Justin Madders
Main Page: Justin Madders (Labour - Ellesmere Port and Bromborough)Health and Care Bill (Nineteeth sitting)
Justin Madders ExcerptsWednesday 27th October 2021
(3 years ago)
Public Bill CommitteesRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 27 October 2021 - (27 Oct 2021)
The Chair
I thank the hon. Lady for her point of order. I should point out that this is not a matter for the Chair. Mr Speaker has encouraged everyone to wear masks when they are not speaking. It would be extremely helpful if people were to abide by that. The hon. Lady’s point is on the record and I am sure it will be drawn to Mr Speaker’s attention.
Justin Madders (Ellesmere Port and Neston) (Lab)
Further to that point of order, Mr McCabe. I understand that it is out of your hands, but this is an important matter for the safety not only of Members but of all staff here. We are in a smaller room than we have been recently, so circulation is probably not as good as we would like. When was the most recent risk assessment on this Committee meeting, and what did it say about the wearing of masks?
The Chair
I have just been advised that there was a statement from the Commission yesterday, but I do not believe there has been a specific assessment in relation to the Committee meeting in this room or any update on that. Again, I point out to the hon. Gentleman that it is not an issue for me. His point is on the record and it will be drawn to Mr Speaker’s attention. I am not sure there is a great deal more that we can achieve at this stage.
Justin Madders
It is a pleasure to follow my hon. Friend the Member for Bristol South, who gave a superb analysis of why the new clause is important and she picked up on many of the themes that we have already debated. The topicality of NHS senior management is there for all to see, with some of the recent headlines being orchestrated to divert from the growing waiting list crisis in the NHS.
Our view is that NHS senior management cannot be all that bad because they have seriously outperformed the private sector on efficiency for nearly a decade. If the NHS is one of the most efficient services in the world as many international studies have demonstrated, that is a credit to the managers who form a relatively small proportion of the overall workforce. I hope the Minister will join us in congratulating NHS managers, along with all the other brilliant staff, who have got us through the pandemic over the last 18 months—although, as we know, we are not through it yet. The contrast with some of the political decisions made has been exposed recently by the joint report by the Health and Social Care Committee and the Science and Technology Committee.
As we have discussed on a number of occasions, the Bill seems to specialise in the centralisation of power, with more and more being explicitly given to the Secretary of State. Do we want the Secretary of State appointing every chair, non-executive and chief executive, even in bodies that are meant to be independent from the Department? Amendment 18, which we debated earlier, would have gone some way to addressing that: alas, it was not to be. This is a serious issue that needs tackling. My hon. Friend is an expert on these matters through her own knowledge and experience, and I absolutely support what she has said.
While good governance might sound a little cheesy, I am sure that we could spend a lot of time discussing what exactly this new clause should be called.
I think we can all understand what good governance means and what it should look like, because we have certainly seen what it does not look like in how the Department operates at the moment. As my hon. Friend said, there was something similar in place previously, before it was burned in the bonfire of quangos under the coalition Government. Something should be in place, be it a revitalised appointments commission or even some independent standing committee or panel—something that has independent oversight of these very senior positions.
As we have said before, we would like more direct democracy in our integrated care boards. We are not going to get that, by the looks of it, but we would at least like some independence in appointments. When my ICB chair is finally appointed, I want him or her—it is a “him” at the moment, and it is an interim position—to be looking outwards, not upwards to NHS England all the time. That is something that a good governance panel would help facilitate.
A fit and proper person test should be applied independently, even to get on a shortlist, and there should be some process for removing those who should not be on there. This needs to be applied by people who are independent and competent, and not people who are already on the lists or making the appointment decisions. Perhaps we should even have some people who have oversight of how people in senior positions are appraised, trained and supported. There is a lot of experience and expertise out there that we could harness. I hope that, whatever this body ends up looking like, it can assist the NHS in dealing better with issues such as diversity, succession planning and leadership—all areas on which we can always strive to do better.
I hope that nobody mentions bureaucracy or cost as an excuse to leave things as they are. We know from published NHS experience that having an appointments commission was not really an overhead; in fact, it was a valuable resource that, in the end, saved money. We know how much it costs to replace someone who has proved unsuitable, and to undo the mistakes that they made. Appointing the right people in the first place is the best solution. The Minister will, of course, be aware of the importance of recruitment and retention across the whole NHS. I think that we can do more in respect of senior leadership roles.
As my hon. Friend the Member for Bristol South said, transparency is key throughout the systems. Where the funding goes is a key question that will become even more key as we move into the ICBs, with larger areas and different funding streams merging into one. Transparency will be important there. Of course, there will be local differences, as she said, but there should still be accountability to someone for where that money goes and who is taking those decisions. We have what we have described as a permissive approach to running ICBs at the moment, but that does not mean that we cannot have transparency and accountability. That is why we support the new clause.
The Minister for Health (Edward Argar)
It is nice to see you back in the Chair, Mr McCabe. I am grateful to the hon. Member for Bristol South. Although we may not fully agree, again I take the new clause in the spirit in which she tabled it. I will reflect on what she said, but I will also set out why I cannot accept what she is proposing. I will always reflect on what she says and proposes; when she proposes things, they are well thought out. We may come to different conclusions, but the points she made are certainly deserving of reflection. I can give her that assurance up front.
As in our oral evidence sessions, I join the hon. Lady and the shadow Minister in paying tribute to those in our amazing NHS and care workforce. It is also important that we recognise, as I think she said during questioning of witnesses, that the complexity of the organisations we are talking about—the complexity of an acute trust, for example—means that strong and effective leadership, both financial and administrative, are hugely important to the overall success of the enterprise of our NHS. I therefore join her in paying tribute to those staff who often find themselves, particularly in media commentary and similar shorthand critiques, on the receiving end of criticism. People may ask, “What are they there for?”. They are hugely valuable—just as much as frontline clinicians, nursing staff and those who work in the canteens or clean the wards. It is a team.
Edward Argar
Although I do not always agree with the hon. Lady, I find myself in complete agreement with her. She made a couple of points that referred back to those made by the hon. Member for Bristol South. The hon. Lady is absolutely right that the system needs high-calibre, high-quality people with the right skills, particularly given what we are seeking to do with integrated care systems. We must foster an environment in which those high skills are valued, continually reinforced and refreshed.
On the point about the Kark review, the hon. Member for Central Ayrshire is right. How should I phrase this delicately? People may move on, or be moved on, from posts because it was not a success for whatever reason; I will phrase it like that. We need to look at the challenge posed by those people suddenly reappearing in another equivalent senior post in a different part of the country. There may be a reason why someone has not been a success that is not due to particular circumstances or something beyond their control, and we need to look at the recycling of those people who have not been found to have hit the mark. We need to look at that carefully.
Edward Argar
I see the look on the shadow Minister’s face, which makes me wonder what is coming.
Justin Madders
I am not trying to catch the Minister out. I can think of a specific example where what he mentioned has happened. I am, frankly, angry that this individual has been able to do that. What does the Minister think can be done to ensure that the revolving door is shut on those whom it deserves to be shut on?
Edward Argar
The shadow Minister is right. It is a challenge, and it is something I continually reflect on, because it intersects with legal employment rights, the nature of the terms on which someone leaves, how these matters work and the fact that NHS trusts around the country are individual. It is not a simple issue. It is one that I continue to reflect on. I hasten to add that it is not just the shadow Minister but Members from both sides of the House who have, on occasion, raised the issue. It requires further thought and reflection.
New clause 8 would involve creating a new special health authority, effectively, to provide independent oversight of NHS appointments. I recognise the importance of such appointments, and everyone would agree that good governance arrangements should and must be in place for managing them. Appointments to NHS trusts, NHS England and special health authorities are public appointments; they are managed in line with the principles of the governance code for public appointments and are regulated by the Commissioner for Public Appointments. The chair of an ICB would be appointed by NHS England, with the approval of the Secretary of State. That reflects a point that has been considered on a number of occasions during the passage of the Bill, namely that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, Parliament, as part of a national health service.
I acknowledge what the hon. Member for Bristol South said about the need for people to be answerable and responsive to their local community. The counter-challenge is avoiding the fragmentation of the national health service and the vertical arrangement. She mentioned police and crime commissioners, and although our police forces operate in a similar way, the difference is that we have never had a national police force. Each force is based on a county—or a city, in the case of the Metropolitan Police Service—and works on a locality basis, as local authorities do.
Justin Madders
This is a slightly cheekier question than my last one. Has the Minister conducted a similar exercise in his own Department?
Edward Argar
In respect of Ministers or senior civil servants? When it comes to Ministers, though I suspect that is not the point he wishes to push—
Justin Madders
I think we can see who the Ministers are, at least this week. I was referring more to the senior civil servants.
