Oral Answers to Questions

Justin Madders Excerpts

Tuesday 19th February 2019 Commons Chamber

[Stephen Hammond]

My hon. Friend rightly points out that there are several routes into healthcare professions, and I am delighted by what is happening in Cornwall. I understand that my right hon. Friend the Secretary of State will be visiting him in the very near future.

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

We are in the midst of the worst-ever NHS workforce crisis, with more than 100,000 vacancies. The situation is unsustainable. Well-respected think-tanks say the figure could rise to 350,000 vacancies within a decade. What does the Minister consider a sustainable vacancy level both now and in a decade’s time?

[Stephen Hammond]

The hon. Gentleman will recognise that the £20.5 billion in real terms that we are investing in the NHS under the long-term plan will make a significant difference. He will also want to recognise the roll-out of medical places, the fact that more people are applying for nursing places now than they were last year and the detailed implementation plans that my right hon. Friend the Secretary of State has commissioned. These will deliver a sustainable workforce.

NHS 10-Year Plan

Justin Madders Excerpts

Tuesday 19th February 2019 Commons Chamber

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

With five and a half minutes of speaking time per year of the plan, I suspect that we have not quite done it justice tonight. However, we did manage to hear from nine Back Benchers during the debate. While I cannot refer to everyone in the time I have, I want to draw particular attention to certain contributions.

My hon. Friend the Member for Hartlepool (Mike Hill) spoke about the importance of improving GP access—something we can all relate to—and the importance of mental health, a big driver of the 10-year plan. My hon. Friend the Member for Stroud (Dr Drew) made important points about threats to services in his constituency, and we heard such points across the Chamber. I was particularly pleased to hear from my hon. Friend the Member for Easington (Grahame Morris), who, of course, speaks about cancer treatment from personal experience. He rightly pointed out the deficiencies in the 10-year plan in relation to that. My hon. Friend the Member for Enfield, Southgate (Bambos Charalambous) was absolutely right to highlight the postcode lottery in palliative care. As with other areas such as neonatal care and IVF, it varies depending on where in the country someone lives. He also made a very important point about the cancer workforce.

I want to say a few words about the workforce. In recognising their invaluable work, which we thank them for, we also recognise—we on the Labour Benches do, at least—that without a fully staffed, respected and motivated workforce, the NHS would simply not be able to deliver the service that our constituents deserve. Last June, there was at last some Government recognition of the importance of the workforce, when the 10-year plan was announced. The then Health Secretary—now the Foreign Secretary—said:

“Alongside the 10-year plan, we will also publish a long-term workforce plan recognising that there can be no transformation without the right number of staff, in the right settings and with the right skills.”—[Official Report, 18 June 2018; Vol. 643, c. 52.]

We now know, however, that the workforce plan will not be with us until some time later this year, so is it not the case that without a workforce plan, we simply do not know how much of the 10-year plan is achievable?

As we know, the House of Lords Committee on the Long-term Sustainability of the NHS said that the lack of a workforce strategy

“represents the biggest internal threat to the sustainability of the NHS”.

Amazingly, the 10-year plan makes no reference to the actual numbers of staff expected to be employed during this period, so I put in a written question to the Minister about how many staff the NHS expects to employ by the end of the period covered by the 10-year plan. I was told in response:

“The Department does not hold the data requested.”

So there we have it in black and white: the Government do not have a clue.

[Matt Western (Warwick and Leamington) (Lab)]

Does that not just underline the fact this evening’s debate has been so ridiculously short on such an important subject? We need more time; we need another debate.

[Justin Madders]

I thank my hon. Friend for his contribution. Of course, we were not actually meant to be here at all this week, but it is absolutely right that this debate took place tonight. We need another one and we will very shortly need a debate on the social care Green Paper, when that is published. We also need a debate on what we are going to do about some of the legislative changes that the Government have promised, because all these things need to take place in the public eye.

[Anneliese Dodds (Oxford East) (Lab/Co-op)]

Does my hon. Friend agree that we also need a debate on privatisation, given that we are seeing no public consultation on very significant changes, such as what is purported to happen to the PET—positron emission tomography—scan centre at Oxford University Hospitals NHS Foundation Trust, causing a huge amount of local concern?

[Justin Madders]

I thank my hon. Friend for her intervention. She is absolutely right. The Secretary of State has said on the record that he wants to stop privatisation, but we have identified a number of very important contracts lasting many years and costing millions of pounds that should be halted if the Government are going to stick to their word. It has not happened and it should.

The timetable for the publication of the plan has itself not gone to plan. Again, when the Foreign Secretary was Health Secretary, he said:

“we now intend to publish the social care Green Paper in the autumn around the same time as the NHS plan.”

I am not sure which autumn he was talking about for the social care Green Paper, but the intention was right, because, as he also said:

“It is not possible to have a plan for one sector without…a plan for the other”—[Official Report, 18 June 2018; Vol. 643, c. 52.]—

but here we are.

In conclusion, whatever fine words, gimmicks and spin we have in the 10-year plan, we know that the reality is that the NHS is on its knees and that it cannot survive another decade of Tory Government. It is time for Labour to come to the rescue again.

Early Parenthood: Supporting Fathers

Justin Madders Excerpts

Wednesday 30th January 2019 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Davies. I congratulate the hon. Member for Chatham and Aylesford (Tracey Crouch) on securing the debate and on her excellent introduction. As the hon. Member for Glasgow East (David Linden) just said, it has been a very good and well-informed debate, and it has struck the right tone. Perhaps we should take that into other arenas.

The hon. Lady raised three main issues. She referred to the important work of the Centre for Social Justice and mentioned interesting survey statistics—for example, that seven out of 10 fathers said they felt like a spare part, and that six out of 10 had no conversations with their midwife. I think a lot of us would recognise that territory. I remember being on holiday with my wife and her going up to talk to a woman I had never seen before, who turned out to be her midwife. That shows how difficult it is to engage both parents. I know that the Government are pushing for greater consistency, with the same midwife throughout the journey, but the fact that we have 3,500 midwife vacancies makes that a challenge.

The hon. Lady raised the subject of loneliness, too. I thank her for her work to introduce the Government’s loneliness strategy in 2018, building on the Jo Cox Commission, which is led by my hon. Friend the Member for Leeds West (Rachel Reeves) and the hon. Member for South Ribble (Seema Kennedy). That is a hugely important part of Jo’s legacy, and I am sure that Members across the House recognise the excellent contribution that the hon. Member for Chatham and Aylesford has made to drawing attention to that issue. There are, of course, many triggers for loneliness, one of which is being a new parent.

The hon. Lady also raised the important role that children’s centres can play. Several Members raised concerns about whether they are well enough used. Cuts of 60% to local government funding in recent years have led to the closure of 1,000 children’s centres, which provide support to both mothers and fathers in those early years. There is no doubt that that has had an impact.

The hon. Lady is right that we have a long way to go to reach true equality, with shared parenting. Shared parental leave legislation, which has been about since 2015, enables employed couples to split 50 weeks’ time off work after the birth of their child. The Government originally estimated that 8% of parents would take up the option of shared leave. However, disappointingly, take-up at the moment is only about 1% or 2%. A recent freedom of information request showed that take-up is particularly low among new parents, with only eight out of every 1,000 eligible people taking up the option. Some 8,700 new parents took up shared leave in 2016-17, and that increased by only 500 the following year.

The Women and Equalities Committee highlighted a number of problems with shared parental leave, including the complexity of the system, low uptake and low pay, and fathers’ fears about taking leave because of its perceived negative effect on their careers. There is a cultural issue here, so will the Minister say what can be done to address that?

Shared parental leave does not extend to self-employed parents. At present, self-employed mothers are entitled to statutory maternity pay of £140 per week, but they must take all that in one go and they risk losing their payments if they undertake work outside their 10 allotted “keeping in touch” days. Self-employed fathers do not have access to that at all. I hope that hon. Members will support the Shared Parental Leave and Pay (Extension) Bill promoted by my hon. Friend the Member for Batley and Spen (Tracy Brabin), which would enable self-employed parents to split parental leave and pay between them. Given that the ranks of the self-employed seem to increase every year, will the Minister say whether the Government have any plans to legislate in this area?

Better pay and the option of part-time take-up of shared parental leave would improve access to leave for fathers, particularly those from lower-income groups. There is strong evidence of the effectiveness of non-transferable paternal leave as a lever for encouraging shared care and reducing the gender pay gap. We know that fathers want to play an active role in their children’s lives and families want to spend more time together with a new baby. That is why, as the hon. Member for Glasgow East said, we made a manifesto commitment to double paid paternity leave to four weeks. Fathers are parents too and they deserve to spend as much time as possible with their family.

The hon. Member for East Renfrewshire (Paul Masterton) gave a personal and touching account of his own experiences and set out well how fathers are almost removed from the scene shortly after birth, which is an experience that most of us who have been through that will recognise. Unfortunately, I think that sets a tone for the rest of the early years, if not the whole life.

The hon. Member for South West Bedfordshire (Andrew Selous) drew an interesting and important link between income and antenatal group attendance. He is right that fathers are not included as much as they could be in many of the inspection frameworks. His central point—this is something that we see across a lot of the NHS—is that the best practice is only in pockets, and does not always disseminate out into the whole of the system.

The hon. Member for Congleton (Fiona Bruce) spoke about the importance of families and said that there can sometimes be a cycle of negative experiences throughout the generations.

The hon. Member for Moray (Douglas Ross) gave us the good news about his impending fatherhood, and he raised an important issue about the proximity of maternity services. That does not just relate to the reorganisation of services, as in his case; it is a sad fact that last year, about half of all maternity units had to close their doors temporarily at some point, which meant that someone who was in the process of labour would have to find somewhere else pretty quickly, which can be distressing and inconvenient.

The hon. Member for Mansfield (Ben Bradley) gave a thoughtful and personal account of his experiences of fatherhood; we will all recognise many of things he described. He is right that parenthood is expensive, and that can add to the strain that young families experience. He made an important point about the silo-working that we often see across public sector agencies—a situation that we all want improved.

Finally, the hon. Member for Walsall North (Eddie Hughes) gave some contrasting examples of approaches to flexibility in the workplace and spoke of some of the cultural issues that we have already discussed. There is a need for a more consistent approach across workplaces.

As a father myself, I would like to spend more time with my children—or I certainly did until they became truculent teenagers; things got a little less pleasant then. Seriously, every parent wants to play as much of a role as they can in creating a safe, loving and stable environment for their children, so that they grow up into happy and healthy adults. We know that long working hours and the inflexible working approaches of some organisations make shared parenting duties a challenge. If we are to support men in taking a greater role in the family unit, we need to support men and women having a real and meaningful choice about how they organise their lives; that means family-friendly employment, applied equally to both parents.

It is a well-known fact that the gender pay gap is still here in 2019. The impact of women’s being more likely to be in part-time, low-paid or non-paid caring roles has implications for fathers in the workplace. We committed to tackling the gender pay gap and have pledged that in addition to reporting gender pay gap figures, companies will be required to demonstrate how they plan to close their gender pay gap, by producing action plans and taking steps to address the factors that contribute to the pay gap. That will include tackling unequal pay and discrimination and improving access to flexible working and take-up of shared parental leave, to ensure that all employees have a better work-life balance.

I note with interest the proposal from the hon. Member for Chatham and Aylesford for a dad test, which would be applied to the relevant commissioning and inspection frameworks for the perinatal period. We know that this country offers some of the best neonatal care in the world, along with some exemplary psychological and bereavement services. However, as we have already touched on, there is an unacceptable variability across the country. As many as 41% of neonatal units have no access to a trained mental health worker. As has been highlighted in the past few years in our debates about baby loss, that has been an unfortunate experience for some constituents, while others have had access to the very best services. I am sure that we want greater consistency across the board.

I welcome the commitment in the NHS long-term plan to enhanced support for perinatal mental health services, including assessment and signposting to professional supports for fathers and partners. The question—which is the same for a lot of the long-term plan—is, are the resources and staff there to deliver on those important aims?

