Cities and Local Government Devolution [Lords] Bill

Karin Smyth Excerpts

Wednesday 21st October 2015 Commons Chamber

[James Wharton]

What I am saying is that, if this amendment is not made, deals with areas including Greater Manchester and the Sheffield city region would potentially be at risk; they would be open to legal challenge. The whole point of this Bill is to enable us to deliver on the deals that we are making with areas. That is the whole reason why we need this legislation. If we were able to deliver those deals without it, we would not be here debating it in this Committee today. I do not think that the loss of those deals is an outcome that many would wish to see. I therefore commend to the Committee the amendments that we need to make to ensure that we can deliver on our manifesto commitments and on those deals that we have made.

I now wish to consider amendment 51, which was tabled by my hon. Friends the Members for Hazel Grove and for Shipley (Philip Davies). It provides that a combined authority mayor can be established only after a referendum. Our manifesto commitment states that we will

“devolve far-reaching powers over economic development, transport and social care to large cities which choose to have elected mayors.”

We are committed to cities making the choice for a mayor, but, as I have made clear, a mayor will not be imposed anywhere. This principle of choice is a principle which I am confident that my hon. Friends accept.

[Karin Smyth (Bristol South) (Lab)]

rose—

[James Wharton]

If the hon. Lady will let me make a little progress, I will give way to her soon. I know that she has been keen to get in.

In the traditions of our democracy—the traditions of a representative democracy that go back to the days of Edmund Burke if not before—it would be curious if that choice could not be made by those elected at the ballot box by the people of the city to represent them. That is the approach that is provided for in the Bill. The Bill specifically provides that each council in the area must consent to any order establishing a combined authority mayor. There is a good precedent for such an approach. A council can decide to establish a directly elected mayor for its area now. It was Liverpool City Council, which, in 2012, decided that Liverpool should have a directly elected mayor. If one council can decide to have an elected mayor, why cannot a group of councils decide to have a mayor over their combined area?

To require a referendum to be the only way for a combined authority to have a mayor would seem not fully to recognise the role that those democratically elected can legitimately have. The choice at root, as Greater Manchester has shown—

[James Wharton]

My hon. Friend raises an important point. He gives me the opportunity to clarify again the difference between the local authority mayors, of whom we have talked before, who took powers up and away from people, and the metro mayors who take powers down towards people and away from central Government and public bodies. It is an important distinction and one that is at the heart of the difference that explains the approach the Government are taking to my hon. Friend’s concerns.

As Greater Manchester has shown, the choice at root is whether or not to have wide-ranging devolution. If the choice is for devolution, it goes without saying that there must be accountability arrangements commensurately strong for the scale of powers being devolved. Holding a referendum on the narrow question of whether there should be a mayor risks not fully recognising the choice that is to be made. In short, our democratic traditions do not demand the approach provided for in amendment 51. Indeed, the approach we have in the Bill of the choice for a combined authority mayor being made by councils is exactly the same approach that is open to councils for choosing a local authority mayor—accepting the difference that I have already explained in my comments to my hon. Friend the Member for Hazel Grove about these powers coming down from central Government. Accordingly, I hope that this amendment will be withdrawn.

[Karin Smyth]

I wish to come back later to make some other points, but let me raise now this issue of two-way opportunity and choice for local people, which I very much welcome. Bristol does not have the opportunity to reverse the decision it made in 2012, which is a fundamental principle of democracy and accountability. I am interested to hear whether the Minister will support clause 21, which has come from the Lords.

[James Wharton]

I hear what the hon. Lady says and that issue will be given a great deal of consideration. I will comment on the matter later in the course of the Committee, but the message has been heard loud and clear by Government. As I said in my opening remarks, we are keen to find consensus where we can on this agenda. I hope that at this stage, subject to the debate that might take place, that will sufficiently reassure the hon. Lady so that she can await those discussions in due course.