Edward Argar
I like to think that I am a constant in the Department, this week and in previous weeks. It is piece of work that we have done. If one looks at the very senior civil servants—the directors general and permanent secretaries—there is a good gender balance. He is absolutely right, however; having assumed responsibility for workforce more broadly a few weeks ago, it is a piece of work that I want to do. I was responsible for the implementation of the Lammy review and race disparity audit when I was at the Ministry of Justice, and it is an interest that I have taken with me to my new Department. The last year has been a little bit busy, but it is something of which I have not lost sight.
I do not believe that it is necessary to create a new body to oversee appointments, given that good governance arrangements are already in place. I therefore remain unconvinced by the argument. As ever, and as behoves me when the hon. Lady proposes something, I will continue to reflect on it carefully.
The Chair
Therein lies a lesson for us all.
Clause, by leave, withdrawn.
New Clause 11
Consultation with staff and patients on service changes
“(1) The Secretary of State must consult staff, staff representatives and patient representatives on any changes in services which fall within the definition of reconfiguration of services or which impact on the roles of more than 20 staff and publish the results of the consultation.
(2) NHS England, ICBs, NHS Trusts and FTs must publish a response to the results of consultations undertaken under subsection (1) and have due regard to the outcome of any consultation.
(3) Where significant changes to services are proposed by any NHS body, that body must produce a business case using the Five Case Model recommended by Her Majesty’s Treasury, or other requirements as set out in guidance prepared and published by the Secretary of State under this section.
(4) The business case mentioned in subsection (3) must be published for consultation and the responses to the consultation taken into account when a decision is taken whether to implement the change.”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
We have wandered down the avenue of reconfiguration before in this Committee, and I am sure that we will do so again. The Opposition have been far from reassured about the Secretary of State’s ability to intervene at any moment when there is the slightest hint of movement in a podiatry clinic or a change of hours at a walk-in centre, but that is where we are.
We all know that in a few more White Papers’ time, there will be more changes in the NHS and in social care, and possibly more integration—who knows what is in store for us? There will be changes in the way that services are delivered, with, we hope, the aim of making them better. For more than three decades, there has been an acceptance that changes to services can be of vital interest to the patients who receive them and the staff who deliver them.
The Committee has already discussed several times the importance of involving people in those debates, and there is an acceptance that there must be a process that engages with patients and all service users. That is what we are trying to achieve through new clause 11. I hope we all agree that any proposals to change the way that services are delivered have to be subject to consultation with patients and, as we have seen in other parts of the Bill, with carers. I hope that we start from that uncontentious common ground. The big issue is just how well that consultation is delivered in practice.
At this point, I take the Committee to the Cabinet Office guidelines of 2018 and the consultation principles, particularly paragraph D, which states:
“Consultations are only part of a process of engagement. Consider whether informal iterative consultation is appropriate, using new digital tools and open, collaborative approaches. Consultation is not just about formal documents and responses. It is an on-going process.”
The NHS does not always understand that they should consult before making a decision, and not on a decision that has already been made, using consultation as a tick-box or rubber-stamp exercise. Genuine consultation, with open dialogue on both sides, before decisions are made almost always results in a better decision in the end.
Of course, the Minister will tell us that the NHS constitution talks about those things and pledges,
“to engage staff in decisions that affect them and the services they provide, individually and through their representative organisations and local partnership working arrangements, and empower all staff to suggest ways to deliver better and safer services for patients and their families.”
That is a pledge, not a requirement, and those fine words are often ignored when it comes to consultations with staff groups.
Even the Health and Social Care Act 2012—the Lansley Act—accepted that there were issues, because it states:
“In exercising functions in relation to the health service, the Secretary of State must have regard to the NHS Constitution.”
Having due regard to the constitution also formed part of the licensing conditions for NHS Providers.
We know what “due regard” means and we have already debated its limits. We know that it means that there must be some sort of formal documentation to demonstrate that consideration has been given to representations. Even that sometimes does not happen, or it happens after a decision has been made. On a number of occasions, no attempt has been made to empower staff and proactively ask for their views on how to deliver the service in a better or safer way for patients. A decision is made and presented as a take it or leave it.
A helpful factsheet that was issued for the 2012 Act states:
“Our reforms will enable change to be driven from the bottom-up, by the clinicians who know the health needs of their patients best, and underpinned by proper local engagement, partnership working and effective local authority scrutiny.”
I draw the Committee’s attention to the words “partnership working”. Again, the NHS can do better in respect of that.
In the new clause, we are trying to codify something that the NHS should be doing anyway when we look at the documents, guidelines, explanatory notes and good intentions, but on a number of occasions fails to do. We therefore move from “due regard” to an actual requirement. That is a beacon of best practice, which we should aim for rather than watering it down. What harm can it do? What is the disbenefit of involving the people who know the service best and deliver it on the ground? That is why there must be consultation with patients, their carers and staff.
The latter part of the new clause provides that there has to be an agreement to provide a business case. Any significant proposal should have a business case attached to it. Paragraph C of the Cabinet Office guidelines states:
“Give enough information to ensure that those consulted understand the issues and can give informed responses. Include validated impact assessments of the costs and benefits of the options being considered when possible; this might be required where proposals have an impact on business or the voluntary sector.”
It stands to reason that giving people the full pictures means that they can give a fuller and more informed response. That is at the heart of the new clause. It will mean delivering better outcomes, better services for patients and better engagement with staff. If we refer back to the evidence sessions––gosh, some six weeks ago; it seems longer but it was only six weeks––this was one of Unison’s highest priorities. Witness Sara Gorton said of principal staff involvement
“I think trade unions and staff would feel as though they had a stake and would be reassured that they had involvement in future decisions with workforce implications made by those new bits of the system if that pledge were placed in the legislation and were the underpinning principle.”––[Official Report, Health and Social Care Public Bill Committee, 9 September 2021; c. 93, Q119.]
That is what we are seeking to do here.
It goes without saying that any significant service change should have the business case disclosed, as we discussed earlier with the new clauses tabled by my hon. Friend the Member for Bristol South. Business cases are where proposals are developed and where challenge, and teasing out of alternatives and improvements, can be found. That is the heart of what good consultation should be. We value our staff and the input they can have. We value the impact that service changes can have on patients and the importance of involving them at an early stage with full information. That will improve decisions in the long run and that is why new clause 11 should be supported.
Edward Argar
I am grateful to the shadow Minister for giving us the opportunity to debate this issue further. As he suggested, we have touched on it at various other points in the passage of the legislation, but it is right that we debate it again.
The new clause would require the Secretary of State to consult staff, staff representatives and patient representatives on any reconfiguration of services or any service change impacting more than 20 staff. NHS bodies would be required to publish their response to the results of any such consultation and an NHS body proposing significant changes to services would need to produce a business case in a specific model to be published for consultation.
Health service bodies are already under wide-ranging duties on public involvement and consultation on proposals for changes in commissioning arrangements and the reconfiguration of services set out under the National Health Service Act 2006 and regulations made under the Act. In addition, the current guidance issued by NHS England makes clear the importance of engagement and appropriate consultation. That approach will continue to be reflected under new guidance produced under the reconfiguration provisions in the Bill, set out at paragraph 8 of new schedule 10A inserted into the 2006 Act.
Guidance can provide a level of detail that is not always suited to inclusion in primary legislation and allows for flexibility so that the system can work as efficiently as possible. That approach has worked well under the current reconfiguration system and guidance has played an important part. The Government are unconvinced that there is a need for an additional duty to consult patients’ representatives when NHS commissioners and providers must already involve service users in any proposals to change health services delivered to those users and which service users can access.
Moreover, it would not be appropriate for the Secretary of State to carry out a consultation for each reconfiguration or service change affecting staff. To run national consultation for every local change would be disproportionate. It would not be the best use of resource or lead to the local level of engagement that is so important. It is right that NHS bodies responsible for arranging for or providing health services should lead the consultations on proposed changes. These should be done primarily at local level with local expertise. There is always a challenge between the national and the local. I was not quite sure whether the hon. Member for Bristol South was alluding to that when she said that she was more Morrison than Bevan, and suggested that I was more Bevan than Morrison in my approach. Neither comparison has been made about me in the past, but when I next see her, I will ask. There is a real challenge in the local-national balance that runs through several clauses and in respect of the way the NHS has operated for decades.
The new clause would require consultation not just of patients but of staff and staff representatives. Staff views are of course vital in the design of service changes. That is made absolutely clear in the current guidance issued by NHS England, which repeatedly emphasises the need to involve clinicians whose practices would be affected by proposed changes. This approach will not change in the future, and updated guidance will continue to reflect that position and ensure that affected staff provide meaningful input.
