and reasonably framed and strike the right balance in ensuring that people can access NHS care, while rightly making a contribution to the services they are accessing—obviously with certain things exempt from charging for public health and other reasons. I do believe they strike the appropriate balance. There is nothing in what we are proposing today that fundamentally changes people’s ability to access healthcare, nor indeed changes those charging regulations. On that basis, I commend clause 14 to the Committee.

Question put and agreed to.

Clause 14 accordingly ordered to stand part of the Bill.

Ordered, That further consideration be now adjourned. —(Maggie Throup.)