In conclusion, we are on a journey—we are not there yet—towards a greater understanding and facilitation of the father’s role. Every day of a child’s early years is hugely important. The more we can do to encourage more and better-quality support during those earlier years, the better.

Draft European Qualifications (Health and Social Care Professions) (Amendment etc.) (EU Exit) Regulations 2018 Draft European Qualifications (Pharmacists) (Amendment etc.) (EU Exit) Regulations (Northern Ireland) 2018

Justin Madders Excerpts

Tuesday 29th January 2019 General Committees

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

It is a pleasure to serve under your chairmanship, Mr Howarth.

I thank the Minister for introducing the regulations. As we have heard, current EU law sets out a reciprocal framework of rules for the recognition of health and social care professionals. That enables EEA and Swiss nationals to have their qualifications recognised, and to gain access to the regulated professions in which they are qualified to work in the UK on a temporary or permanent basis. Of course, in the event of a no-deal Brexit those rules will no longer apply.

As we have heard, the draft regulations on health and social care professions would amend the relevant legislation for the nine health and social care professional regulators in the UK. The other set of regulations would similarly amend the relevant legislation for regulation of pharmacists in Northern Ireland. The aim in both cases is to put in place new regulations for EEA and Swiss-qualified professionals to register to work in the UK in the event of a no-deal Brexit after 29 March.

As that date is fast approaching, the regulations are important. It is right to make arrangements, although it is a matter of regret that we are dealing with them at the last minute. Clearly they must be temporary. We accept the need in principle for some arrangements to be put in place, but we have several questions about their potential impact on the delivery of healthcare.

First, on registered professionals, an estimated 3,200 EEA and Swiss-qualified health and social care professionals join the relevant registers to practise in the UK each year. According to the General Medical Council, doctors from the 31 EEA countries and Switzerland currently make up about 9% of the UK’s medical workforce, rising to around 20% for some specialities, including surgery, with similar figures in other important areas. According to the Royal College of Nursing, the figure for nurses and midwives is between 5% and 6%.

We are therefore talking about a significant chunk of the workforce, in the context of a record number of vacancies, so there is clear potential for workforce disruption if EEA and Swiss nationals cannot register. We must do all we can to minimise the risk associated with that in a no-deal scenario. The NHS workforce is already in a precarious position, with 100,000-plus vacancies and more nurses and midwives leaving the register than joining. There is no doubt that the workforce challenge has been exacerbated since the referendum result, with 3,692 staff from the EEA leaving the Nursing and Midwifery Council register between 2017 and 2018, for example. At the same time, the number of EU nurses and midwives coming to work in the UK has fallen to its lowest level, with just 805 joining the register in 2017-18.

My first question to the Minister is this. Given the huge contribution of EEA and Swiss-qualified professionals to the NHS, which he was generous enough to acknowledge, what assurances can he give that the NHS will begin to stem the huge losses of these important staff that we currently see? Furthermore, future arrangements for EEA and Swiss applicants will be dependent on discussions with the EU. The costs attached to these future arrangements are unknown, but regulators are expected to continue to operate on a full cost recovery basis. The Government assume that any extra cost of assessing applicants with EEA and Swiss qualifications for registration will be recouped via the regulator’s setting and charging fees to recover those costs from the applicants, which has been confirmed by regulators including the General Medical Council.

At the same time, the Government have acknowledged that changes to the procedure for recognising qualifications could make access to health and care professions more difficult, which could affect the availability of professionals. Has the Minister carried out an impact assessment to determine whether additional costs will affect the number of applicants from EEA countries and Switzerland and what affect that will have on the health service?

There is also a potential impact on healthcare, because the draft regulations will remove the right of EEA and Swiss professionals to work in the UK on a temporary or occasional basis. Examples that we have been given include a Dutch-qualified paediatrician working in the UK full time but participating in European-funded international research projects, or a Portuguese-qualified doctor working in Lisbon but undertaking weekend locum work in the UK. In December, when the draft instrument came before the Secondary Legislation Scrutiny Committee in the other place, there were 134 EEA or Swiss professionals providing healthcare services in the UK on that basis. How will the Government ensure that the removal of this right will not have a detrimental effect on the NHS?

The draft regulations will give UK regulators the discretion to designate EEA and Swiss qualifications as not acceptable in the UK after exit, but they do not set out clearly the process for deciding what is or is not a comparable qualification. Two months from our exit, we do not know how healthcare professional regulators will operate their new powers to remove a qualification from automatic acceptance, should they have patient safety concerns; all we know is that the Privy Council will approve such a measure. It is unclear on what grounds a regulator will be able to make such a request and what information will be needed to satisfy the Privy Council. I am aware that at least one regulatory body, the General Medical Council, has been asking the Government for further clarification on that point. Will the Minister provide us and the regulators with guidance on what information will be requested to obtain Privy Council consent to remove a qualification from automatic acceptance where patient safety is a concern? How will he ensure consistency across the board when dealing with such applications and in the mechanism for reporting these issues to Parliament?

The impact on regulators also needs to be considered. The Department has said that there will be no additional administrative or resource burden on regulators. Given that UK regulators will have the additional function of having to assess whether qualifications are comparable, what assurances can the Minister give that UK administrators will have the administrative capacity and resources to deal with those burdens at no extra cost?

It is clear that these regulations are a stopgap to avoid an immediate cliff edge, should the UK exit without a deal. There is no clarity on plans to introduce more sustainable long-term arrangements for registering and licensing EEA and Swiss nationals beyond a review in two years. The Minister did not go into detail in his opening remarks, but it is legitimate to ask how the Government intend to approach the two-year review of the instrument and whether in the long run they will commit to reform of the legislation on professional regulators to allow for the registering of healthcare professionals regardless of where they qualified.

The Minister touched on this briefly, but what is most concerning is that the regulators will lose access to the internal market information system, or IMI, the online tool for sharing information. That will apply whether we leave with or without a deal. The IMI allows details about applicants and their qualifications to be shared and, crucially, provides an alert mechanism, which makes EEA and Swiss regulators aware of professionals with compromised fitness to practise or of restrictions on their practice. I appreciate that it is not in the Minister’s gift to commit to ensure continued access to the IMI, but as the instrument revokes provisions that require UK regulators to access and use the IMI as part of their mutual recognition procedures, it is fair to ask what plans he has to ensure that patient safety is not jeopardised by its removal. This is a very important point. What plans are in place in the short and long term to enable continued sharing of information relating to the fitness to practise of professionals across the EEA and Swiss area?

Finally, as is often the case with Brexit-related debates, we forget that there is movement both ways. The impact on UK professionals wishing to work in the EEA must not be forgotten. After exit day, professional qualifications awarded in the UK will no longer be covered by the directive. The EU has agreed that holders of UK qualifications that have been registered in EEA countries and Switzerland will continue to be registered. However, in the absence of an agreement with the EU, that will be a matter for individual EU member states to determine. Has the Minister had any discussions with his EU counterparts about the impact of no deal on UK professionals wishing to practise in the EU after exit day? Does he know, for example, how many UK professionals would be affected? Has there been any consideration of mutual qualification recognition for emerging roles such as nurse associates?

In conclusion, we do not oppose the regulations or what they seek to achieve. We recognise, as the Minister does, the valuable contribution to the NHS of staff from the EEA and Swiss areas. I hope that these regulations will not result, inadvertently or otherwise, in our deterring or losing more of them than we already have. I would welcome any reassurance from the Minister in response to my concerns.

--- Later in debate ---

[Stephen Hammond]

I would like to reassure hon. Members that, while it is essential to the public’s protection that we put in place this legislation, I recognise that a number of important and significant issues have been raised. I also recognise the potential impact on patients and citizens of the whole of the United Kingdom of not getting this right. There have been a lot of questions, which I shall try to address in some sort of order, perhaps lumping together some of the points put to me.

Initially there was a lot of talk about the impact on the numbers. From the overall number of EU, EEA and Swiss health and care professionals practising in the United Kingdom, the number working in NHS trusts in England increased by over 3,500 in the 12 months following the referendum. That includes an extra 600 doctors. As of June 2017, over 21,000 EEA doctors were registered with a licence to practise with the GMC. The number of joiners from the EEA has remained steady since 2016; therefore, these regulations would allow that to continue. The hon. Members for Ellesmere Port and Neston and for Gedling might like to point out that there has clearly been a decline in registered nurses. That is a significant concern to the Department, and we have looked not only at the number of current vacancies resulting from EU nationals not coming forward but, as importantly, at the need to train, recruit and retain UK nurses, which is why there are a number of routes into nursing.

There are language issues. One reason for the nursing staff shortage in respect of EEA applications is down to the language controls introduced by the NMC, which took full effect in July 2016. Although some people might concentrate on the referendum as the contributory factor, the language testing is also judged to have had an impact. Therefore, since November 2017 the NMC has introduced a number of changes to the language requirements for nurses and midwives trained outside the UK, which has increased the options available to such applicants to demonstrate their language ability. The changes appear to be having a positive effect on international recruitment, with 2,500 more overseas joiners to the register between January and December 2018.

The hon. Member for Gedling asked about a slightly different language issue. I will confirm this in writing, but it is my understanding that we do not intend to change the language tests.

The temporary permissions argument is clearly of concern, and I have tried to address the hon. Gentleman’s questions about that. The numbers currently working under the regime are relatively small; however, that does not mean that they do not have a positive impact. It is right that under a new regulatory system people should seek full registration. However, over the EU exit day period and the period post that, the regime will continue. As temporary and occasional permissions last for up to 18 months, there will be plenty of time for those working under the regime to decide to apply for full registration.

The hon. Member for Ellesmere Port and Neston asked about the impact on UK professionals wishing to practise in the EU after exit day. I said in my opening remarks that it is the UK that is the main beneficiary of mutual recognitions. After exit day, professional qualifications awarded in the UK will no longer be covered by the directive, and the EU has agreed that holders of UK qualifications who have been registered in EEA countries and Switzerland will continue to be registered. However, in the absence of an agreement with the EU, recognition of UK qualifications after exit day will be determined by the national policy of the individual member state.

The hon. Gentleman and I have discussed reciprocal international healthcare arrangements on several occasions, both on the Floor of the House and in Committee, and he will recognise that the Government hope that a widespread and encompassing international healthcare reciprocal agreement will be in place with the whole EU after exit day—that is our ambition. In the event of a deal, during the implementation period the current arrangements will pertain and we can look to put in place such a treaty.

[Justin Madders]

Will the Minister give way?

[Stephen Hammond]

One moment, and then I will. As the hon. Gentleman rightly knows, in the event of a no-deal EU exit—which is a lot of what we are talking about this morning—it is the Government’s ambition first to put memorandums of understanding in place and then hopefully to have a widespread agreement with the whole EU or, if not, individual arrangements with member states.

[Justin Madders]

We all hope that arrangements will be in place, but my question was: have any discussions been entered into yet with individual member states about the arrangements in a no-deal scenario?

[Stephen Hammond]

There are ongoing and widespread discussions with the Commission and with member states. A number of member states are of high priority because the numbers of UK nationals currently living there make reciprocal international healthcare arrangements particularly important. A number of issues are being discussed. Given the nature of the discussions, I hope the hon. Gentleman will accept that reassurance.

[Stephen Hammond]

The hon. Gentleman is correct. That is why we discussed in depth the reciprocal healthcare arrangements under the Healthcare (International Arrangements) Bill. Although it is absolutely the Government’s intention, in either a deal or no-deal scenario, to ensure continuity of international arrangements, at the moment that cannot be absolutely guaranteed. I hope the hon. Gentleman heard me say to the hon. Member for Ellesmere Port and Neston that it is the Government’s intention to ensure that, in the event of a no-deal scenario, memorandums of understanding will be put in place. We have already stated that anyone seeking emergency medical care, from wherever they come, will be treated by the NHS. We hope to ensure the continuity of current arrangements in a deal or a no-deal scenario.