Justin Madders
We are not going to push the new clause to a vote, because we recognise when the Minister is not for turning—I am not sure whether he likes that comparison. But I have a couple of reflections on what he said. He was obviously very keen that the Secretary of State not get involved in lots of consultations, but of course he gives himself the power, under the Bill, to do that in relation to any reconfiguration of any size, anywhere in England. That does, I think, highlight a little bit of inconsistency.
The Minister said that there was plenty of guidance and the Government did not want the inflexibility that putting something in legislation would develop. We take the view that actually what we are trying to show is that the guidance does not work to the extent that we would want it to, which is why we think that having something in legislation is an important baseline. It does not prevent further guidance and flexibility from being built in on top of that. I know when we are not going to persuade the Minister, but I think that this is a matter that we will need to return to many times. I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
New Clause 12
NHS as the preferred provider of NHS contracts
“(1) The NHS is the preferred provider of NHS contracts.
(2) NHS contracts must be provided by NHS suppliers unless the NHS supplier is unable to fulfil the terms of that contract.
(3) Where the NHS is unable to fulfil the terms of a contract, a competitive tender must be held to identify an alternative provider.
(4) For the purposes of this section—
(a) ‘alternative provider’ means private companies and independent sector treatment centres, and
(b) general practice and GP-led community services are NHS suppliers.”—(Justin Madders.)
This new clause would establish NHS suppliers of services as the preferred providers of NHS contracts. Independent sector providers could hold NHS contracts after winning a competitive tender.
Brought up, and read the First time.
Question put, That the clause be read a Second time.
Alex Norris
That is a very kind offer and I am almost certainly going to avail myself of it. On that basis, I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 16
Licensing of beauty and aesthetics treatments
“(1) No person may carry on an activity to which this subsection applies—
(a) except under the authority of a licence for the purposes of this section, and
(b) other than in accordance with specified training.
(2) Subsection (1) applies to an activity relating to the provision of beauty or aesthetics treatments which is specified for the purposes of the subsection by regulations made by the Secretary of State.
(3) A person commits an offence if that person contravenes subsection (1).
(4) The Secretary of State may by regulations make provision about licences and conditions for the purposes of this section.
(5) Before making regulations under this section, the Secretary of State must consult the representatives of any interests concerned which the Secretary of State considers appropriate.
(6) Regulations may, in particular—
(a) require a licensing authority not to grant a licence unless satisfied as to a matter specified in the regulations; and
(b) require a licensing authority to have regard, in deciding whether to grant a licence, to a matter specified in the regulations.”—(Justin Madders.)
This new clause gives the Secretary of State the power to introduce a licensing regime for cosmetic treatments and makes it an offence for someone to practise without a licence. The list of treatments, detailed conditions and training requirements would be set out in regulations after consultation with relevant stakeholders.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
It will be noted that new clause 16 has attracted considerable support from a wide range of Members across the House. I pay tribute to the beauty, aesthetics and wellbeing all-party parliamentary group, whose work in the area has been influential in producing the new clause. Many of the Members who put their name to it are also members of that group. I pay tribute to a constituent of my right hon. Friend the Member for North Durham (Mr Jones), Dawn Knight, who has been assiduous in this area, as has my right hon. Friend himself. Their tireless campaigning, which I suspect will continue for some time, has been vital so far. This is such an important area and it needs an awful lot of attention. We know there is a lot more to be done.
As we know, cosmetic treatments can include a wide range of procedures aimed at enhancing or altering appearance. Many common treatments are offered on the high street and include lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and—one that we are more familiar with—tattoos. Perhaps one day the Minister will show us all of his. If the Minister wants to respond on that point, he is more than welcome to.
Justin Madders
Many of these procedures are becoming increasingly popular. There is a well-articulated concern that non-medically and medically trained practitioners are performing treatments without being able to evidence appropriate training, or the required standards of oversight and supervision. One need only look on Facebook, for example, to see the proliferation of adverts for all types of treatments. These are usually done by unlicensed individuals who call themselves doctors. We have talked recently about the lack of proper regulation of social media. Although such a debate is not for today and falls outside the scope of the new clause, it is a matter that also needs to be addressed.
Cosmetic treatments can cause serious harm if not carried out correctly, in a safe environment and by competent, trained practitioners. Anything that punctures the skin carries the risk of the transmission of blood-borne viruses. There are countless tragic stories of people who have had life-changing injuries and conditions as a result of poor treatments. The amendment seeks to put the protection of the public at the forefront by giving the Secretary of State power to bring into force a national licensing scheme for cosmetic procedures. It would be a departure from the wild west we face at the moment. We recognise that significant research and engagement with all stakeholders would be needed to develop a scheme that will work well for all cosmetic treatments, as well as providing a practical and efficient system that will be understood and adhered to by members of the public, regulators and practitioners.
Any new scheme would have to have some flexibility in order to capture new cosmetic treatments coming on to the market in future. It would need to be able to set standards for training, qualifications and competency requirements of practitioners, including, we think, periodic checks of premises. Importantly, it would provide for continuous professional development of the practitioner. There would be a requirement for indemnity insurance and access to redress schemes for members of the public to be provided, should complications arise as a result of any aesthetic procedure. There are a number of sad stories about supposedly reputable companies doing damage to their customers, going into liquidation and their insurers then refusing to pay out. I do not think any Member wants to see that happening anymore if we can do something about it.
We would hope that any licensing scheme would have the characteristics that I have set out, and there would be accompanying sanctions for those who contravene it. At present, there is no provision to ensure that prescription-only medicines, such as Botox and anaesthetic creams, adrenaline and hyaluronidase, which are prescribed by regulated prescribers, are actually prescribed in accordance with safe practice. For example, beauty therapists are reliant on registered prescribers prescribing injectables, such as Botox, which they are unable to obtain without a prescription.
Although doctors are required to have a face-to-face individual assessment of each service user prior to prescribing to third parties, such as beauty therapists, a significant body of evidence exists to confirm that individual assessments are not actually taking place in many cases and that telephone prescriptions are being provided remotely. The proposed licensing scheme would provide a requirement for all prescribers to be officially named and to operate in accordance with required practice standards.
Of equal importance is the need for a licensing scheme to close the loophole that currently exists relating to the import of unlicensed injectable products from Korea, such as Botulax. There is a registration scheme in England for certain specialist treatments, such as electrolysis, tattooing, piecing, semi-permanent make-up and acupuncture. However, some of the riskier and newer types of cosmetic treatment cannot be included within the scope of the current regulatory regime. The system also does not allow regulators to specify conditions, qualifications or competency requirements, or to remove anyone from the practitioner register.
Only a small handful of areas across England have introduced their own licensing schemes in order to protect the public—London, Nottingham and Essex are notable examples. There are currently two Professional Standards Authority-approved voluntary registers of accredited practitioners, and one voluntary register of approved education and training providers that operate in the sector. However, joining is not mandatory, which means there are many unaccredited practitioners providing treatments to members of the public without any checks.
The creation of a national licensing scheme in England for practitioners of cosmetic treatments would ensure that all those who practise are competent and safe for members of the public, and it would also cover some of the newer practices not covered by existing licensing laws. There is a large body of support for such a move, including the Chartered Institute of Environmental Health, the Royal Society for Public Health, the Institute of Licensing, the Joint Council for Cosmetic Practitioners, the UK Public Health Network, the Faculty of Public Health and Save Face, as well as about 90% of the public, accordingly to at least one survey.
The Minister is keen on giving the Secretary of State additional powers, but I know that he is also keen on finding savings wherever possible. Were he to support this new clause, there would undoubtedly be a saving to the wider NHS in the long run—for example, through reduced visits to A&E and GPs to correct mistakes made by poorly trained and unregulated practitioners.
Here are some examples of the impact on the NHS of that lack of regulation: outbreaks of infection at skin-piercing premises, resulting in individuals being hospitalised and, in some cases, disfiguration and partial removal of the ear; second and third-degree burns from lasers and sun beds; allergic reactions due to failure to carry out patch tests or medical assessments, which have led to hospitalisations; and blindness in one eye caused by the incorrect administration of dermal fillers. Those are all tragedies for the individuals involved and mistakes that could be avoided. They are a cost to the NHS and to wider society. I believe that a system of licensing would put a stop to a lot of those tragedies.
Dr Whitford
I rise to support the new clause. As a surgeon working in general surgery, I know that, as many of these new techniques emerged, the pressure on the NHS became obvious—for example, as a result of local infections and extensive necrosis. Fillers can also migrate. That might seem a minor side effect, but it can create a lot of psychological and mental health distress for the person who went ahead with the procedure and ended up disfigured because the filler was incorrectly administered. Botox has become ubiquitous, but we should remember that it stands for botulinum toxin, which is one of the most dangerous toxins on the planet. It is used in tiny doses, but it can still cause problems if incorrectly administered.