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[Mr Rees-Mogg]

May I add to what the Minister has just said? In my dealings with Mr Meacher in this House, he never put his strongly held political views above his fundamental good manners and civilisation. He was always the most decent man to talk to, even though I doubt there was a single subject of any political importance on which we agreed. He is a loss to this Chamber.

I will come on to my amendment 46, which would exempt Somerset, God’s own county, from the provisions on having a mayor. The Minister suggested that Somerset was not exceptional. I think that that was a momentary lapse because he is not only a most honourable gentleman, but somebody of fundamental good nature and wisdom. We will forgive him such a momentary mental lapse on this occasion and put it down to the wet weather or something like that.

The Government are giving fine and good undertakings. I will quote briefly from the Secretary of State on Second Reading:

“It is a fundamental tenet of this Bill, in contrast to other reforms debated over many years, that it does not give me or any of my ministerial colleagues the power to impose any arrangement on any local authority.”—[Official Report, 14 October 2015; Vol. 600, c. 326-327.]

My hon. Friend the Minister has reiterated those undertakings. They are excellent and encouraging, and they provide a solid basis for proceeding. Unfortunately, there is a “but” coming.

Everything I hear from local councillors in North Somerset and Bath and North East Somerset tells me that they are having their arms twisted. We are seeing a velvet glove today—a finely manufactured velvet glove of the highest quality velvet. Behind it, however, is a firm iron fist that expresses the Government’s will that things should go in a certain way. I encourage the Government, through my amendment, to make the background noises—the conversations in smoke-filled rooms—match the fine words that we are hearing in this House.

And so I come to why I want to exempt Somerset. Well, there is history—there is always history! I will start, as always, with Alfred the Great. If we go all the way back to 879, Bristol was in Mercia and Somerset in Wessex. One of those two kingdoms was completely under the Danes—that was obviously the Gloucestershire bit. The borderline between the two has been there for over 1,000 years. There is a strongly embedded history in Somerset and, indeed, in Bristol which means that they see themselves as independent, distinct units.

It is important that the Government go with the grain of communities that have built up over generations, centuries and, in this case, even a millennium, rather than create new administrative regions that mean very little to people. Most people have no interest in the title of their council. They have an interest in where their home is. Their home may relate to a great city, to a great county or to a village, a county and the country. The use of power needs to go with that. Therefore, devolution from the United Kingdom to an administrative body with which people do not have sympathy and about which they do not have a feeling makes things no better. People have a loyalty to the nation and a loyalty to their locality, but if interspersed between them is some random political agglomeration that came about through a sudden burst of enthusiasm by a Government, people have no association with that, no enthusiasm for it and no loyalty for the institution.

Of course, this has been tried before. This is my second and perhaps more important appeal to history in the context of Somerset, particularly in relation to North Somerset and Bath and North East Somerset. We were part of a much disliked, most unsuccessful, high-cost organisation called Avon. It is known to the cognoscenti as CUBA—the county that used to be Avon. The name CUBA was appropriate because it was almost as left-wing as Mr Castro in its approach to government and it was exceptionally expensive. It had one of the highest increases in rates in the 1980s. It was felt by people in the rural areas that it was run for the benefit of Bristol, with the cost being borne by people in rural areas.

We continue to see that in Avon and Somerset police, the cost of which is borne by the rural areas, even though—I am sorry to say this with the hon. Member for Bristol South (Karin Smyth) sitting opposite me—most of the crime is in Bristol. Inevitably, being an inner city, Bristol has more drug dealing, more armed crime and more social disorder than Nempnett Thrubwell and other villages in my constituency, which are bastions of law-abiding civility.

[Karin Smyth]

I was not going to intervene, but the hon. Gentleman is maligning the great city of Bristol, which draws in people from North East Somerset with its great employment and cultural opportunities. Indeed, that causes some great problems in my constituency in respect of travel arrangements and so on, but we are grateful to have his constituents coming to work in the city. Perhaps we can have a more balanced discussion.