To give Members a bit more flavour and depth, let me say, in response to both the initial inquiry, from the hon. Member for Ellesmere Port and Neston, and the inquiry from the hon. Member for Stockton South, that there is understandably a widespread agreement in this area that the current arrangements are to the mutual benefit of the healthcare systems of both the UK and the whole EU and should continue. In that light, very positive discussions are taking place, particularly with the countries where most UK nationals currently reside.

I do not need to write to the hon. Member for Gedling; I can confirm that the regulators will continue to apply the language tests as currently set out.

The hon. Member for Ellesmere Port and Neston talked about the loss of the internal market information system. If the UK exits the EU without a deal, it will no longer have automatic access to the EU systems, including the internal market information system, which regulators across the EU use to exchange information. We hope that the discussion about international healthcare arrangements will continue, but it may well be the case that UK regulators have to seek information from their European counterparts directly, rather than from the Commission. UK regulators are aware of that and are preparing for it, although, as I have said, that may well be part of the discussions about international arrangements and encompassed in a future bilateral or EU-wide international healthcare arrangements agreement. However, the regulations mean that UK regulators will not be required to carry out more assessments of European qualifications than they do now and they will allow bilateral applications for information.

[Justin Madders]

The Minister has been very generous in giving way. We should be clear that, as things stand, the early warning system will not be in operation. It is important to express our concern about that and our sincere wish to put in place an arrangement to avoid it.

[Stephen Hammond]

The hon. Gentleman is absolutely right to raise that concern, but as I have sought to reassure him, it will be perfectly possible for UK regulators and EU regulators, either in whole or individually, to exchange information. It will be possible under this arrangement for UK regulators to seek that information from their individual European counterparts, should they need to do so.

The hon. Gentleman asked about the capacity of regulators to check qualifications. Although it is not the Government’s intention or desire to have a no-deal outcome, regulators have been preparing for that possible scenario. These regulations will ensure that there will be little additional work for regulators in recognising EEA and Swiss qualifications at exit date. Under the regulations, the regulator can choose to review automatic qualifications that it was previously obliged to accept and to designate those qualifications where there are patient and public safety concerns. An applicant will be obliged to supply the regulator with the relevant documents, and if the regulator is not satisfied, it can reject the application. My point is that there is no extra administrative burden on regulators.

On the potential for an additional financial burden, the UK and the regulators have been preparing for a possible no-deal outcome. As the regulations seek to maintain the current systems as far as possible, for at least two years from their coming into force after the expected exit day until the review, there should be little extra cost or impact. There is, as the hon. Gentleman pointed out, the potential for regulators to recover those costs through additional fees, and that is true of current regulatory systems, in many cases.

The hon. Members for Ellesmere Port and Neston and for Linlithgow and East Falkirk asked whether the regulations reduce the ability to safeguard public and patient safety, making the health service less safe. At the heart of these instruments is the recognition that public protection and patient safety must be the foremost ambition; therefore, public protection is the key purpose of regulating health and care professionals. The instruments provide the regulators with the necessary powers to protect the public by introducing the power to designate EEA and Swiss professionals, who they are currently obliged to accept automatically. In addition, they will still be able to check applicants’ language skills and, as I confirmed to the hon. Member for Gedling a moment ago, the language tests will not change.

I was asked about the review process. It is appropriate that a two-year review of the regulations is put in place, which will potentially be wide-ranging and encompassing. The regulations are intended to be subject to review two years after they come into force. As I said earlier, it would be wrong of me either to limit the scope of the review or to predict the factors that may be in place at the time. I am often asked by the hon. Member for Ellesmere Port and Neston and others to commit to reviews of regulations and other legislation, and, as we are committing to a review after two years, I hope that he will accept my assurance on that.

Several hon. Members, including the hon. Member for Linlithgow and East Falkirk, asked me about the impact assessment. There is no significant impact. The impact for the instrument falls below the £5 million threshold of the annual net direct cost to business, as detailed by the business impact target. There is no significant impact on business, and no significant direct impacts have been identified as a result of the changes. Hon. Members have asked about the potential impact regarding allowing recognition so that EEA and Swiss professionals who are valued in the health service can continue to practise in the UK post-EU exit day in a no-deal scenario. That is the impact, and the regulations seek to minimise it. They put in place sensible measures to ensure that that recognition can happen.

Finally, I was asked about whether the regulations support cross-border co-operation between Northern Ireland and the Republic of Ireland. The regulations ensure the continued recognition of Irish professional qualifications in the UK for at least two years after exit day. They allow professionals practising under an existing and temporary or occasional status to continue until the end of that—

Healthcare (International Arrangements) Bill

Justin Madders Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Monday 21st January 2019 Commons Chamber

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

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

[Mr Deputy Speaker (Sir Lindsay Hoyle)]

With this it will be convenient to discuss amendment 1, in clause 5, page 3, line 44, leave out subsections (5) and (6) and insert—

‘(5) Any statutory instrument which contains regulations issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a resolution of each House.”

This amendment would make all regulations issued under this Act subject to the affirmative procedure and require approval from Parliament before they become law.

[Justin Madders]

We want to ensure that there are appropriate safeguards with regard to costs, not least because the Bill currently gives the Secretary of State authority not only to facilitate a continuation of existing arrangements, but to enter into any number of bilateral agreements with individual member states, with very little opportunity for parliamentary scrutiny. It also provides the authority to strengthen existing reciprocal healthcare agreements with countries outside the EU, or to implement new ones across the globe, in line with the Government’s aspiration to develop trading arrangements with countries beyond the EU. There is therefore a potential for the establishment of multiple complex agreements.

New clause 1 addresses the important point that the Bill before us is rightly intended to provide for all reciprocal healthcare arrangements in the future, and to provide for all eventualities. As we know, a no-deal Brexit could lead to a multitude of new bilateral agreements within the EU27, let alone the rest of the world. At this stage, none of us can be clear about how many of those agreements will come into being. We cannot assess their likely cost or impact, and, indeed, the Government’s own impact assessment is inadequate in that regard. It suggests that the cost will be similar to, or lower than, the current £630 million per year.

[Mr Jim Cunningham (Coventry South) (Lab)]

My hon. Friend has mentioned potential bilateral agreements with different countries. Does he agree that there could be a problem if our citizens are not covered when travelling to those countries for a variety of purposes, and insurance companies send premiums through the roof? That is always a big factor, even with the current arrangements in Europe.

[Justin Madders]

It is true that there is some concern in the insurance industry about our potential failure to secure bilateral agreements. I think it inevitable that unless those agreements are secured, premiums will rise. That is why the Opposition support the thrust of the Bill.

It is impossible to provide reliable estimates of the costs of the new agreements in advance without knowing who they would be with or what they would cover. The British Medical Association has said that any prediction of costs is likely to be unreliable, and we cannot afford to give the Government carte blanche.

New clause 1 proposes a sensible and very reasonable requirement for the Government to report back to Parliament annually. It would require the Government to provide details of all payments made by the UK Government for all healthcare provided outside the UK to British citizens. It would also stipulate a requirement to provide details of all payments received by the UK Government as reimbursement for healthcare provided by the UK to all non-British citizens. It would also write into law a requirement for the Government to set out any outstanding payments owed to, or by, the UK Government. This would provide an important opportunity to monitor efficiency in this area and may provide an incentive to address some of the concerns raised by the Public Accounts Committee in its 2017 report, “NHS treatment for overseas patients”, which stated that

“the NHS has been recovering much less than it should”,

and

“The systems for cost recovery appear chaotic.”

Even with the Government’s recent funding announcements, the NHS continues to struggle. I am sure that the Minister would not want to see funds destined for patient care swallowed up by the additional administrative burden created by the introduction of a range of complex charging arrangements and a failure to recover the costs that have been incurred. It is imperative that hospital trusts are not required to shoulder additional financial burdens because of the costs of administering the collection of charges. That is why if the Government are, as the Minister said in Committee, committed to transparency and parliamentary scrutiny, new clause 1 should be supported.

Turning briefly to the amendment that I tabled, we have discussed previously widely held concerns about the scope of this Bill that are exacerbated by the fact that the powers contained within it to create regulations will, in many cases, be subject only to the negative procedure. The Delegated Powers and Regulatory Reform Committee in the other place set out very clearly the potential impact of this Bill should my amendment not be accepted today. It said:

“If…the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure.”

It added:

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

I am sure that is the case, but we must consider how the powers could be used, not just how we would expect and hope them to be used.

There is always merit when examining legislation in considering all potential scenarios as well as the stated intentions of the Government at the time, and in such an unprecedented period of uncertainty it is prudent to consider all eventualities. As the Government have included these powers in the legislation we cannot simply consider the world as it is now, nor how it might be in a year or two—indeed, if anyone knows what the world will be like in two or three weeks’ time I will be very impressed. We need to look at what the world might be like in many years’ time and how the powers in the Bill can be used.

If we require further persuasion about the need for caution, the Committee set out in its report a devastating list of reasons why the negative procedure is inappropriate. It said:

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions (that is, powers and duties, including discretions) on anyone anywhere. The regulations can delegate functions to anyone anywhere.”

The Committee concluded:

“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”

Just for good measure, it went on to describe the powers sought in the Bill as “breath-taking”.

Parliament is not alone in having concerns about the scope of the clause and the lack of clarity about how the powers might be used. In the Committee evidence session, Raj Jethwa, director of policy at the British Medical Association said:

“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6, Q14.]

Picking up on the Committee’s comments, despite the Government having ample opportunity both on Second Reading and in Committee to justify the need for these exceedingly wide powers, I believe that the arguments that they advanced during the passage of the Bill have not only failed to do so, but have strengthened the case for greater scrutiny. The Minister conceded in Committee:

“The Bill also provides flexibility to fund healthcare even where there is no bilateral agreement, which we might explore using in exceptional circumstances to secure healthcare for certain groups of people.”

That is the nub of it: we know the well-rehearsed and necessary reasons why the Bill is required to secure the continuation of arrangements as we leave the EU, but it is on the record that the Bill can potentially do far more than that. We do not know what those exceptional circumstances are, and we do not know who those groups of people might be, and even if the Minister were able to set out here and now what he was referring to in that statement, he cannot bind a successor to that. The Bill gives the Secretary of State what I might describe as Martini powers: any time, any place, anywhere. If he is to have such wide powers they must at the very least be subject to the affirmative procedure.

The Minister also said in Committee that not only would the Bill encapsulate existing healthcare agreements but that it

“will potentially add to their number as part of future health and trade policy.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 29 November 2018; c. 23-24.]

That is also a concern. I do not know whether the Minister intended it to come across as it did, but it sounded very much to me as if the Government were intending to couple trade negotiations with access to healthcare. I hope that that is not the case.

Many people have expressed concern over a number of years that the Government appear willing to open up the NHS to American private healthcare companies as part of trade negotiations, but I am not sure that many people imagined that the Government also had designs on opening up the NHS to patients around the world as part of a strategy to secure trade deals with other nations. Perhaps I am wrong about that, but it is clear that the Bill can be used in that way, which is why any arrangements ratified under it need proper scrutiny.

We also to consider the impact of new arrangements on the NHS. Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, said in the Committee evidence session:

“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]

We went through some of the implications of that when discussing new clause 1.

Finally, there is a practical element to this. As we know, under the negative procedure, once an instrument is laid in draft it cannot be made law if the draft is disapproved within 40 days. This would be done via a prayer against, usually by way of an early-day motion. If that is not invoked then the legislation is passed. Under the negative procedure, that is still a 40-day process in the best-case scenario, and if we leave without a deal the Secretary of State in the next three weeks will have to reach agreement with each of the 30-plus other countries, sign those agreements, draft statutory instruments and lay them before Parliament so they are with us no later than Friday 15 February, the last date on which they could be laid in order for them to be passed by 29 March—and that is assuming they are not prayed against.

If we assume this Bill completes Third Reading today, that gives the Lords about three weeks to complete their consideration—and the Minister will no doubt be crossing his fingers that they do not table any amendments. That seems to be a tall order, and given the Committee’s comments on this amendment the Lords may well be minded to send the measure back to us, but in either case it all seems rather a tight, if not unrealistic, timetable. I therefore urge the Minister to think through the practicalities of this; the affirmative procedure could be significantly quicker than the negative one, and it has the advantage of being far more transparent.