In addition to these aesthetic techniques, which have become extensive because they appear minor and are often delivered by people without significant training—part of their danger is that they are projected to the public as being very simple techniques—we have the issue of more extensive cosmetic surgery, such as breast surgery, abdominal uplifts, liposuction and so on, which involve anaesthetic—often a general anaesthetic—and major intervention. The public think that plastic surgeons and cosmetic surgeons are the same. Although a plastic surgeon, who is a trained and licensed NHS surgeon, may also carry out cosmetic surgery, there are many clinics providing cosmetic surgery that is not carried out by plastic surgeons. Here the side effects and repercussions for a patient can be quite extensive, and indeed they have previously led to loss of life, which in some cases has been well publicised.
If this issue is taken forward, I would like to see a recognition that both these minor aesthetic interventions and cosmetic surgery should be regulated.
Edward Argar
I am grateful to the hon. Member for Ellesmere Port and Neston for bringing this discussion before the Committee today, and I join him in paying tribute to my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) and the right hon. Member for North Durham. I know that both are tenacious campaigners, and both are due to meet me in the coming days to discuss their work in the context of the all-party group and the constituency case, exactly as the hon. Member for Ellesmere Port and Neston mentioned.
I also pay tribute to my hon. Friend the Member for Sevenoaks (Laura Trott) for her success, within a year or so of coming to this place, in getting her private Member’s Bill through. It imposed some further restrictions in relation to botulinum toxin treatments or procedures, particularly in terms of the age limit from which they could be undertaken.
This new clause would give the Secretary of State the power to introduce a licensing regime for beauty and aesthetics treatments, and make it an offence for a cosmetic practitioner to practise without a licence. I appreciate the intention behind the new clause, and I am sympathetic to its intended purpose. As we are aware, cosmetic treatments are an ever-expanding, multi-million pound industry, and we need to ensure that that industry operates in a safe way.
The breadth of the recent beauty, aesthetics and wellbeing all-party group inquiry into non-surgical procedures, which the shadow Minister alluded to, demonstrates that this is an extremely complex area to tackle and address. There is a huge range of non-surgical cosmetic procedures available, which vary in their level of complexity and invasiveness. The Government are carefully considering the findings of that report and the need for additional regulation in this area in the light of it.
We are considering the case for a licensing system alongside the other specific, and in some cases more narrow, recommendations made in the all-party group’s report. As part of that, we need to work further with stakeholders and within Government to clarify the scope of any further regulation and which procedures it might apply to. The private Member’s Bill introduced by my hon. Friend the Member for Sevenoaks came into force at the start of October. It prohibits the availability of botox and dermal fillers to under-18s, apart from in a very narrow set of defined circumstances. We will consider the impact and effectiveness of this important legislation in parallel with the all-party group’s report in assessing whether to expand further the role of local authorities in overseeing cosmetic procedures.
I reassure the Committee that my priority is to ensure that the right regulatory framework is in place to provide consistent and high standards of practice, and the Government are committed to improving the safety of cosmetic procedures through better training for practitioners and clear information so that people can make informed decisions about their care. I hope I can reassure the Committee that we are actively considering whether increased oversight of practitioners performing some of the most invasive non-surgical procedures is the right way forward, and one that we could work with.
We continue to explore carefully how to achieve a proportionate system of practitioner regulation. The all-party group’s report is a very valuable contribution to that work and that active assessment. As soon as that work has been done, we will look to determine the need for and scope of further regulation in this area, and we look forward to reporting our conclusions from that assessment in early 2022. I therefore encourage the shadow Minister not to press the new clause to a Division, and I invite him to work with us in looking at the issue.
Justin Madders
I am encouraged by what the Minister has said. I am pleased to hear that he is meeting the right hon. Member for Romsey and Southampton North and my right hon. Friend the Member for North Durham shortly, and that we will hopefully have some progress on this in the new year. In the light of that information, I beg to ask leave to withdraw the clause.
Clause, by leave, withdrawn.
New Clause 17
Secretary of State’s duty to maintain safe staffing levels
“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—
‘1GA Secretary of State’s duty to maintain safe staffing levels
The Secretary of State has a duty to maintain safe staffing levels in the health and care service in England.’”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
This is a probing new clause, and I will not press it to a vote. I am not sure that this is the best legislation for it, but we are trying to make some points about the importance of patient safety. I hope we can all agree that for good care to be central, there need to be enough staff, not just notionally through some measure of the number of posts, but by ensuring that those people are actually in place at the time of giving care. We can have a debate about what level of staffing is enough. For a long time, the issue was left to the good sense of managing clinicians but, of course, that has always been strongly impacted on by the level of budget that could support staff.
Across the world, much attention has been placed on setting out what levels of staff and skill are needed in various settings to achieve the required levels of safety. The debate is not at any fixed point in time, because pathways, models of care, and staffing skills and mixes develop and evolve, but there will always be a correlation between safe staffing and levels of funding. It is a sad fact that our NHS, which should find planning easy as a single national system, has struggled for some time in almost every of aspect of workforce planning. It has shied away from asking questions about safety that come when the available workforce is not matched to the resources. At the end of the day, it is the patients who lose out when we are in that situation.
Much of the discussion on this topic historically has focused on the nursing workforce, which is by far the biggest of the staff groups. The Royal College of Nursing put out guidance pre-covid and during covid and set out where the legal responsibilities lie. It also pointed out recently:
“These are unprecedented times. Nursing staff in almost all settings are facing challenges beyond what were ever expected. Staffing levels are poor in many places, on most shifts and care is being compromised as a result”—
“care is being compromised” can be read to mean unsafe staffing levels.
New clause 17 calls for a duty to be placed on the Secretary of State to ensure that there are in fact safe staffing levels, even if there is not a specific legislative requirement in England. I say in England because in Wales, Labour has led the way with the Nurse Staffing Levels (Wales) Act 2016. In Scotland, the Health and Care (Staffing) (Scotland) Act 2019 became law, although I understand that covid has meant that there has been some delay in its implementation. I also understand that Scotland included social care staff in that remit.
A decade ago, research showed that low levels of nurse staffing are linked to worse patient outcomes and unsafe conditions. Before 2013, decisions to assess and review staffing levels were made locally, with little national guidance. However, the Francis inquiries in 2010 and 2013 identified nurse staffing as a patient safety factor that contributed to the care failings identified at Mid Staffordshire NHS Foundation Trust. They highlighted that decisions about nurse staffing were made without full consideration of the risks to patient safety. Francis said:
“So much of what goes wrong in our hospitals is likely, and indeed it was, in many regards, the case in Stafford, due to there being inadequate numbers of staff, either in terms of numbers or skills”.
In response to that statement and the Francis inquiries, the Department of Health developed four strands of policy that aimed to create safe nurse staffing levels in the NHS. The National Institute for Health and Care Excellence published guidance for safe staffing in all NHS acute hospitals in 2014. It endorsed the safer nursing care tool to help hospitals to plan their staffing. There was a National Quality Board report outlining the principles that NHS trusts were expected to apply in relation to planning staffing, and trusts were required to monitor the differences between planned and achieved nurse staffing levels and to report them through NHS Choices.
A lot of emphasis was placed on the providers of care, and rightly so. They should use their staff effectively and efficiently to keep patients safe. However, there is also a wider responsibility on commissioners—that is where I think we have fallen down—to ensure that providers do what is required, and on system managers and others who allocate the resources, to ensure that they do it in a way that permits safe levels of staffing. Community, maternity and learning disabilities are all nursing specialities where shortages are most acute. Our new clause makes it clear that all settings would have to adhere to the same standards, with no distinctions, because we believe that good and safe care should be for everyone.
In 2013, the National Quality Board set out 10 expectations and a framework within which organisations and staff should make decisions about staffing that put patients first. The document, entitled “Putting people first”, made it clear that safe staffing was both a collective and individual responsibility and central to the delivery of high-quality care that is safe, effective, caring and responsive. In England we have a website full of guidance, and NHS boards are required to take that guidance into account or have regard to it, but there does not appear to be anything similar for social care. Of course, the point I am trying to make, rather unsubtly, is that that is just guidance.
Looking more broadly, the NHS entered its new planning mode from 2015, and we had the emergence of sustainability and transformation partnerships. There was a requirement for them to design local plans to develop, recruit and sustain levels of staff with the right skills, values and behaviour in sufficient numbers, and in the right locations, to ensure the safety of patients. The plans were developed in great haste, but they did not actually go anywhere. Now we are to have more structured ICBs and new plans, but we still do not have a national workforce plan, which means that ICBs cannot plan properly either.