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[William Wragg]

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

I pay a warm tribute to the Minister and the Secretary of State for their approach to this Bill and the constructive dialogue that they have had with—dare I say it?—the caucus of Greater Manchester MPs, including two who are sitting next to me. The Minister warmed my heart by quoting Edmund Burke earlier. I do not know how Burke’s “Reflections on the Revolution in France” compare with my Second Reading speech, “William Wragg’s reflections on Devolution in Greater Manchester”, although in some respects my speech was probably equally as intemperate as the fiery language that Burke deployed against the French revolution. If I at all offended the Minister with my remarks on Second Reading, I wish to atone for that entirely.

The point about amendment 51 is no different to the point that I made last week about having confidence in the arguments and trusting the people to win them over. My hon. Friend the Member for Altrincham and Sale West (Mr Brady) expanded on the qualities of the Minister and the Front-Bench team in persuading and engaging with the public, and if they were to test this issue with a referendum in Greater Manchester, they might be pleasantly surprised with the result.

My neighbour, the hon. Member for Stockport (Ann Coffey), has recently left the Chamber, but I pay tribute to her work on child sexual exploitation. I was pleased to serve on one of the sub-committees of Stockport Council which took evidence from her. I say gently, however, that I would distance myself from any temptation to link the topic on which she has done a great deal of work with whether an elected mayor would impact on that, as I think it is a slightly spurious argument.

As a former teacher I should perhaps apologise to the hon. Member for Nottingham North (Mr Allen), who took issue with how the explanatory statement was drafted, and I hold my hands up as that was due to a lax approach on my part. There was never intended to be threshold on which 50% of the population would have to agree. Amendment 51 is supported by a growing list of colleagues, and it simply asks that fundamental changes to local government and the governance of my constituency are put to the test at a referendum, so that they can be endorsed and back the Government’s welcome programme of devolution.

[Karin Smyth]

I am pleased—along with my neighbour the hon. Member for North East Somerset (Mr Rees-Mogg)—to give the Committee a bit of respite from the subject of Manchester and to talk a bit about Bristol instead. Bristol has been a trailblazer for devolution and, in 2012, it was the only city to choose to have an elected mayor when the question was put in a referendum. I am a keen supporter of devolution and of transferring power closest to the people it affects, and I was proud to make my maiden speech on that subject. I am perhaps not as much of an evangelist as the hon. Member for Altrincham and Sale West (Mr Brady), but I am keen for devolution to happen.

Let me pick up on a unique issue which means that the people of Bristol do not share the same democratic rights as the rest of the country. The Bill started in the House of Lords, where Baroness Janke moved an amendment, now clause 21, which, if passed, would give Bristolians the right, after 10 years, to reverse, if they so wished, the decision we made in 2010 to have an elected mayor to govern our city. If the model is not fit in 10 years, we would like the opportunity to change it. By that time, citizens will have had ample opportunity to assess the value or otherwise of the current model, how it works in Bristol and, crucially, with the changing situation, how it would work across—I will not use the word CUBA, or indeed Avon—the wider Bristol area and with our neighbours in a combined authority.

This is not about personalities or whether we like or dislike the current mayor or would prefer a different person in office; it is about the system that works best for us in the city region. It is not about party politics either, because all the major political parties on the city council agree and supported a joint motion to that effect. I am very grateful to Baroness Janke, a Liberal Democrat peer, who did a lot of work in shaping and gaining support for the clause when it was in the House of Lords. It is about democracy. It is about whether we should have a voice and a new model. We should now be given that say. In an era when we are supposed to be seeing an increase in devolution and empowerment, it feels wrong that we as Bristolians should have to go through a long and tortuous legislation-making process to know whether we have the right to determine the way our city is governed. This clause would allow us to do that much more easily.

I hope the Government are able to support that provision, and give me and the people of Bristol a greater say in how this works for us in the future.