The Minister tried to reassure me in Committee that there would be adequate scrutiny by virtue of the Constitutional Reform and Governance Act 2010, but I am afraid that that just does not cut the mustard. Under that Act, there is a specified process enabling Parliament to object to a treaty being ratified within 21 days, but that does not automatically lead to a debate and a thorough examination of the issues of concern. The Act simply says that in the event of an objection the Government must issue a statement setting out why they still want to ratify; this process could apparently be repeated ad infinitum, and crucially under the Act there is no requirement for a debate. It would be open to either Government or Opposition to set aside some of their allotted time to facilitate a debate, but there is no requirement to do so. In addition, there are exceptions that enable the Government to ratify treaties outside the Act—for example, if there are “exceptional circumstances”, which of course is a judgment that is within Government’s gift. The measure does not cover memorandums of understanding either, and some of the older reciprocal healthcare arrangements fall within that description.

Putting new agreements into force in these extraordinary circumstances is necessary, but we simply cannot accept the clause as it stands. No matter how well-intentioned everyone might be now, once that power has been given away it is not easily taken back. Do Members want us to fund hip replacements in Arizona? Are Members comfortable with access to the NHS being used as a bargaining chip in trade deals? Of course they are not, so why do they not vote for the amendment tonight?

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

I suspect this debate will be slightly less contentious than the earlier statements, and probably a lot quicker.

The Bill basically gives powers to the Secretary of State to agree reciprocal deals. However, I believe that we will not get a better reciprocal arrangements than those we currently have. We recognise the need for all these arrangements to continue, and the Scottish Government will do all they can to work with the UK Government to ensure that they do, and of course we note the legislative consent motion that has been granted. Through the Joint Ministerial Committee we believe a common framework system can be achieved that ensures these specific health arrangements can be administered through common agreement between the UK and Scottish Governments. Clearly, Brexit threatens the loss of reciprocal healthcare arrangements for millions in Scotland and across the UK. The Bill’s impact assessment makes this conclusion in relation to a no-deal scenario:

“If UK citizens in the EU are treated as 3rd country nationals (i.e. they cease to have rights of movement and access to services in EU Member States, and are treated like citizens coming from non-EU countries) some may face additional financial costs or difficulties accessing healthcare services, with potential implications for their health and wellbeing.”

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 15th January 2019 Commons Chamber

[Stephen Hammond]

My hon. Friend is right, and we are ensuring more routes into the nursing profession, such as nursing apprenticeships and nursing associates. We are training more GPs, and we are determined to get 5,000 extra GPs into general practice. A record 3,400 doctors have been recruited into GP training and, as part of the long-term plan, newly qualified doctors and nurses entering general practice will be offered a two-year fellowship to support them to stay there.

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

The long-term plan admits that staffing shortfalls are “unsustainable”, yet incredibly there is no mention anywhere in the document of the damage done by the abolition of the nursing bursary. The plan contains an ambition to double the number of volunteers within three years, and although we should rightly celebrate the fantastic contribution made by volunteers, is it not damning that, with a record 100,000 vacancies in the NHS, the main plank of the Government’s strategy to tackle the workforce crisis is to rely on volunteers?

[Stephen Hammond]

The hon. Gentleman is right to say that volunteers in the NHS provide an invaluable service, but he is completely wrong to suggest that any part of the long-term plan relies on volunteers. There is an expansion in numbers of nursing associates to deal with those vacancies and, as I have said to other hon. Members, we have seen an increase in the number of doctors in GP training. Obviously, he will welcome the £20.5 billion a year that is going into the national health service. That will inevitably mean more doctors and nurses, which is why we are making more training places available.

NHS Reorganisation

Justin Madders Excerpts

Wednesday 12th December 2018 Westminster Hall

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

Thank you, Mr Gapes. I am sure hon. Members will be keen to return for the remainder of my speech, however long that turns out to be. It is of course a pleasure to serve under your chairmanship.

I congratulate my hon. Friend the Member for Warrington South (Faisal Rashid) on securing this extremely important debate. It is also very timely as we eagerly await the NHS long-term plan. He made a powerful case about the weaknesses in the Government’s approach and the disgraceful lack of parliamentary oversight of very significant changes to local and national services. I agree that the creation of the NHS was one of the great achievements of this House and this country.

My hon. Friend was right in his analysis of the Health and Social Care Act 2012. He highlighted his concern about accountability in CCGs and the potential for conflicts of interest in them. He also highlighted the lack of transparency that has characterised the STP process since its inception, and he summed up the benefits, from the patient’s perspective, of good integration —of course, no one wants to have to repeat their story on multiple occasions.

My hon. Friend talked about the challenges that the NHS faces with its infrastructure. He will know that those challenges have been exacerbated by the continual capital raids on budgets. His analogy about a football team was amusing—sadly, my own team appears to be taking things rather too seriously at the moment—but it did sum up a lot of the confusion and the illogical approach that we have to healthcare in this country. He was of course right to say that the hard-working staff of the NHS bear the brunt of these many pressures. He also made the point that many of the changes that we have been talking about have not been made in the most open way.

We also heard from my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh). She followed up her question to the Prime Minister with a much more detailed, and devastating, critique of the proposals that affect her constituency. I was staggered to hear that £50 million has been spent on consultation so far. It was also disturbing to hear how bad things are at her accident and emergency department now, before we enter the real depths of winter. I was staggered to hear about the approach to consultation there. I am sure the Minister will want to address that. [Interruption.]

[Mike Gapes (in the Chair)]

Order. We will break for 15 minutes, I hope, and come back as soon as possible.

--- Later in debate ---

On resuming—

[Justin Madders]

Before we were interrupted by important business in the Chamber, I was referring to contributions from other hon. Members. The hon. Member for Strangford (Jim Shannon) gave his perspective from Northern Ireland, and set out clearly what a proper consultation should look like—a standard that, as we have heard, is not really being reached by the NHS at the moment. He also raised issues with the GP out-of-hours service. That is slightly beyond the scope of the debate, but he is right to say that the issue covers the whole United Kingdom. Indeed, recently there have been numerous newspaper reports about people having to wait for many weeks to get a GP appointment.

Looking at current NHS performance, it is clear that, on all key performance measures, as my hon. Friend the Member for Warrington South said, the NHS is struggling to keep up with demand. A&E performance is at a record low this year. More than 4 million people are stuck on waiting lists, and cancer targets are being repeatedly missed. This has led to the Government effectively giving up on trying to meet the NHS’s constitutional targets. As my hon. Friend said earlier, waiting lists for operations are likely to hit 5 million people within the next three years. While the eight years of a financial plan that has failed to keep up with demand have clearly been a driver of that failure, it is also clear that the 2012 top-down reorganisation has exacerbated the issues that the NHS faces.

We have been left with a fragmented, marketised system, which prevents the kind of transformation and integration of services that we would all like to see. At a time when everyone is calling for various parts of the health and social care sector to work together, we remain bound by legislation. As my hon. Friend said, it is this legislation that enforces a siloed, market-based approach, which imposes statutory barriers to integration.

Against this backdrop we have seen a whole series of acronyms encapsulating a range of reorganisations to health services, including STPs, ACOs, ACSs, ICPs, ICSs and so on—all part of what the Health and Social Care Committee has described as a culture of

“changing titles and terminology, poorly understood even by those working within the system.”

It is all clearly an attempt by NHS leadership to reverse the impact of the Health and Social Care Act 2012 by any means that do not require primary legislation or parliamentary oversight. These reforms could have wide-ranging impacts, from causing walk-in centres, cottage hospitals, maternity centres and A&Es to relocate or close altogether, to introducing a new form of 10-year contract, which raises the spectre of private companies once again running our local health services.

I know the Government are not particularly fond at the moment of testing the will of the House, but something as fundamental as transforming our most treasured asset clearly should not be taking place without parliamentary consent. Ministers and NHS leaders are tiptoeing around the 2012 Act, but if we are to have meaningful proposals and an effective integration process, we need an admission that that legislation has had its day. To all intents and purposes, the 2012 Act is no more; it has expired and gone to meet its maker. Yet the Government refuse to acknowledge that central fact.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others a vast and unwieldy network of commissioners and providers with completely different approaches was put together at very short notice. The only beneficiaries of that process seem to be the private consultants who were drafted in to complete these hastily arranged plans. Professor Chris Ham has pointed out that

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Despite the fact that plans were designed to cover the period from October 2016 to March 2021, NHS England and NHS Improvement said in a letter to local leaders last month that sustainability and transformation partnerships and integrated care systems will be expected to develop and agree their plans during the first half of 2019-20. Will the Minister update us as to how many of the 44 STPs developed as part of this process have, as NHS Providers puts it, had no further work done? What was the cost of developing those plans? Can the Minister justify forcing the entire health and social care sector to stop what it was doing and embark again on a hasty and expensive process to come up with new five-year plans, only to be asked to do the same again a few years later? In the few local areas that have proceeded to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean.

The accountable care organisation—now rebranded as integrated care provider—process has the potential to radically alter the entire health and social care landscape, but, again, it is continuing without any parliamentary legislation. One of the primary concerns about that new model is that it would be compulsory to advertise the contracts to the market, and commissioners are forbidden from discriminating between NHS and non-NHS bidders. Bids can be made by a group of organisations, so an NHS trust or a group of GPs could partner with a private company. Previous high-profile attempts to do this kind of thing in Staffordshire and Cambridge collapsed spectacularly with millions of pounds wasted. As my hon. Friend said, it is also deeply worrying that one of the criteria used to assess bids will be whether they are able to deliver value for money. That marks a significant change to the status quo, and one that I do not believe should be countenanced without new legislation.

I have heard Ministers speak on several occasions to assure those of us who have concerns that this will not see mass privatisation. However, during the debate on integration in September, the previous Health Minister, now the latest Brexit Secretary, was asked four times by Conservative, Scottish National party and Labour Members to expressly rule out new organisations being run by the private sector. He failed to do so on every occasion he was asked. Is the Minister now prepared to give that kind of assurance, and if not, why not?

It is also less clear what will happen in the event that an ICP ends up in deficit, particularly if a private sector organisation or a charity has won the contract. While the consultation document sets out that efforts will be made to ensure that ICPs are financially viable, the same assurances have been offered about the existing configurations, and almost half of all NHS providers were in deficit last year. That has led us to the disastrous situation where, according to the 2017-18 accounts published by NHS Improvement, NHS providers owed the Department of Health and Social Care more than £11 billion, up from £8.1 billion in the previous year. That sharp increase was a result of bail-outs given to trusts that ran into deficit as a result of underfunding. Borrowing from the Secretary of State now exceeds private finance initiative liabilities. In 2016-17, £1.3 billion was repaid from trusts to the Department, of which £161 million was interest. Can the Minister set out what will happen if an ICP reaches financial deficit or collapses?

One thing that is clear from the draft ICP contract is that if the annual budgets provided are not sufficient to deliver the current levels of service, the ICP will be responsible for “managing changes in demand.” While there are merits in a system that incentivises keeping people well, there is a clear danger that demand will be managed by rationing access to treatment. Will the Minister rule out unilateral rationing of services by ICPs if they cannot keep to their budgets? What safeguards are in place to prevent further rationing of services, and who will be accountable in the event that patients want to challenge such a situation? It is far from clear who will ultimately make these decisions and who will be accountable for them. Where the split between the legal commissioner and provider is technically maintained, it is impossible to see in practice how an ICP would not be taking on core commissioning functions.

All this raises the spectre of a new postcode lottery, where patient experiences are uneven depending on who was contracted by an unaccountable panel of commissioners. The whole approach is farcical, and none of this has come before the House for what could be described as a meaningful vote. Experts from across the health and social care sector, and even the chief executive of NHS England, have all acknowledged not only the desirability, but the inevitability of new legislation. Will the Minister commit as part of the NHS long-term plan to set out in full the direction of travel for NHS reorganisation, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for the necessary primary legislation?