It would be good to know not just the levels of vacancies, but the gap between the staffing needed to maintain safe levels of working and what is actually in place. We touched on this aspect earlier, and we hope the Government respond positively even if they do not accept the new clause. I am sure the Minister will agree that safe staffing levels are better than unsafe levels. We should all agree that it is possible and desirable to enshrine in law guidance from experts on what constitutes safe levels of staffing in various settings and scenarios. We should absolutely be allowed to know when unsafe levels of staffing occur, especially when it becomes an endemic issue due to staff or funding shortages.
As we have mentioned before, we do not want to overburden the Secretary of State, because he already has a number of new powers under the Bill that will keep him busy. We have tried to remove the attempts to give him more work through the power grab, but it would not be for the Secretary of State to do the rotas or phone round for additional staff in the mornings. He just has to ensure that the duty to have staff levels of staffing is fulfilled by those delivering the service. Any wisdom that the Minister can provide on issues around defining, establishing and enforcing safe staffing, and on who carries the systemic responsibilities, will be greatly appreciated.
Dr Whitford
There is no question but that the workforce in both health and social care is one of the biggest challenges across all four nations of the UK. As the shadow Minister highlighted, both Scotland and Wales have passed legislation and aspire to having in law what level should be aimed at, which is quite important. Although covid has impacted in terms of staff leaving the service and the demand on the service, Brexit has also had a huge impact, in that there was an almost 90% drop in European nurses coming to the UK within just months of the referendum. The situation has not recovered, and that impacts right across the system and indeed in social care, where European citizens represented a significant part of the workforce.
When I first came to this place, the former Health Secretary, the right hon. Member for South West Surrey (Jeremy Hunt), talked very much about patient safety but claimed that, in essence, doctors were not really available in the NHS outwith nine to five, and that this was causing what were called “weekend deaths”. Having worked long hours for over three decades, I was a bit afraid that my husband would think I was having serial affairs if I was working only nine to five in the hospital, so I refuted that utterly. However, the evidence available at the time was that the only staff ratio that had any provable impact on patient outcome was that of fully trained, registered nurses—not trainees, not associates and not assistants—to patients. Obviously, that ratio changes, based on the dependency of the ward—whether it is an ordinary ward, a high-dependency ward or an intensive care ward. That is what leads to the basic formula in safe staffing legislation, and England does not have it.
Although covid, Brexit and other things have impacted on the ability of Scotland and Wales to achieve what they aspire to, the guidance has been there for years and it has not been achieved, as the shadow Minister said. Having safe staffing ratios in hospitals is critical, but what action should be taken if that safe level of staffing is not there? What work should not be done so that patients with emergencies can be cared for properly? Otherwise, there is pressure on management to get things done where they want to see throughput. Sometimes, staff simply end up between a rock and a hard place, and that drives staff out of the service. Ultimately, coming home after an exhausting shift feeling that they have delivered poor care because they were covering too many patients is demoralising. It undermines the retention of staff and adds to the problem.
Edward Argar
I am grateful to the shadow Minister, the hon. Member for Ellesmere Port and Neston, for his framing of the new clause in his opening remarks.
The new clause would place the Secretary of State under a statutory duty to maintain safe staffing levels in the health and care service in England. I fear that its effect would be to detract from the responsibility of clinical and other leaders at a local level to ensure safe staffing, supported by guidance—I certainly take on board the point about guidance made by the hon. Member for Central Ayrshire—and regulated by the Care Quality Commission. I am afraid that the Government cannot agree with the new clause as worded for a number of reasons, which I will enunciate for the shadow Minister to illustrate my thinking.
First and foremost, we do not believe that there is a single ratio or formula that could calculate what represents safe staffing. It will differ across and within an organisation and, indeed, across organisations. Reaching the right mix requires the use of evidence-based tools and, crucially, the exercise of professional judgment and expertise and a multi-professional approach.
Consequently, we think that responsibility for staffing levels is best placed with clinical and other leaders at a local level, responding to local needs and supported by guidelines, all overseen and regulated by the CQC. Those guidelines, notwithstanding the challenges posed by the hon. Lady and the shadow Minister, are issued by national and professional bodies such as the National Quality Board and National Institute for Health and Care Excellence. They are based on the best available clinical evidence and are designed to ensure patient safety.
Appropriate staffing levels form a core element of the CQC’s registration regime for health and social care providers. Providers are required by the CQC to provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the care and treatment needs of the people using the service at all times. Staff must also receive the support, training, professional development, supervision and appraisals necessary to carry out their role and responsibilities.
Secondly, the new clause would require the formulation of safe staffing ratios against which performance could be assessed. I fear that that could be a retrograde step and inhibit the development of the skill mixes needed for a more innovative and productive future workforce, which will be crucial to the successful implementation of the new models of integrated care that the Bill is intended to support. Just as there is no one-size-fits-all approach for the new models of care, there will be no identikit approach to the mix of staff needed. The ultimate outcome of good quality care is influenced by a far greater range of issues than how many of each particular staff group are on any particular shift, according to a prescribed ratio. It requires the professional expertise and judgment of those who know the situation best in a given circumstance. The point I seek to make is that, although those numbers are a key part, they are not the only part.
This is, perhaps, more of a technical point than a point of substance, but the specific wording of the new clause is incredibly broad. It would potentially require the Secretary of State to assess safe staffing levels across all healthcare settings across the whole of England for all medical and clinical staff. Such a duty would, I fear, be challenging to implement, notwithstanding the shadow Minister’s assertion that he would not expect the Secretary of State to sit there each morning going through shift rotas and shift patterns himself. It would be challenging for not only the Department but the wider system and, in particular, clinical leaders in individual settings.
For those reasons, while I appreciate the sentiment and the objective sought by the shadow Minister, I do not believe the new clause is the appropriate practical solution.
Justin Madders
I am grateful for this Minister’s response. I am not surprised that he is not prepared to the support the new clause. Unfortunately, I think there is a large chasm where responsibility for workforce issues probably lies, and this is an example of that. It was certainly not our intention to expect the Secretary of State to deliver each individual setting, but for someone in the system to have that responsibility of advising the Secretary of State. No doubt we will return to this. We will see the practice in the devolved nations and how that has proved to be a success or otherwise, which may strengthen or weaken the argument. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 18
Workforce responsibilities of integrated care boards
“(1) Each integrated care board must at least every two years publish a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.
(2) In drawing up the report the Board must consult—
(a) the Trusts and Foundation Trusts that provide services in its area,
(b) providers of primary care in its area, and
(c) the recognised trade unions.”—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
We are back on the workforce. We had a brief discussion about the proposals in clause 33 on the Secretary of State and workforce planning, and how they are by universal acclaim wholly inadequate. Now is not the time to repeat that debate, although I may shoehorn in one or two references to it. We hope that at some point there will be a better proposal on the national efforts to assess and meet workforce needs.
The new clause tries to repeat the intentions of the amendment to clause 33, and to take some of that thinking and translate it to ICB level. That makes a lot of sense to us, and in an ideal world some of the national plan would be made up of individual local assessments of need and add together the 42 ICBs into one national workforce plan. We will see where we end up with that. As I said, we have had some attempt at this with each STP trying to produce its own plan to a very abrupt timetable. I do not think anyone actually added up all their assessments to come up with a national figure. Because of the truncated timetable they faced, there was not a great deal of engagement with the workforce on that.
There is therefore a bit of a precedent in the work that was done on that. It is probably what you would call a gap analysis: what is needed against what we are likely have unless something is done to close that gap. The new clause follows that approach, which has had some support in some other areas. We felt that a two-year cycle was about right, with reporting on that two-year cycle covering short, medium and longer-term need.
It is hard to see why we will not have local plans if we are going to have national plans, to make sure that there is alignment when, as we hope, the Government come back with something better on clause 33. Looking at the total staff in the NHS and social care for an ICS, some of the larger ones will be running into hundreds of thousands of people. It is hard to think of any system with that many staff where some sort of workforce planning is not going on. If we are looking at things across system level, as the ICS is, surely workforce needs across the system would be part of that. We know that ICBs, together with the relevant trusts and foundation trusts, have the general duty to produce a plan annually, setting out how they propose to exercise their functions over the next five years. They will not be able to do that without the right staff.
A lot of the ground work entailed in the new clause will have been done already. It is our intention that it will try to remove any possibility of blame shifting, where inadequate resources lead to reduced services and the service providers are blamed, rather than those who hold the purse strings in Whitehall. The reporting required by the new clause will make it clear whether there are enough staff to meet all the reasonable requirements of the ICB.