[Victoria Borwick (Kensington) (Con)]

Turning to another aspect of devolution, I would like to talk about the importance of health devolution. I obviously welcome the Government’s devolution revolution, which the Bill will help to deliver. In London, the Mayor has been campaigning for greater fiscal devolution and I know he applauds the recent announcement on business rate reform, as this will benefit our capital.

The devolution revolution that the Bill champions will ensure that Greater Manchester becomes the first English region to have full control of its health spending. However, as the Minister will be aware, London government has also been exploring how a similar model could work in the capital. As we all know, health is no respecter of ward or council boundaries. People live in one area and work in another, and may receive treatment for complex conditions in more than one area. That is why it is so important, in cities such as London and others that have been instanced today, that it should be viewed as a whole.

For a patient receiving many different treatments, it is far more effective for their care to be under one authority. As the previous deputy Mayor of London watching over this brief, I chaired many cross-London forums where councils and health authorities have come together to share resources and work together for better outcomes instead of being able to afford a smaller service in their locality. I would therefore argue that London, like Manchester, should explore ways to reform health and care provision, including a rebalancing towards prevention, early intervention, and proactive personal care and support. The aim should be to reduce hospitalisation, invest more in primary care, and integrate planning and decision-making for both the health and care services. Inevitably, there needs to be a review of NHS properties, including underused facilities, so that new integrated care centres can be opened and we have a more efficient use of the health estate.

There is agreement among London partners that the scale and complexity of health and care issues in London means that a model of reform should include actions at local, sub-regional and pan-London level. As part of their submission to the comprehensive spending review, London government made the case for greater devolution over health and social care. In the interests of brevity as we are short of time, I shall reduce the list substantially and just mention public health powers, including regulatory and fiscal interventions; multi-year allocations of NHS and local authority funding on a borough footprint; and London’s share of national NHS transformation funding.

As the Minister will know, representatives from the Greater London Authority, London Councils, NHS England, the London office of clinical commissioning groups and Public Health England are developing a memorandum of understanding to progress this work and to look at the powers that could and should be devolved to London. The recent London Health Commission report also advocated a London health commissioner, who could focus on the particular concerns of our growing city with its transient population. In London, we see diseases that many of us thought had died out, such as tuberculosis and rickets. They are often seen in people who were born or have grown up elsewhere, bringing pressures to the health system in London.

I am asking the Minister to welcome the approach being taken by London and support the aspiration for the greatest possible speed of reform to improve the health of Londoners.

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Clause 19 and the amendments I have described provide further clarity about the role of the Secretary of State for Health, and what will and will not be included in any future transfer order giving local organisations devolved responsibility for health services. This clear statement in legislation, making provision for the protection of the integrity of our national health service, is intended to provide further confidence for future devolution deals. I ask hon. Members to support the Government amendments and clause 19 standing part of the Bill.

[Karin Smyth]

I welcome the devolution of some health and care services to local areas. My hon. Friend the Member for Denton and Reddish (Andrew Gwynne) recalled our manifesto pledges for the “what” and the “how”, and I have a lot of concerns about the structural changes that might come as a result of all this. As has been mentioned, Bristol, an area of nearly half a million people surrounded by more rural areas, has two major acute hospitals, both of which offer a range of services, including highly specialised ones. I would like the Minister to say something on the issue of specialised commissioning. Patients are drawn from across the south-west; one hospital draws half its patients from Bristol and the other half from neighbouring South Gloucestershire. Two different clinical commissioning groups are involved, and a plethora of different organisations are involved in both the commissioning and the provision of services. In an earlier exchange on this type of devolution, the Minister sometimes talked about the provision of services and sometimes about the commissioning of services. It would be helpful to understand the devolution aspects: are we talking about provision in the new marketplace or about commissioning, and how will we bring those two things together? That is problematic for us in Bristol.