[The Minister for Health (Stephen Hammond)]

It is a pleasure to serve under your chairmanship, Mr Gapes. It is a pleasure to respond to the hon. Member for Warrington South (Faisal Rashid). I am pleased that he secured this debate, and I agree with him that the NHS is a great credit to our country. I know that the Opposition spokesman will have heard me say yesterday—I will repeat it—that the Government and I, as Minister for Health, greatly value the staff who work in the NHS. It is our absolute intention to ensure that they recognise that and that we continue to show that.

I want to start with a few facts, because having listened to what the hon. Member for Warrington South described, I think there are other things that are worth pointing out. There are 11,000 more nurses in the NHS than there were in 2010. There are 18,200 more doctors than in 2010. Almost nine out of 10 patients are seen within four hours in an emergency department. We are committed to 5,000 training places for doctors in general practice—this year saw 10% more than we aimed to achieve. Of course, this is the highest level of funding that the NHS has had in its 70 years. The hon. Gentleman raised a number of other issues, as did the Opposition spokesman, and I will try to respond to those in my speech.

The hon. Member for Mitcham and Morden (Siobhain McDonagh) made a contribution. I have immense respect for her. Anyone who knows her knows that she always argues her case passionately and stands up for her constituents, and she did that again today. She and I have occasionally shared joint endeavours on St Helier Hospital. I think we both agree that there is a substantial case for keeping the acute services there. I think we would both agree—I say this in a constituency capacity—that the infrastructure needs upgrading, and I think we have had that discussion. She rightly points that we have had another consultation this year. As a Minister, I say that we expect any significant service changes to be subject to exactly the full public consultation she has described, if it is going to happen, and that the proposals must meet the Government’s four reconfiguration tests, which are support from GP commissioners; strengthened engagement with the public; clarity on the clinical evidence; and clarity and consistency with patients’ choice. She says that there have been rounds of consultations, as I certainly saw when I was on the council—I think she was already a Member of Parliament then—under Governments of all colours over the past 20 years.

It is the same with the hon. Member for Strangford (Jim Shannon). I have had the pleasure of taking interventions from him in several debates. He is always a powerful advocate for his constituents. I listened carefully to his point about out-of-hours care, which may have been slightly out of the scope of the debate. Yesterday, I had the chance to visit the North Middlesex University Hospital. Some of its work on the integration of out-of-hours care and triaging in A&E moves along the lines that he discussed. I have seen that several times.

To address the crux of the debate, between 2016 and 2036, the UK population is expected to increase from 65.6 million to 71.8 million, which is a growth rate of about 10% in 20 years. In the same period, the number of people aged 75 and over is expected to grow by 64% from 5.3 million to 9 million. Those figures are clearly something to celebrate, showing that the NHS is doing exactly what we want it to, but they mean that more will need to be done to make sure that those years are quality years.

For the NHS to continue to deliver high-quality care in the next 20 years, as it has done for the last 70 years, we need to look at new models of care that promote more joined-up care across the NHS and social care. In the past few years, the Government have supported a number of pilots at local and national levels to test new models of care that bring together the NHS, local authorities and wider public services to develop new ways of ensuring that services are delivered in a more joined-up way. Those areas have seen some improvements in access to services, patient experience and moderating demand for acute services.

It is time for the NHS to move beyond those pilots and embrace wholesale transformational changes across the whole system in every part of the country. It is therefore developing a 10-year plan for its future, which is underpinned by a five-year funding offer. To support the NHS in delivering for patients across the country, the Government announced a new five-year budget settlement for the NHS, in which funding will grow on average by 3.4% each year to 2023-24. The hon. Member for Strangford, who has just left the Chamber, welcomed the fact that that means the NHS budget will increase by more than £20 billion compared with today, underpinning the 10-year plan to guarantee the future of the NHS.

The hon. Member for Warrington South remarked on sustainability and transformation partnerships, and commented on his own local STP. The Government are fully committed to NHS England’s vision of STPs transforming how care is delivered and putting the system on a sustainable footing for the future. We will back STPs where they are clinically led and locally supported.

The hon. Gentleman questioned some aspects of local democracy. Each partnership has to set out agreed priorities and say how they are going to be delivered, and have a strategic priority to work with partners in local authorities. The Cheshire and Merseyside STP is making some progress in building those relationships, but he is right to acknowledge—I acknowledge it as well—that it is an extremely large and diverse area.

Clearly, the hon. Gentleman and the hon. Member for Ellesmere Port and Neston (Justin Madders) will recognise that there are now nine local footprints, including Warrington Together. The idea is that they will develop some of the integration suggestions and plans, and the consultation with local authorities to which the hon. Member for Warrington South referred. The STP brings local areas together to tackle the challenges, and I think he would acknowledge that it makes sense to do that across a bigger area, so the smaller areas build into the larger area.

Last week, the Government announced that they were supporting the Cheshire and Merseyside STP with £11 million in capital spending for improving emergency department capacity at the St Helens and Knowsley Teaching Hospitals and for a 12-bed, tier-4 child and adolescent mental health services unit at Alder Hey Children’s Hospital. The hon. Member for Ellesmere Port and Neston challenged me on STPs, so I will say that, in their more mature form, they are integrated care systems that promote collaboration between NHS bodies, local government and local communities. The 10-year plan will set out how they will spread the integrated care models that have been developed and tested through the whole vanguard programme.

There was also a challenge about what were formerly known as accountable care organisations and are now called integrated care providers, with several questions about that. At a small number of sites, commissioners are looking at how contractual models can support more integrated care. To support that, NHS England has developed the draft integrated care provider contract which, if introduced, will give the NHS the option of having a single lead provider that is responsible for primary, community and hospital services, with the aim of integrating services across traditional silos.

If NHS England chooses to introduce a contract for the ICPs, Parliament will have a chance to debate the regulations. I recognise that the regulations are subject to the negative procedure, so there is not an automatic debate, but as the hon. Member for Warrington South will have spotted, in those circumstances, if Parliament decides, there will be an opportunity to have that debate. NHS England has recently concluded the public consultation on the draft ICP contract and we expect a response in due course.

I want to touch on the premise that the ICP contract is privatisation. It is completely misleading to suggest that an integrated provider model is a step towards privatising the health service. The NHS will always offer free healthcare at the point of use—that is not just the Government’s view. I am sure that the Library briefing that the hon. Member for Strangford challenged me to read notes the evidence from the Health and Social Care Committee, whose Chair, my hon. Friend the Member for Totnes (Dr Wollaston), said that the evidence received by the inquiry into integrated care—the report was published in July 2018—was that ICPs

“and other efforts to integrate health…and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”

That is quite powerful and I hope that the hon. Members for Ellesmere Port and Neston and for Warrington South take note.

[Justin Madders]

I know what the Select Committee said; I am interested in what the Government are saying. Is the Minister ruling out any private provision from ICPs?

[Stephen Hammond]

I am not ruling out private providers from bidding, but it has been made clear, and I say again, that we expect any ICP contract to be won by NHS bodies. As I said, the evidence to the Select Committee inquiry tends to support that that is our view and that is what is likely to happen.

The Government have made it clear that the change is not about reorganising the NHS from the centre or adding more layers to an already complex system. As the Prime Minister reiterated in her speech in June, the Government should learn the lessons of the past and not try to impose change on the NHS. To achieve that, we firmly believe that any changes to the model of care for patients need to be locally led, informed by knowledge of the population and the population need, and supported by clinicians on ground.

That is why we have asked local leaders in STPs and integrated care systems to create five-year plans detailing how they will improve local services for patients and achieve financial sustainability. Of course, this is something that we may want, but it cannot just be wished into being, which is why the Government are supporting the NHS with £20 billion of additional funding.

Local plans will build on the work of the last three years to develop new ways of delivering services and enhance collective efforts to use that additional funding to improve people’s health and wellbeing. It is essential that that process proceeds in a spirit of genuine partnership and that all local partners, including local government, are fully involved from the outset.

For any significant system reconfiguration, we expect all parts of the system to be talking to the public regularly; it is vital that the public shape the future of their local services. That relates directly to the point that the hon. Member for Mitcham and Morden made earlier. To make it absolutely clear, no changes will take place without public consultation and engagement.

After all, the aim of integrating services is not an end in itself; it is to improve the patient experience and quality of care, so it is essential that the views of the public should be at the heart of local plans. Integrated care means a health and care system built around people’s needs, whereby physical, mental and social care needs can be addressed together, and patients should feel as if their care is being provided by one organisation.

Integration also gives us the means to avert ill health, preventing unnecessary hospital visits and supporting patients to have happier, healthier lives into old age, and taking the pressure off NHS staff. For example, in Thanet, the Margate Task Force is an integrated service that brings staff from 16 different agencies together in a single “street-level” team.

In conclusion, integrated care provides the best opportunity to ensure that the NHS continues to deliver the highest level of quality services to people and to meet the demands of the 21st century. The Government have supported the NHS to implement the five-year forward view and to develop new integrated ways of working to meet those demands. It is now time to drive those initiatives and spread them across the whole country. That is why we are committed to those plans and it is why we have committed to increase the NHS budget, to support the national move towards integrating care.

NHS: Staffing Levels

Justin Madders Excerpts

Tuesday 11th December 2018 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Hollobone. I congratulate my hon. Friend the Member for Batley and Spen (Tracy Brabin) on securing this extremely important debate, and on the tour de force that she presented. She touched on many important issues. Time restrains me, so I will not be able to pick up on all the points that she made, nor on all the impressive contributions made by other Members, particularly those who have had frontline experience, and had practical examples that we need to look into further.

My hon. Friend talked about her local trust being a big employer in her constituency and beyond. Indeed, it employs some 8,000 people, but has a 10% vacancy rate—sadly, very much in line with the national average. She was right that covering the gaps in the rota is an expensive business. I was pleased to hear that so many initiatives were being undertaken by the trust, but the fact that there is still a 10% vacancy rate shows that something is broken with the system.

My hon. Friend highlighted the impact on patients that staff shortages can have regarding closures, and she was right to highlight the nursing workforce crisis and the whole range of specialisms that are at risk. She was also right to raise the uncertainty that Brexit brings to staff, and to highlight the lack of legal powers to require safe staffing levels, and the overall strategy that we need to get the correct staffing levels.

I was also delighted, as always, to hear from my hon. Friend the Member for York Central (Rachael Maskell). She was right that agency spend sucks away vital resources and that recruitment challenges will never be solved unless we get the right framework. That is why we deeply regret the abolition of the nurse bursary, to which I will return.

We know that the NHS workforce is extraordinary. The NHS is one of the biggest employers in the world, and we must pay tribute, as we do every time, to the staff who work so tirelessly, day in and day out. We also have to recognise that there are simply not enough of them. Last month, the King’s Fund, the Nuffield Trust and the Health Foundation joined forces and warned that the staffing crisis in the NHS is deepening so fast that the service could be short of up to 350,000 staff by 2030. That warning is stark. Clearly there is an existential threat to the NHS if action is not taken to address the staffing crisis that we are now being told about.

According to official figures, there were more than 102,000 vacancies across the NHS at the end of September. That means that one in 11 posts in the NHS is currently vacant. The chair of NHS Improvement, Baroness Harding, recently acknowledged that

“the single biggest problem in the NHS at the moment is that we don’t have enough people wanting to work in it.”

However, the issues that we face run far deeper than merely how attractive the profession looks to applicants.

As my hon. Friend the Member for Batley and Spen said, we face a perfect storm of a retention crisis caused by factors including pay and conditions, ongoing uncertainty about Brexit, demographic challenges in many sectors of the workforce and the ongoing impact of the catastrophic decision to scrap bursaries for nurses, midwives and allied health professionals. Although many of those issues are clear and long-standing, there is no credible overarching strategy to address any of them. As the House of Lords Select Committee on the Long-term Sustainability of the NHS found, the lack of such a strategy

“represents the biggest internal threat to the sustainability of the NHS.”