The other key point covered by the new clause is who is consulted in the local planning process. We believe it vital that recognised trade unions are involved. That should be a given anyway, in the light of the general commitments from the NHS over partnership working, but as we have covered before, we think that needs to be explicit in the legislation because of the behaviour of a few NHS bodies in trying to marginalise staff involvement in recent times.
The ICBs will new bodies, and they will need to understand the importance of partnership working from day one. If the levelling-up and devolution agendas are to continue to flourish, surely the regional and sub-regional identification and development of skills in this important area ought to be part of the mix. It feels, I am afraid, as though the whole issue of workforce is being assiduously side-stepped by the Department. That is the Department’s prerogative, but it is a mistake and it is those on the frontline who will bear the brunt. We need someone to take responsibility, so why not the ICBs?
Without its workforce, the NHS is nothing. We are grateful to each and every one of its staff for the work that they do. We owe it to them, the patients and the taxpayer to have in place a proper system of workforce planning. Although we do not pretend that the new clause is the whole answer, it would begin to put in place the building blocks to achieve that.
Edward Argar
The new clause would place a new statutory responsibility on integrated care boards to publish, at least every two years,
“a report setting out an analysis of the current workforce, the workforce requirements to enable the Board to fulfil its duties over the following 2, 5 and 10 years, and the plans the Board has to close any gaps identified.”
Under the new clause, ICBs drawing up that report would be placed under a statutory duty of consultation with the trusts and foundation trusts in their area, providers of primary care and the recognised trade unions. The Government’s view is that that is an unnecessarily prescriptive duty on ICBs, and that clause 33 —alongside our non-legislative work and investment—remains the right way to develop the NHS workforce.
On the workforce nationally, what is needed is greater transparency and accountability for the various bodies involved in workforce planning. Clause 33 requires the Secretary of State to produce a report describing the workforce planning and supply system—including the roles of DHSC and its arm’s length bodies; NHS bodies, including ICBs and others; and how they work together—to provide that greater transparency.
To support local ICBs on workforce matters, work is already being taken forward on workforce planning through NHS England and NHS Improvement’s draft guidance to ICBs on the discharge of their functions. The draft NHSEI guidance, published in August 2021, states that the intended outcomes for ICBs will include,
“Growing the workforce for the future and enabling adequate workforce supply”,
as well as,
“Leading coordinated workforce planning”.
The guidance notes state explicitly that ICBs will have the responsibility to develop
“plans to address current and future predicted workforce supply requirements”,
which I believe addresses the core intention of the shadow Minister’s new clause.
The production of those plans will require ICBs to develop and regularly refresh collaborative workforce plans for their integrated care area, with demand and supply planning based on population health needs. As part of that work, we can expect ICBs to work with local stakeholders in their areas. ICBs will also be supported by Health Education England on such workforce planning matters. Under the guidance, ICBs will also have the responsibility to provide workforce data to regional and national workforce teams to support workforce planning and inform the prioritisation of workforce initiatives and investment decisions.
We join the shadow Minister in putting on the record our gratitude to our health and care workforce, but we think that that guidance already sends a strong signal to the system about the importance of the issue, and we therefore do not support his new clause.
Justin Madders
I am not surprised, although I am a little saddened, that the Minister has once again adopted the permissive rather than prescriptive approach. We think that the issue is so important for the NHS that it needs a firmer hand. I am sure that I will quote back to him his comments about the need for greater accountability and transparency in workforce planning, because that is something that we absolutely agree on. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 19
Secretary of State’s duty to provide access to occupational health services to NHS staff
“After section 1G of the National Health Service Act 2006 (but before the italic heading after it) insert—
‘1GA Secretary of State’s duty to provide access to occupational health services to NHS staff
The Secretary of State must provide access to occupational health services to meet the reasonable requirements of all persons who are employed in an activity which involves or relates to the provision of services as part of the health service in England.’”—(Alex Norris.)
This new clause would place a new duty on the Secretary of State to provide access to OH services to meet the reasonable requirements of all NHS staff. The duty would apply to all healthcare professionals delivering health care including doctors, dentists, nurses, midwives, pharmacists, healthcare scientists and the allied health professions.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
One of the livelier arguments during the passage of the Lansley Act was about trusts doing lots more private patient work. Under the Act, up to 50% of a trust’s income could be derived from private patients. That was obviously an attempt to take the NHS in a whole new direction. The previous private patient cap was removed, and a new definition of “principal purpose” was brought in.
We need to be clear that this new clause is not about the parallel argument that we sometimes have about private providers doing more NHS-funded work, though that is a major concern when we hear the news that the private sector is now doing more hip replacements for NHS patients than the NHS. We are in a slightly ludicrous and paradoxical situation: private providers are doing more NHS-funded work, while NHS providers are doing more private work. The new clause tries to put the brakes on that. We say: why not just build up NHS capacity to the point where it does all NHS-funded work, so that the need to keep dipping into the private sector is removed?
The 2011 argument is mirrored in the way the original foundation trusts, when invented, were allowed to develop private patient income, but only to a very low level. That was not a great situation, but it recognised that there were already a few NHS organisations, mostly in London, for which private patient income was so significant that there would be a risk of destabilisation if that income were blocked. The point at the time was that the amount permitted then was acceptable, but that it should go no further. Incidentally, the plain-old NHS trusts could do as much private patient work as they were allowed to by the Secretary of State, who could direct them to do it. If memory serves, he allowed one trust to become the private patient income league table toppers at one point. It did not want to become a foundation trust. What a strange and paradoxical world we live in.
Anyway, in 2011, the cap was raised from 3% to 50%, which started many hares running. We heard predictions of a whole new generation of private patient units being built, and that we would be back to the old days when the NHS was the largest provider of private patient care. Fortunately, that never happened. In the real world, there are now only around a dozen trusts that have any significant private patient income, and it is not increasing at a significant rate, although recent developments in Oxford suggest that the issue has not gone away.
One might argue that in those circumstances there is no need for the new clause, but we would say that there is every need to renounce the approach set out in Lansley, and to go back to a public NHS. The only reason for gaining income from private patients is to benefit the NHS as a whole, not to benefit one NHS organisation. This is a real and live issue, as we saw during covid. There were tensions, and every spare bed was vital; indeed, every spare bed is vital now to support the mammoth effort that is needed to bring down waiting lists. In all seriousness, why would we sanction a trust’s building more private patient capacity, when waiting times for NHS treatment continue to go up? Then we go, as we have done in recent times, cap and wallet in hand to the private providers and pay them huge sums to allow the NHS the option of using their services and capacity, as we did during covid. As we saw recently, that did not get used anything like as much as it should have been. That might be a fortunate thing, but it was a shocking lack of value for money. The report by the Centre for Health and the Public Interest on the contract with the private sector found that none of the five objectives set for the contract were achieved, with large amounts of healthcare resources wasted.
Edward Argar
The hon. Gentleman’s new clause would effectively prevent NHS foundation trusts from increasing their income from private patients year on year unless a number of specified conditions were met.
If hon. Members are students of history, they will recall that in 2012 we abolished the private patient cap, while clarifying that the foundation trusts’ principal purpose was
“the provision of goods and services for the purposes of the health service in England”,
meaning that foundation trusts must make the majority of their income from NHS activity. That was a more rational and sensible way of managing the issue than the previous cap, which caused practical problems for some NHS organisations that wanted to become foundation trusts and were prevented from doing so by the prescriptive nature of the previous regime. We also retained the requirement that additional income be used to benefit NHS patient care. It has been used across the system to offset maintenance costs, finance alternative transport such as park and ride, and fund patient care.
I should also be clear that we are talking about a very small percentage of the NHS’s income. The most recent set of provider consolidated accounts for 2019-20 shows income from non-NHS sources as 2% of income, of which less than 1% relates to private patients. Again, all that income has gone to improving care for NHS patients.
The new clause introduces a new cap by a different door; it creates a requirement for foundation trusts to agree with their ICB and ICP their income from non-NHS sources, and if they raised more than in the previous year, they would no longer be fulfilling their primary function as a foundation trust. That would be a significant bureaucratic and administrative burden on foundation trusts, and it would require them to either forgo raising additional income, or seek agreement via a multi-stage process before raising it.
The provision would also mark a significant new restriction on foundation trusts’ freedoms and autonomy, and could potentially dissuade some from wishing to become foundation trusts. As all non-NHS income must benefit NHS patient care, and an NHS foundation trust must always have as its primary purpose the delivery of NHS services, I fear that would potentially be putting ideological purity over practical interests and the practical working of the system.