We all eagerly await the publication of the NHS long-term plan, but I would welcome the Minister’s confirmation of precisely when that will happen. I was deeply concerned to hear Simon Stevens’s comments about how the plan will not definitively address staffing problems. Will the Minister confirm whether that is the case? If so, when will we see the comprehensive strategy for the NHS workforce that we so desperately need?

As many hon. Members have said, the workforce crisis has been compounded by the abolition of undergraduate nurse bursaries. When it was announced that bursaries would be abolished, we were told that our many concerns were misguided and that the changes would lead to an additional 10,000 training places being provided. However, just as everyone but the Government predicted, the exact opposite has happened. As of September 2018, almost 1,800 fewer people are due to start university nursing courses in England, while the number of mature students has plummeted by 15%.

In our debate on nursing higher education on 21 November, the Minister said:

“We expect NHS England to clearly set out its commitment to the nursing workforce in the long-term plan, and ensure that there is a clear way for that plan to be implemented…The Government will be consulting on the detailed proposals on future funding for higher education that the RCN has put forward”.—[Official Report, 21 November 2018; Vol. 649, c. 372WH.]

Will he provide greater detail on that point and say when that consultation will take place?

The issues that hon. Members have discussed today are acute, systemic and entrenched, but they have been exacerbated by the Government’s short-term and flawed approach. Any long-term strategy for the NHS will fail if it does not address them. Staff and patients deserve more than a health service in a constant state of crisis. They deserve better than this Government.

Healthcare (International Arrangements) Bill (Second sitting)

Justin Madders Excerpts

Committee Debate: 2nd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

It is essential that the Government take appropriate measures to ensure that we can respond flexibly to facilitate healthcare for UK nationals abroad, and that is ultimately what the clause is about. In my closing remarks on the clause, I stress to members of the Committee exactly how vital it is for the Government to retain sufficient flexibility to facilitate the access to healthcare abroad across a range of potential EU exit outcomes. The powers in the clause will ensure that the Government can make regulations to provide for complex and varied schemes, such as EHIC, should they be part of future reciprocal arrangements. I recommend that the clause stand part of the bill.

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

It is a pleasure to serve under your chairmanship, Mr Stringer. First of all, I join the Minister in thanking those witnesses who came and gave evidence on Tuesday. There were certainly some helpful comments that we will no doubt return to in Committee.

As was made clear on Second Reading, this is a very important piece of legislation. More than 190,000 UK expats live in the EU and of course there are 50 million British visits within the EEA countries each year: all those people want clarity about what the arrangements are in the event that they will need healthcare. So we do not oppose the principle of the Bill. We absolutely agree that it is important that there are arrangements in place after 29 March 2019 and into the future. However, we are concerned about a number of issues, some of which I referred to on Second Reading and some of which we will discuss today.

It is fair to say that there are concerns about the breadth of powers that the Secretary of State is requesting in clause 2; I do not believe they would be countenanced at all under normal circumstances. I appreciate that we are not in normal circumstances and I am grateful to the Minister for setting out how he envisages those powers will be used in practice. We are not here to judge things just on what the situation is at the moment, but on how the powers could be used at some point in the future. With regard to that, the Minister referred to this Bill being used possibly to further foreign policy and trade objectives. When he responds, I would be grateful if he expanded on what he has in mind.

To compound our issues about the scope of the regulations, we are also concerned about our lack of opportunity to scrutinise them; we will return to those concerns when I move amendment 2 to clause 5 later on. Of course, we are not alone in having concerns about the scope of this clause and the lack of clarity about how the powers might be used. In the evidence session, Raj Jethwa, Director of Policy at the British Medical Association, said:

“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6.]

We will certainly push for that today.

The Delegated Powers and Regulatory Reform Committee in the other place went further than that, describing the scope of clause 2 as “breath-taking”. As that Committee correctly pointed out, there is no limit to the amount of any payments, to who can be funded or to the types of healthcare being funded. The regulations can confer or delegate functions to anyone, anywhere, and primary legislation can be amended for these purposes.

It is also worth noting that although this legislation has been presented as a Bill to enable us, as far as possible, to retain the arrangements that we already have—who would disagree with that?—the powers conferred by the clause, as I think has been conceded by the Minister, can go far beyond the current EU and EEA countries that we are primarily concerned about.

We consider the powers in the clause to be inappropriately wide, if they are not going to be subject to the correct levels of scrutiny. At this eleventh hour, we understand why a certain level of flexibility is being sought by the Government, but with that request comes a responsibility to ensure that proper parliamentary scrutiny is exercised.

Rather than oppose the clause in its entirety, we believe that the appropriate remedy would be to ensure that any regulations introduced under the Bill will be subject to the affirmative procedure. We will return to that point when we consider amendment 2 to clause 5.

[Stephen Hammond]

The hon. Gentleman is right to say that these powers are flexible. Part of the reason for that is that there may well be a need to anticipate the sort of bilateral arrangements that we put in place in the future—notwithstanding our hopes that we will secure a continuation of the current reciprocal healthcare arrangements, which is our ambition. When we come to debate not only the hon. Gentleman’s amendment, but clause 5—when the discussion on scrutiny of these arrangements should take place—I will seek to reassure him that the procedures in place will allow for the usual and appropriate parliamentary scrutiny of the Bill.

The hon. Gentleman talked about the powers being too broad. The Bill has a very focused purpose: to ensure that the reciprocal healthcare arrangements, which benefit UK nationals abroad and also EU and non-EU nationals in the UK, are continued. He also challenged me on the issue of potential future trade or foreign policy objectives. As he will know, we already have arrangements with a number of countries outside the EU, and the Bill must have the flexibility for the continuation and updating of those arrangements. The matter will clearly be of operational importance—potentially, it will be a policy decision after exiting the EU. Were a UK holidaymaker going abroad to a non-EU country, they would clearly expect the Government to have in place—or to have the potential to put in place—the reciprocal healthcare arrangements that would allow them to be treated should that be necessary.

I hope those words will satisfy the hon. Gentleman that the clause needs to stand part of the Bill. We can have the appropriate discussion about scrutiny in somewhat more depth when we debate clause 5.

Question put and agreed to.

Clause 2 accordingly ordered to stand part of the Bill.

Clause 3

Meaning of “healthcare” and “healthcare agreement”

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

--- Later in debate ---

[Stephen Hammond]

I will try to limit my comments, given that we have already had discussions on the amendment. I am sure that will be welcome on this cold November day in a rather warm room.

Clause 4 provides a clear legal basis for processing personal data under the Bill for the purposes of UK data protection legislation. At present, the EU regulations provide a lawful basis for processing data for the purposes of reciprocal healthcare. Personal data is integral for providing healthcare abroad. It is vital that authorised persons in the UK can process data for that purpose. The clause ensures that, after exit day, there is a clear and transparent basis for processing personal data for the purposes of providing healthcare abroad, as required by UK data protection legislation. Clause 4 will ensure that safeguards are in place for that processing.

Subsection (1) limits processing to that which is necessary for the purposes of the Bill. Subsections (2) and (3) ensure that any such processing must remain in compliance with UK data protection legislation and the Investigatory Powers Act 2016, and any other relevant restrictions. Finally, the persons who can process data under the Bill are limited to those authorised in subsection (6), which we have just discussed.

The safeguards limit the scope of clause 4 to what is necessary and proportionate to provide healthcare abroad. For reciprocal healthcare, personal data is required to process reimbursements to and from other countries, and where reimbursement is made to a person as well. It is also sometimes necessary for healthcare providers to share medical information to facilitate treatment. The clause ensures that the Government can continue to process personal data as necessary, after exit day, in an effective and lawful way. Personal data transferred from outside the UK will remain subject to the need for safeguards to be put in place before it is transferred. Those safeguards will not be able to be contracted out as part of any healthcare agreement with the EU or member states or third countries.

As I said a moment ago, subsection (1) provides for an authorised person to process data related to the provision of healthcare abroad. Personal data is defined in the GDPR as data that relates to a living person who can be directly or indirectly identified from the data. Specific category data is personal data containing health and genetic data. At present, there are different routes for providing healthcare abroad, such as the S1, S2 or EHIC routes, and each route requires different forms of personal data.

Subsection (2) disapplies the duty of confidence and any restriction on the processing that would otherwise apply. The exemption ensures that data can be disclosed where it is necessary for the limited purposes of the Bill. The measure is necessary and appropriate. For example, authorised persons may need to share data if a person is unconscious and therefore not in a state to provide it themselves. Importantly, as expressed in subsection (3), data processing must continue to comply with the UK data protection legislation, which ensures there are further safeguards around data processing. The GDPR also governs data transfers between the UK and other countries. All EU and EEA countries are bound by the GDPR, which means the relevant national data protection safeguards in each country are adequate, allowing the free transfer of data between countries.

Subsection (3)(a) expressly requires that the processing of data does not contravene existing data protection legislation, and subsection (3)(b) requires that the processing of data must comply with parts 1 to 7 or chapter 1 of part 9 of the Investigatory Powers Act 2016. The only purposes for which investigatory powers may be required are to investigate and tackle suspected cases of fraud and error relating to healthcare abroad.

As set out in subsection (1), the processing of data under the Bill is limited to authorised persons who, as we have discussed, are defined in subsection (6). The list reflects those persons and bodies currently involved in processing data, including personal data under existing reciprocal healthcare arrangements.

I mentioned that, for clarity’s sake, subsection (6)(a) lists

“the Secretary of State, the Treasury, the Commissioners for Her Majesty’s Revenue and Customs, the Scottish Ministers, the Welsh Ministers and a Northern Ireland department”.

Healthcare abroad is entirely managed and operated by the Department of Health and Social Care in co-operation with the Executives in the devolved Administrations and their local healthcare systems. Although the Bill is about the provision of healthcare abroad, it is vital that the Executives of the devolved Administrations are considered authorised persons, since healthcare abroad is often facilitated in co-operation with them. Under subsections (6)(b), (c) and (d), healthcare bodies and providers are considered authorised persons as they are directly involved in the provision of healthcare.

Finally, subsection (6)(e) gives the Secretary of State the power to add to the list of authorised persons, which will ensure that the Government can respond appropriately, whatever the outcome of EU exit. It is also deemed necessary to allow the Secretary of State to respond to the changing demands of systems and operations. In future, duties may change and adding to the list will be difficult, so it is necessary to have the power in place.

Clause 4 is an important component of the Bill. It provides the Government with the necessary power to process and share data that relates to healthcare provided abroad. Therefore, I recommend that the clause stand part of the Bill.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Regulations and directions

[Justin Madders]

I beg to move amendment 2, in clause 5, page 3, line 44, leave out subsection (5) and subsection (6) and insert—

“(5) Any statutory instrument which contains regulations issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a resolution of each House.”

This amendment would make all regulations issued under this Act subject to the affirmative procedure and require approval from Parliament before they become law.

This amendment is probably one of the most important items that we will discuss in Committee. As I made clear when we discussed clause 2, there are widely held concerns about the scope of the regulations, which are exacerbated by the fact that these extraordinarily wide powers, necessary as they may be in the circumstances, are subject only to the negative procedure.

As I referred to earlier, the Delegated Powers and Regulatory Reform Committee in the other place clearly set out the potential impact of my amendment not being accepted when it said:

“If, without such amendment, the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure. Of course, these examples will not be priorities for any Secretary of State in this country.”

I hope that is the case, but we are here to look at how the powers could be used over, possibly, the next 100 years, and not just how we would expect them to be used in the foreseeable future.

Nobody knows where this process will take us, and when examining legislation there is always merit in considering the unlikely as well as the stated intentions of the Government at the time. The Minister’s comments about wider objectives reaffirms the importance of our scrutinising the regulations as much as possible. We find ourselves in an unprecedented situation in Parliament, and it is therefore important that we consider all eventualities.

If Committee members need further persuasion that the amendment should be carried, that Lords Committee set out a devastating list of reasons why the negative procedure is inappropriate. It said:

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere. The regulations can delegate functions to anyone anywhere.”