New clause 23 would only apply to foundation trusts, as I read it, not NHS trusts. NHS trusts do not have a limit on the amount of income they can raise from private patients, and a very small number of trusts raise significant income in this way. Putting an additional requirement on foundation trusts before they can raise non-NHS income, but not doing the same for NHS trusts, would potentially further unbalance the playing field and give an additional nudge in the direction of foundation trusts.
The hon. Gentleman raised the issue of the costs or spending on the independent sector in the context of the pandemic response. I have been clear throughout that when the accounts are fully consolidated and audited, those figures will have to be reported. I cannot say exactly when that process will be complete, but it is a requirement that those accounts be gone through, consolidated and audited. I would hesitate to give him an inaccurate figure, but it is my intention for those figures to be made available at the appropriate time. With that, I invite the hon. Gentleman to consider withdrawing his new clause.
Justin Madders
I hesitate to withdraw the new clause, because I have to say that the Minister’s arguments about not wanting to deter foundation trusts from making applications rang a little hollow, but we would not want to be accused of preventing that procession from continuing. We have set out very clearly why we do not think this residue from the 2012 Act should remain on the statute book. We think it sends out the wrong message and is actually unhelpful at this time, but we will not push the new clause to a vote. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 24
Requirement for NHS trusts to publish Royal College invited review reports
“Each NHS Trust in England must publish the reports produced by Royal Colleges of invited reviews of the Trust, including any conclusions and recommendations.”—(Justin Madders.)
This new clause would require Trusts to publish Royal College invited review reports.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
The clause seeks to require all trusts to publish reports produced by royal colleges following invited reviews, including any conclusions and recommendations. Invited reviews are advisory, non-regulatory and non-statutory ways for healthcare organisations to assure patient safety and improve patient care through the use of a collaborative, independent, objective and expert review process undertaken by medical royal colleges when asked. Invited reviews have a clear and important role in supporting improvements in services. They aid trusts in understanding issues within departments or teams, particularly where these are multifactorial and involve team dynamics. An independent, external expert opinion is often invaluable in helping senior clinicians see a different viewpoint and in articulating where and why professional differences of opinion in practice are occurring.
The reports can help move issues of contention forward and improve relationships. Trusts value the insight and objective evidence of these reviews, particularly where quality issues have been raised. They are often a vital tool in resolving a complex, seemingly intractable issue. They are also invaluable in ensuring the NHS can continually learn, improve and deliver the safest and best quality care for patients. However, we think that can only be achieved if the information and learning within the reports is shared for the benefit of others across the system.
Independent and external expert reviews are a key part of any assurance process. To us, their value is beyond dispute. How the organisation being reviewed responds to the report produced is again crucial. Although we would expect in most cases the organisations to accept those recommendations and do what is required, we know that does not always happen. Shockingly, BBC “Panorama” revealed that, of 111 invited service reviews over five years, only 16 were put into the public domain. Panorama accuses trusts of burying important reports on patient safety. The invited reviews are organised by the Academy of Medical Royal Colleges, which follows the published framework. The framework has a section on openness and transparency:
“Where a healthcare organisation has commissioned an invited review of clinical activity in response to concerns about the quality of patient care, they should also be open and transparent with patients, their relatives and the public…Healthcare organisations should also work closely with their regulators and share information about invited reviews with them proactively where necessary to ensure that the safety of patients can be maintained.”
As with all such external reviews, there is a balance between protecting certain information, for example by attributing views or comments, and being open. For such reviews it is necessary that those interviewed or otherwise asked to become involved are happy to do so and happy to speak out confidentially. As we discussed earlier, ensuring that staff and whistleblowers feel safe to come forward and disclose information about an incident is critically important.
The new clause does not intend to get in the way of that protection. It is deliberately not prescriptive about the timing of publication, so that trusts maintain appropriate control. It is not about blame or ensuring that trusts are named and shamed when improvements are needed; it is about transparency. In the NHS, after mistakes have been made, it is vital to have transparency to ensure that necessary improvements are made.
It is concerning that so many reports produced by royal colleges have not been shared with the public and therefore we do not know whether they have been acted upon. As part of the conditions of an invited review, trusts are in effect signing up to publishing and showing the findings. Yet, as we know, that is not happening.
Everything favours openness, although patient-identifiable information would of course have to be redacted. On some occasions, there may be other reasons for part of the report to be withheld, but not the overall conclusions and certainly not the recommendations. That would ensure proper accountability for the follow-up and implementation of the recommendations or, in some cases, a justification for why the organisation did not accept or act on the recommendations.
We have talked several times already about the defensive culture that pervades parts of the NHS and how it sometimes gets in the way of what patients and families want. They want answers and assurances. Most of all, they want the truth. These reviews are part of that truth. We have had the same argument many times, because, although the NHS claims to be open and transparent, it is often not.
Given the fragmented and convoluted set of organisations within the new structure, it is harder to know sometimes who will be responsible for what. With the present system, there is always the issue of who owns the report, who controls what is published and who follows up and ensures that the necessary changes are made. That is why we believe that that the disinfectant of sunlight is vital. We should know everything unless there is a good reason for us not to, not the other way round. We should not be required to protect the reputation of bits of the NHS or even the reputations of those individuals who have failed to do their jobs properly.
We have heard in the many scandals how things were known by a few, but they failed to act and prevented anyone else from acting on the information they had. Sadly, it is necessary to be clear about rules. There ought to be some sort of sanction for those who have broken rules of publication. It may not always be easy for the individuals or the individual organisations, but it is almost certainly always going to be in the interests of the NHS as a whole.
The Academy of Medical Royal Colleges and the CQC are looking at guidance on invited reviews at the moment. The new clause seeks to focus the Minister’s mind on an issue that has not gone away. I know it is controversial. I hope the Minister can give us some assurances that his Department is committed to developing a system that works better in this area and puts patients at the heart of everything that happens.
Unfortunately, in the last financial year prior to the pandemic, there were 472 serious patient safety issues classified as never events across the NHS in England. There is work to be done to get the NHS to the level of patient care and safety that we would want to see. It is only by seeking to understand why these events happened in the first place and the circumstances that led to them that we can ensure they never happen again. That is the heart of what most patients and their families want to know.
We believe that the safety of patients should be a golden thread running through every aspect of healthcare delivery and we will do everything in our power to make sure that the NHS is one of the safest and most supported healthcare systems in the world. I ask the Minister to tell us why the reviews should not be published on a regular basis. Is 16 reports out of 111 being published good enough? We certainly do not think it is.
I will finish on a quote from the Francis report. We have mentioned this one already, but it needs repeating as it is so important. He said:
“It is a basic and just expectation of the public that organisations are open, honest and transparent about their performance standards, about the rights of patients and about what happened, and why, if things go wrong. This is the only way to begin to restore full public trust in the NHS.”
We hope that this new clause, by requiring publication of the reviews, will go some way to restoring confidence and increasing the transparency that patients deserve.
Edward Argar
The new clause would require each NHS trust in England to publish any report by a medical royal college of an invited review of the trust. That includes any conclusions and recommendations. It is right, as the hon. Gentleman mentioned, that trusts are open and transparent in managing any concerns about the quality and safety of their services, and, in particular, regulators should have access to any royal college invited review of a trust.
I have considerable sympathy with the intention of the new clause. We all want to improve patient safety and care, and I recognise the key role that transparency can play as part of that. However, I will explain why I am not convinced that this objective is best advanced by acceptance of this particular new clause. Managing concerns about clinical quality openly and transparently is essential for trusts if they are to provide consistently high quality, safe care, to show quality of leadership and to maintain trust in the trust and the service it delivers.
When the CQC finds that there has been a failure to do so or that fundamental standards of care are not being met, it is reflected in the CQC’s reports and ratings and in the range of enforcement powers it can use. The CQC’s inspection teams maintain ongoing engagement with trusts and make it clear that they expect trusts to be open and honest about issues of quality and safety of services. Furthermore, the CQC has been clear with trusts that reports, including invited reviews by royal colleges, should be made available to relevant commissioners and regulators, including the CQC. The CQC, NHS England and NHS Improvement expect trusts to take prompt actions to address appropriate recommendations, and the framework for invited reviews from the Academy of Medical Royal Colleges is clear that trusts and royal colleges undertaking reviews should share any serious patient safety issues from reports with the CQC.
As part of the CQC’s monitoring and inspection activity, it assesses how trusts have acted on recommendations from these reviews, including implementing any learning to make improvements. Since July 2018, the CQC has set a very clear expectation on trusts to share copies of the full final report of external reviews, including those by royal colleagues, and to inform it of steps they are taking to implement any recommendations. The CQC, working with providers, NHS England, NHS Improvement and the Academy of Medical Royal Colleges, has seen improvement in the development of an open and transparent culture.