The Committee concluded:

“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”

The most significant reason why we do not object to the legislation is that the biggest risk at this stage is that arrangements are made that do not safeguard the ability of our constituents, when they travel abroad, or of UK citizens who currently live overseas to access healthcare, as they do now. However, because of the way the Bill is drafted, we will find that we are unable to debate whether those safeguards are in place as a matter of course. We have heard many references to the 190,000 UK expats living abroad and the 50 million or so nationals who travel to EEA countries every year. These are huge numbers of people, and the impact of the legislation on them is potentially huge. We owe it to all those people to ensure that any future arrangements are properly scrutinised.

We also need to consider the impact of any new arrangements on the NHS. As Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, set out in evidence on Tuesday:

“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]

He went on:

“In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q9.]

If we do not agree to the amendment, Parliament could end up in that scenario without any voice.

While there is scope for the affirmative procedure to be used in cases where Henry VIII powers are invoked to amend primary legislation, I think it is pretty clear that potentially the most significant changes to reciprocal agreements that could be enacted under the legislation are those that are subject only to the negative procedure. As we know, the negative procedure means that an instrument is laid in draft and cannot be made if that draft is disapproved within 40 days, normally via a prayer against, which is usually by way of an early-day motion. If that does not happen, the legislation is then passed. That is a 40-day process in the best-case scenario.

If I am correct, and if we leave without a deal, the Secretary of State will have to reach agreement with each of the 30-plus countries no later than Friday 15 February, assuming that Parliament does not sit on the following Sunday. At this stage, who knows where we might end up, but we will assume for now that the sitting days are as set out, so Friday 15 February will be the last day that an instrument can be laid that will pass before 29 March, assuming that it is not prayed against. Hopefully the Minister will be able to advise whether my understanding of the timetable is correct.

Will the Minister concede that, on a practical level, it would be better for regulations moved under the Bill to be moved using the affirmative procedure? We could then get them through scrutiny in both Houses much quicker than the 40-day procedure currently allows.

[Stephen Hammond]

The hon. Gentleman raises some important issues, including the issue at the heart of the clause—the appropriate, necessary and correct scrutiny arrangements for Parliament. Let me be clear at the start: the Government absolutely recognise the importance of appropriate levels of scrutiny of the Bill and its subsequent secondary legislation. It is clearly the hallmark of any effective parliamentary system that there are processes in place by which we draft, consider and test legislation. After all, that is what we are doing today.

The appropriate parliamentary procedure for the scrutiny of regulations made under the Bill that do not amend, repeal or revoke primary legislation is the negative procedure. If I am not able to reassure the hon. Member for Ellesmere Port and Neston and he chooses to press the amendment to a Division, I am afraid the Government will resist it.

--- Later in debate ---

As I set out at the outset of my remarks, we will ensure that the affirmative procedure is in place for anything that amends, repeals or revokes primary legislation. For technical regulations, it is appropriate that the negative procedure is used. Given my remarks about the Constitutional Reform and Governance Act and my reassurances about how we intend to deal with the negative and affirmative procedures, I hope that the hon. Gentleman is reassured and does not feel the need to press the amendment to a Division.

[Justin Madders]

I am afraid the Minister has not managed to reassure me, despite his best efforts. When a Bill would confer power on the Executive, we have to be very careful about giving that power away. It cannot be done without good reason, even in these extraordinary times. I have not heard any justification for giving such sweeping powers to the Secretary of State without adequate scrutiny. No matter how well-intentioned the Minister is in his responses—I acknowledge his sincerity —we do not know who will be doing what in 12 months’ time. As we said earlier, we could be handing a future Secretary of State the ability to enter into arrangements for hip replacements in Australia or such like.

As the Minister said, the regulations will enable the Government to enter into detailed and complex arrangements on future healthcare. That is precisely why we need them to be subject to the affirmative procedure. I appreciate the point about the treaties possibly containing more detail, but this is about how Parliament will be able to scrutinise and challenge those arrangements.

[Stephen Hammond]

The hon. Gentleman will have heard that the treaty arrangements will be subject to parliamentary scrutiny in the normal way. We are discussing the regulations as to how we enact those treaties. I was hoping that he might be reassured by that.

--- Later in debate ---

[Justin Madders]

I am afraid that I am not reassured.

The Minister has not really addressed the practical issue about the 40-day waiting time for the negative procedure. If we enter a no-deal scenario after 29 March, as I said earlier, all the instruments under the Bill would have to be laid no later than 15 February. I am imagining the Secretary of State whisking around the 30-plus countries that we would need to enter into bilateral arrangements with throughout the whole of January, and having to get that all signed up and put on the Order Paper by 15 February. I am actually trying to help the Minister here by suggesting that if we do it by affirmative procedure, we can get these things through Parliament more quickly and with the appropriate level of scrutiny that these arrangements deserve. Therefore, I will push the amendment to a vote.

Question put, That the amendment be made.

--- Later in debate ---

[Stephen Hammond]

Having failed to reassure the hon. Member for Ellesmere Port and Neston, I will have another attempt in this stand part debate. Clause 5 supplements the substantive regulation-making powers in clause 2. It provides detail on the parliamentary procedure, as we have already discussed, that will apply to regulations made under the Bill. Subsections (1) and (2) introduce standard provisions, and are consistent with regulation and direction-making powers in many other Acts of Parliament, such as the Health and Social Care Act 2012 and the National Health Service Act 2006.

The clause is required to ensure that regulations and directions made under the Bill will be fit for purpose. As I have said, the powers in the Bill provide the Government with the flexibility and capability to ensure and implement detailed and complex arrangements concerning healthcare abroad. For example, the Government may use regulations to confer different functions on different bodies, in order that they may implement and operate effectively what may be provided for in an agreed reciprocal healthcare agreement. We do that now in relation to the EHIC scheme, which, as I said earlier, the NHS Business Services Authority administers on behalf of the Department. That administration includes the registering and issuing of EHICs and the processing of EHIC claims.

Future administrative arrangements to implement reciprocal healthcare agreements may reflect the current situation, or may involve conferring different functions on other bodies, as appropriate. Once the arrangements are negotiated, we will be in the best position to decide what the appropriate bodies to administer those arrangements are. We will be able to provide for the practical processes and implementation arrangements through the regulations. Clause 5 provides the Government with the flexibility to ensure that any healthcare arrangements can be implemented effectively and efficiently.

Subsection (3) provides that regulations made under clause 2

“may amend, repeal or revoke primary legislation…for the purpose of conferring functions”,

or

“to give effect to a healthcare agreement.”

I want to try again to reassure the Committee about that. The Government are conscious that Parliament rightly takes an interest in this area and, of course, we share the view about the importance of scrutiny.

This is a consequential power to make amendments to primary legislation, which is limited to three restricted uses: for the purpose of conferring functions, to give effect to a healthcare agreement and to make modifications to retained EU law. It is not a free-standing power; it is a focused power to ensure that we can implement healthcare arrangements effectively. That may involve conferring functions on healthcare bodies, which could involve amending primary legislation.

Subsection (4) provides that:

“Regulations under this Act may amend, repeal or revoke retained EU law”,

which is the body of existing EU law that the European Union (Withdrawal) Act 2018 will convert into domestic law, together with the laws we have already made in the UK to implement our EU obligations. It is vital that the regulation-making powers extend to amending, repealing and revoking retained EU law, because the bulk of the existing provisions that relate to current reciprocal healthcare arrangements with the EU will be EU retained law.

Subsection (4) will ensure that domestic legislation in that area is clear and accessible. It will allow us to amend EU retained law, where appropriate, to give effect to new reciprocal healthcare arrangements. It would be an oversight if the Bill did not provide for such amendment, given that current reciprocal healthcare arrangements with the EU are entirely bound up in EU law.

I stress again that, of course, Parliament will be given the opportunity for the appropriate scrutiny of regulations made under the Bill that amend, repeal or revoke primary legislation. As such, subsection (6) makes it clear that regulations that contain provisions that make modifications to primary legislation will be subject to the affirmative resolution procedure and, therefore, Parliament will have the opportunity to debate them. That is the parliamentary scrutiny procedure befitting Henry VIII powers, and one that allows for proper scrutiny.

Regulations made under the Bill that do not contain provisions that amend, repeal or revoke primary legislation will be subject to the negative resolution procedure. It is our job—and I think it is only right—to ensure that legislation is afforded the appropriate level of scrutiny. Therefore, regulations that are made under the Bill that do not amend, repeal or revoke primary legislation should be subject to the negative procedure, as is normal.

The remit of our regulating powers is focused. They can be used only to give effect to healthcare agreements or to arrange, provide for or fund healthcare abroad, as is clear in the enabling powers found in clause 2(1). Where the UK negotiates a comprehensive international healthcare agreement, whether multilaterally with the EU or bilaterally with EU members, the most important element that sets out the terms of that agreement would be included in the agreement itself, as hon. Members would expect. Regulations that give effect to such an agreement would likely focus on procedural, administrative and technical details, such as the types of documents or forms that could be used to administer those reciprocal healthcare arrangements, which is a point I made earlier.

In a scenario where a comprehensive healthcare agreement is being implemented through regulations made under clause 2(1)(c), that agreement would be subject to parliamentary scrutiny under the ratification procedure contained in section 20 of the Constitutional Reform and Governance Act 2010. That ratification procedure provides an opportunity for parliamentary scrutiny of the substance of the healthcare agreements being given effect to in the regulations made under the Bill. It is for those reasons that I rejected amendment 2, which the hon. Member for Ellesmere Port and Neston moved a moment ago.

The final provision of the clause, subsection (7), sets out the definition of “primary legislation”. To reassure the hon. Gentleman, and the Committee, the Government absolutely understand and appreciate the necessity for appropriate parliamentary scrutiny. The level of scrutiny must reflect the substance of the piece of legislation. That is what I believe the clause does, and I therefore recommend that it stand part of the Bill.

[Justin Madders]

The Minister and I will not agree on that, unfortunately. I will not repeat the arguments that we have already gone through, but I will remind hon. Members that the Lords Delegated Powers and Regulatory Reform Committee described the powers and regulation as “breath-taking”, and said that

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere.”

The scope of the clause is breath-taking. Although the Minister is trying to reassure us, as parliamentarians, we need the security of the affirmative procedure.

[Christian Matheson (City of Chester) (Lab)]

I am grateful to my hon. Friend and constituency neighbour for giving way. Would he have been a little more reassured by the Minister’s attempts at reassurance if this was not part of a process and of a pattern of behaviour by the Government? There have been power grabs and the use of Henry VIII clauses throughout the Brexit process.

[Justin Madders]

I thank my hon. Friend and neighbour for his intervention. He is absolutely right. One of the things that was stated during the referendum campaign was that Parliament should take back control, and that is what I believe should be happening following the result. Parliament needs to make sure that, as much as possible, the legislation that will be necessary in the coming months is subject to full parliamentary scrutiny. That is why the affirmative procedure should be included in the clause, which we cannot support as it currently stands.

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

Healthcare (International Arrangements) Bill (Third sitting)

Justin Madders Excerpts

Committee Debate: 3rd sitting: House of Commons
Thursday 29th November 2018 Public Bill Committees

Brought up, and read the First time.

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

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

It is a pleasure to serve under your chairmanship, Mr Streeter. I recall that the first Westminster Hall debate that I secured was under your chairmanship. Indeed, you were also in the Chair the first time I was the Opposition Front-Bench spokesman in a Bill Committee. In these turbulent times, you are a consistent and familiar face—certainly to me and, hopefully, to many other hon. Members.

Reciprocal healthcare is of most importance for those countries where it is accessed most—none more so than on the island of Ireland. When the British Medical Association gave evidence on Tuesday, it was clear about the success story that has been achieved, particularly in the border area, particularly with a dispersed population of around 2 million. It said:

“Given the population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, there have been some fantastic examples of where clinicians have either co-located services in a particular trust or facility where there is not the demand from the local population to warrant it, or travelled across the border to work on different sites.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q10.]

Fiona Loud from Kidney Care UK raised the example of patients who currently cross the border daily for their care and treatments. She also mentioned organ donation and organ sharing, and the need to ensure that the existing and very successful arrangements that we have are preserved.

It is easy to talk about scaremongering when we raise the spectre of patients being turned away at the border, and I am sure that we will all do our utmost to ensure that such circumstances do not arise, but we are talking about really important issues here. The healthcare arrangements on the island date back to before the UK and the Republic of Ireland joined the EU, but they are now underpinned by EU law, so we cannot simply revert back to the old arrangements, should a full EU-wide deal not be reached.

I was concerned about the lack of consideration given to the issue in the supporting documents and in the contribution from the previous Minister, the right hon. Member for North East Cambridgeshire (Stephen Barclay), on Second Reading. If we do not get this issue right, the Bill will be a failure. The amendment would ensure that the provisions do not reach the statute book until clarity on this hugely important issue is provided. I appreciate that article 13 of the Northern Ireland protocol in the withdrawal agreement indicates a desire to continue north/south co-operation in a range of areas, including healthcare, but that does not help us if Parliament does not support the withdrawal agreement. That is why the amendment asks for a strategy to be provided as a matter of urgency.

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[Justin Madders]

I am minded not to press the new clause to a vote if the Minister assures us that he will endeavour to keep us updated on the contingency plans, if it looks like we are approaching a cliff-edge scenario. That is really what we are trying to achieve.

[Stephen Hammond]

Let me make the hon. Gentleman the same offer that I made to the hon. Member for Burnley. In that unlikely scenario, I guarantee that I will make my officials available to give a briefing to the hon. Gentleman and any member of the Committee who wishes to understand what our proposals are.

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[Justin Madders]

I am content with the Minister’s comments. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 3

Strategy for settling disputes concerning healthcare agreements

(1) The Secretary of State must, within one month of this Act receiving Royal Assent, lay before Parliament a strategy containing a defined process for settling disputes concerning healthcare agreements between the government of the United Kingdom and either the government of a country or territory outside the United Kingdom or an international organisation.

(2) The strategy under section 1 above must include information on—

(a) the body, bodies or jurisdiction that will be responsible for settling disputes;

(b) the process which will be followed by that body, bodies or jurisdiction when settling a dispute, including details of any further appeal mechanisms; and

(c) anything else the Secretary of State thinks is relevant to such a strategy.—(Justin Madders.)

Brought up, and read the First time.

[Justin Madders]

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

On Second Reading, I spoke about the importance of dispute resolution, and asked the then Minister for Health, the right hon. Member for North East Cambridgeshire (Stephen Barclay), to set out how he envisaged it operating in both a deal and a no deal scenario. Despite some prompting from me and my hon. Friend the Member for Weaver Vale (Mike Amesbury), the Minister was not able to set out how dispute resolutions will be handled under the terms of any new agreement or even if the European Court of Justice will continue to represent a red line for the Government. The latter point is particularly interesting, given the new role of the right hon. Member for North East Cambridgeshire. It appears that he did not provide detail on that point because, at that stage, the Government were simply not in a position to confirm what was in the draft withdrawal agreement.

The Prime Minister categorically ruled out any jurisdiction of the European Court of Justice very early in the process, but I have yet to hear any serious suggestion about how disputes can be resolved, if we manage to reach a full reciprocal healthcare agreement with the EU27 beyond the transition period, without some reference back to the ECJ. The same concerns would apply if bilateral agreements were necessary in a no deal scenario.

Given the importance that the Prime Minister and members of her Cabinet have placed on the ECJ following our exit from the European Union, it is curious to say the least that we do not have a clear statement of intent from the Government while we debate this Bill. If their position continues to be that we will not have truly left the European Union if we are not in control of our own laws, as the Prime Minister put it in January 2017, it is vital that we have clarity about the arrangement that will be used in place of the ECJ. If a new arrangement is established, what will the cost be? Who will the judges be? Where will it be based? Will it be an open process?

If, on the other hand, we look to the ECJ for dispute resolution after all, even if only in the limited area of reciprocal healthcare, would that not represent a significant political U-turn? This issue is fundamental to the Government’s approach to Brexit. For example, they decided that we could not continue to host the European Medicines Agency, causing it to go to Amsterdam at the cost of 900 jobs in this country, and potentially hundreds of millions of pounds of investment. The Health Secretary’s sole justification for that was that the Government were not prepared to accept the European Court of Justice’s jurisdiction. Our purpose in tabling this new clause is to get clarity from the Minister about whether the European Court of Justice remains a red line for the Government.

[Stephen Hammond]

The new clause would place a duty on the Secretary of State to lay before Parliament a detailed strategy defining the process for settling disputes concerning healthcare agreements after we leave the European Union. No one in the room would dispute the spirit behind the new clause. As I have stated throughout our examination of the Bill, it is right that there should be transparency regarding the UK’s future relationship with the EU and other countries after exit. It is right that that transparency should apply to the arrangement of future healthcare agreements, and the processes that underpin them, such as dispute resolution, but, although I agree with the spirit of the new clause, I am not entirely sure that it would achieve its intended aim. I will give a number of reasons why.

The new clause would confer a duty on the Secretary of State to lay a strategy on the process for dispute resolution before Parliament. Both in a deal and a no deal scenario, such a strategy would be unlikely to provide information on the process for settling disputes concerning healthcare agreements that is not already available in the public domain. That is not due to a lack of endeavour; it is an issue of timing and consideration of what is already publicly available. In the expected scenario that the UK agrees a deal with the EU, the proposed process for settling disputes has already been confirmed in the White Paper on the future relationship, the draft withdrawal Bill that governs the implementation period and, most recently, the political declaration on the future relationship between the UK and EU. The processes have already been confirmed. They are outlined in those documents and would apply not only to disputes, but clearly therefore to disputes in any reciprocal healthcare agreement.

The hon. Gentleman asks what the dispute mechanism is. I am sure that the Committee will be pleased that I am not going to quote extensively from the withdrawal agreement, but it is worth putting on the record that the mechanism for resolving disputes will be through consultation at the Joint Committee, with the aim of reaching a mutually agreeable resolution. If the parties are not able to resolve the dispute in the Joint Committee, either party can request the establishment of an independent arbitration panel to resolve it. The panel will be made up of five members, with one person being the chairperson. The UK and the EU will nominate two members to sit on the panel and then mutually agree the fifth member, who will be the chairperson. The panel members will act independently and do not represent the party that nominated them. It is binding that the panel members be independent and impartial and they must possess specialised knowledge or experience of EU law and international law.

The hon. Gentleman challenges me on the role of the ECJ. He is right that the ECJ has a role here, but its role is very clear and very limited. The role of the ECJ after the implementation period will be restricted to ensuring the correct interpretation of EU law. There is no suggestion that the ECJ will determine the dispute, or that we would ever agree to the ECJ determining the dispute.

That is the likely scenario and the processes that are already formally set out via the documents that I described earlier. In the unlikely scenario that the UK leaves the European Union without a deal, the United Kingdom will arrange reciprocal healthcare agreements, and in those agreements, there will have to be bilateral dispute resolution. That would clearly have to be determined on a case-by-case basis as part of the negotiations to put those bilateral healthcare agreements in place, and, therefore, there is unlikely to be a single dispute resolution process, which is what the new clause suggests, so while I accept the spirit of it, the wording would restrict the ability for future reciprocal healthcare arrangements.

More importantly, the requirement for such a strategy to be laid before the House one month after the Bill receives Royal Assent does not align with the aim of the Bill to provide future reciprocal healthcare agreements with countries both inside and outside the EU. Clearly, those agreements are likely to be negotiated over a period of time and, as I have just mentioned, the dispute resolution mechanisms within them are likely to be different and may vary. It would therefore be arbitrary and unhelpful to produce a general strategy immediately after Royal Assent.

I understand the intention behind the new clause, but it would place an unnecessary burden and duty on the Secretary of State. In a deal scenario, the procedures are already there. In the unlikely no deal scenario, it would be likely to frustrate the ability to put in place future reciprocal healthcare agreements.

I hope that, having heard that, the hon. Gentleman will accept that, although we understand the spirit of his new clause, its wording would be likely to frustrate the purpose of the Bill. I therefore ask him not to press it to a vote.

[Justin Madders]

I am grateful to the Minister for setting that out in more detail than we were able to elicit on Second Reading. Given that the withdrawal agreement had not been published at the time, I understand why the then Minister was not able to do that. The present Minister has been very helpful in setting out the process for leaving with a deal. He is right that, if we leave without a deal, we are in uncharted territory. I do not think I heard any confirmation that there are red lines, in terms of the European Court of Justice, in that scenario. That is really what the new clause was meant to establish. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 4

Duty to consult with devolved administrations

Before issuing any regulations under this Act, the Secretary of State must consult the Scottish Government, the Welsh Government and the Northern Ireland Government and have regard for their views on the regulations.—(Justin Madders.)

Brought up, and read the First time.

[Justin Madders]

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

I hope this is a straightforward and uncontroversial new clause. We have already spoken about the importance of reciprocal healthcare arrangement to citizens in Northern Ireland, and of course there will also be an impact on patients in Wales and Scotland. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements, and why would they not?

The Delegated Powers and Regulatory Reform Committee was clear in its recommendation that there should be active participation of the devolved Administrations in setting out the UK’s position in future arrangements, but I am not aware that there have been any discussions. I would be grateful if the Minister could set out what conversations have taken place, because we did not get clarity on that on Second Reading.

The new clause repeats some of the issues that we raised this morning, which you did not have the pleasure of hearing, Mr Streeter. It is about the scope and power of the Bill and the wide range of duties given to the Secretary of State, which will be subject to the negative procedure. We think it is important that, as part of the Bill, when those wide powers are given to the Secretary of State, there must be a clear duty to consult with the devolved Administrations before those regulations are enacted.

The Fisheries Bill and the Agriculture Bill have dealt extensively with the need to involve the devolved Administrations. I think this is the bare minimum that we need. It would represent a consistent and equitable approach across the devolved nations, in terms of our future relationship with the EU.

[Stephen Hammond]

It is a pleasure to respond to this new clause, which addresses the extraordinarily important issue of engaging and working with the devolved Administrations. We completely agree that regulations made under the Bill may relate to devolved matters, by which I mean domestic healthcare. The Government will engage and meaningfully consult with the devolved Administrations in line with our existing arrangements, as found in the 2012 memorandum of understanding between the UK Government and the devolved Administrations, and the principles that underlie relations between us. That reinforces the positive work that the UK Government continue to do with the devolved Administrations daily for the benefit of the whole of the UK on this matter.

I am forced to reflect that, though the hon. Gentleman’s new clause is not necessary, the sentiment behind it is shared by everyone in Committee, I suspect. The regulation-making powers in the Bill provide us with a legal mechanism to implement international agreements domestically. The Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed with the EU, to the benefit of the residents of England, Wales, Scotland and Northern Ireland. The powers offer flexibility and can be used to implement comprehensive healthcare agreements with third countries in the future for the benefit of all UK nationals.

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I believe that the Committee is drawing to a close, so I will take the opportunity to thank all my colleagues, and all hon. Members in the Opposition, for giving this small but important Bill the line-by-line scrutiny that it deserves. I thank you, Mr Streeter, for chairing this afternoon’s proceedings.

[Justin Madders]

The Minister has put on record pretty clearly his intention in respect of ongoing and continued engagement with the devolved institutions. He is right that we are concerned that the powers under the Bill are wide. Those concerns remain, but in so far as they involve the new clause, his comments have done enough to assure us that it will not be necessary for us to press it to a vote.

I echo the Minister’s sentiments, given that we are now making the closing remarks of this Bill Committee. I thank you for chairing, Mr Streeter, and hon. Members for participating in Committee today.

I look forward to Report. We need to continue to explore some important issues, but we must move forward with this legislation, as is necessary in this uncertain time. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

Bill to be reported, without amendment.