The CQC has powers to compel a trust to share an invited review where it is aware of that review. Where serious issues of care are uncovered, NHS England and NHS Improvement can also compel a trust to take whatever steps are necessary to address them. This includes the sharing of an invited review to itself. The CQC is now reviewing its regulatory model, including its approach to monitoring and gathering evidence from providers. In doing so, it will continue to work with trusts and royal colleges, including on sharing and responding to findings from external reviews to encourage a culture of openness and transparency.
There are robust and transparent systems in place to ensure that providers learn from and improve their services. This includes publishing more than 100 reports every year, covering 40 clinical specialisms as part of the clinical audit programme by NHS England and NHS Improvement. NHS England and NHS Improvement also publish regular data on patient safety incidents, other safety indicators and patient safety alerts. They also provide support to challenge providers to improve governance and culture.
Invited reviews are a voluntary process. They are an advisory, non-regulatory and non-statutory way for trusts to assure patient safety and quality of care through the use of an independent review, but compelling the publication of the full report could lead to some unintended consequences. First, it could discourage some trusts from commissioning these invited reviews. That could lead to trusts overlooking specific actions to address safety and quality concerns and opportunities for improvements and learning. Secondly, it could lead to trusts inviting consulting firms and other professional bodies with less expertise in the delivery of clinical care than a team from the royal college to undertake reviews. Thirdly, invited reviews can vary widely in their scope and may not be directly patient safety-related. Therefore a blanket requirement to publish all reports may not be appropriate.
Fourthly, the specific information that a trust can make publicly available will vary from review to review, depending on the circumstances. Invited reviews can often involve sensitive and complex circumstances and cover confidential issues about staff and patients. Trusts need to take account of legislation on patient confidentiality and data protection each time a report is developed. It may therefore not be possible for every invited review to be a published document. The Academy of Medical Royal Colleges recommends that trusts should take steps to make available to the public a summary of the review and the steps they are taking.
Finally, requiring publication of invited reviews could attract attention in a way that affects staff morale and organisational learning, and not in a constructive way. It could make future invited review reports weaker or drive necessary conversations and actions off the record. For these reasons, while I can understand the hon. Gentleman’s point and where he is coming from, we believe that the mechanisms already in place are sufficient and achieve the right balance.
Justin Madders
I am slightly heartened by what the Minister said there. He obviously takes the matter seriously. We are not going to press this to a vote, because we recognise that there is some concern in the sector about this proposal. I ask him to reflect on what he said about a requirement possibly discouraging trusts from seeking invited reviews in the first place. That shows that reputation management is still at the forefront of their considerations rather than patient safety. That is the heart of the problem that we have been seeking to tease out with this new clause. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 25
“Secretary of State’s duty to report on disparities in maternal mortality rates
The Secretary of State must prepare and publish a report each year on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including the steps being taken to address these disparities and improve outcomes for patients.”—(Justin Madders.)
This new clause lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England, including what steps his department is taking to address these disparities and improve outcomes for patients.
Brought up, and read the First time.
Justin Madders
I beg to move, That the clause be read a Second time.
This clause, in the words of Ronseal, does exactly what it says on the tin. It lays a duty on the Secretary of State to prepare and publish a report on variation in the quality and safety of England’s maternity services and disparities in maternal mortality rates in England. The report would include details of the steps that the Department was taking to address these disparities and improve outcomes for patients. We all know that this issue is of paramount importance and has been debated in the House several times recently. I hope that the Minister agrees that it is important that we take whatever steps we can to tackle all forms of inequality in our society and this is another example of how that manifests itself.
Covid has sharpened our awareness of health inequalities, but it is clear that it is not just with respiratory viruses where health outcomes can be staggeringly different for different groups. Maternity services are one of the areas where we can and must do far better. The Care Quality Commission report “Safety, Equity and Engagement in Maternity Services”, published in September, highlighted continued concern about the variation in quality and safety of England’s maternity services and presented analysis of key issues that persisted in some maternity services. It also highlighted where action was still needed to support vital improvements. In the UK’s poorest areas the stillbirth rate is still twice that in the UK’s most affluent ones, with pre-pandemic figures showing that babies in the poorest areas have a 73% excess risk of neonatal death. All mothers and babies deserve the very best care and it simply cannot be right that where people live might dictate the quality of the maternity care received. Action is needed to eradicate maternal inequalities.
It is not just geographical and socioeconomic inequalities that need to be tackled but ethnic inequalities. Evidence from MBRACE-UK––Mothers and Babies Reducing Risk Through Audits and Confidential Enquiries across the UK––shows that the maternal mortality rate is more than four times higher for black women compared with white women. The maternal mortality rate for Asian women is almost twice as high compared with white women. Those inequalities are an injustice, and we need action to address them.
I recognise that many black, Asian and minority ethnic women also do not feel that they are listened to during childbirth. A lack of cultural competency and medical training means that complications are not always spotted early enough. For example, black women have shared experiences of how anaemia has not been picked up soon enough because of their skin colour. We really ought to be doing better than that.
The Government have said that they have hosted several roundtables with experts and have commissioned more research to better understand the issue. However, they believe that a target to address maternal mortality disparities would have limitations in improving the quality of care. Why do they hold that view? NHS England’s long-term plan includes targets for addressing health outcomes in other areas. We need action to address the unacceptable disparities in maternal mortality rates as well.
The Joint Committee on Human Rights found that over 60% of black people did not believe that their health was equally protected by the NHS compared with white people. As we know, covid has had a disproportionate impact on BAME communities.
If not a target, then a report would ensure accountability and focus minds to address these unacceptable injustices. New clause 25 would put explicit accountability on the Secretary of State not only to monitor and report on variation in maternity services but, crucially, to set out the steps needed to tackle it. We need a national strategy to address this country’s health inequalities, which must include serious and urgent action to end the mortality gap between black, Asian and ethnic minority women and white women. The new clause is, of course, not the complete answer, but I hope the Minister will agree that it would be a welcome step in the right direction.
Edward Argar
Again, I am grateful to the shadow Minister. The new clause would require the Secretary of State to publish a report each year on variation in the quality and safety of England’s maternity services and on disparities in maternal mortality rates in England. Again, I understand the intention behind the new clause, which the hon. Gentlemen set out clearly, as it is paramount that we do all we can to ensure the safety of expectant mothers and their babies, which involves understanding and taking steps to address the variation in quality and safety of England’s maternity services and disparities in outcomes.
However, several organisations and bodies already publish reports each year on the variation of quality and safety of England’s maternity services and the disparities in maternal mortality rates. First, the CQC monitors, inspects and regulates maternity services across England to ensure they meet standards of quality and safety. Following an inspection, it provides findings, recommendations and an overall rating of the trusts. It also publishes monthly reports following inspections of maternity services and annual reports that explore areas for improvement in maternity services across England.
Secondly, “Better Births”, the report of the national maternity review, recommended that a nationally agreed set of indicators should be developed to help local maternity systems to track, benchmark and improve the quality of maternity services. In response, NHS England and NHS Improvement, in partnership with NHS Digital, have produced a national maternity services dashboard. The dashboard enables clinical teams in maternity services to compare their performance with their peers on a series of clinical quality improvement metrics, or CQIMs, and national maternity indicators, or NMIs, for the purposes of identifying areas that may require local clinical quality improvement.
Thirdly, MBRRACE-UK publishes annual reports on maternal deaths, stillbirths and neonatal deaths across the UK. Stillbirth and neonatal mortality rates are provided for individual NHS providers, commissioning boards, and local authorities in England, Scotland, Wales and the Crown dependencies. It would not be possible to report annual maternal mortality rates by NHS trusts because the numbers are very small—it would not be a meaningful statistic. That would also potentially risk individuals being identified and could result in contravention of data protection legislation.
The reports by MBRRACE-UK also look at health inequalities; its analysis has identified significant differences in maternal mortality rates, which the shadow Minister mentioned, between women from black or Asian minority ethnic backgrounds and white women, and between women from lower and higher socioeconomic backgrounds.
Finally, the National Maternity and Perinatal Audit, or NMPA, is a large-scale audit of NHS maternity services across England, Scotland and Wales. The NMPA publishes trust-level data and evaluates a range of care processes and outcomes to identify good practice and areas for improvement in the care of women and babies.
Justin Madders
I will disappoint the Minister this time. We will push the new clause to a vote, because we think that it is really important. While the Minister has set out a whole range of reports that have been issued and work that is being done, due to the scale of the injustice we have set out, there needs to be a concrete commitment from the Secretary of State to not only publish the data, but set out the steps he is taking to address the inequalities.
Question put, That the clause be read a Second time.