I am a former board member of a primary care trust and I spent many happy hours discussing the correct configuration of primary care and CCGs in Bristol—whether it should be a stand-alone Bristol or not. We started off with Bristol divided into two and we then talked about doughnuts. The Minister missed an earlier discussion involving the hon. Member for North East Somerset (Mr Rees-Mogg), who wanted to make sure that Bristol stayed Bristol and did not include other areas. [Interruption.] That was a shame, because it is always a joy. We never quite resolved that issue, and similar issues are applicable to many other cities and city regions. I fear that the approach being taken could make an already difficult situation for Bristol much more difficult.

The Minister and I were both at the King’s Fund discussion last week about devolution and health, and I think it was people from Manchester who talked about the fact that they had to bring 38 different organisations around the table to talk about some of these matters. My concerns relate to further structural reorganisation. Given the organisations involved and given the situation in Bristol, I wonder how I, as a patient on my pathway from prevention through primary care to community services, hospital care and possibly specialised services, would understand who is really accountable for that pathway. As we know, we can map a pathway but people do not always map closely to that. In general, I welcome this move, but of course we have concerns about financial stability, particularly of those hospitals and of wider community services. At last week’s King’s Fund event, as was quietly pointed out, we do not want a situation where money is moved from GP services into fixing potholes. We need to be very concerned about such things.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

It is a pleasure to serve under your chairmanship, Mrs Main. I rise to make a few brief remarks in support of this clause and the Government amendments. Clearly, the direction of travel that is outlined is desirable in health and care terms. The amendments will put in place clear safeguards to deal with national regulatory structures, which are there to protect patients and to ensure that the quality of care is universally high throughout the whole country.

The importance of devolving health and care at a local level is something that we have often talked about in this place, but we have sometimes struggled to find the legislative mechanisms to make it happen. These powers will be a desirable step forward in encouraging a more integrated model of health and care. We often talk about how we can move the focus in many parts of our health service towards delivering more services in the community and a more preventative approach to healthcare. Clearly, this Bill is a big step in that direction.

By 2018, we know that there will be 3 million people with three or more long-term health conditions. Many of those people will require support not just from the health service, but from adult social care services, local voluntary and charitable organisations and, in the case of some people with special educational needs, education services. It is vital that we properly link and join up the services that are in place to support these people. Personalised care and mechanisms of support are often found at a local level, which is exactly what this devolution is about.

Other measures have been put in place to integrate better adult health and social care, including the better care fund, which was part of the Care Act 2104. The coalition Government also introduced some strong measures to improve the provision for children with special educational needs. But these measures go further and allow more bespoke and personalised local solutions to be put in place to support people with more complex care needs. Importantly, they also recognise that parts of the country are different in terms of not just their geography, but their cultural make up and their demographics. That is particularly important when we talk about devolving health and care. We know that some city areas have high black and minority ethnic populations with specific healthcare needs. These measures will put us in a much better place to help such areas support those communities, as well as more rural areas, in dealing with the challenges of an ageing population and increasing numbers of people with complex healthcare needs.

This Bill is an important step forward, which builds on many strong measures that have already been put in place over the past few years by both the coalition Government and the previous Labour Government. We all believe in integration and in the need to bring healthcare services closer to the individual and make them more personalised. We know that there is too much duplication in the health service and in adult social care, which costs money. That money should be going to the frontline, but duplication often gets in the way of front-line professionals helping patients. This is a big step forward in allowing local health economies and local areas to put in place the right mechanisms to support the people they look after.

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[Karin Smyth]

I am grateful for that clarification. My concern then would be who the Minister sees as driving the development and improvement of, particularly, the specialised commissioners. We are talking in fairly transactional terms about who might be contracting or who might be accountable but, as he will appreciate, these services, as well as others, require a long lead-in time and a lot of consideration owing to their very technical and, by definition, specialised nature. Who is driving this forward—the local group, if they so choose, who may not have the expertise, or the Department?

[Alistair Burt]

NHS England and the Department must retain the overall control of the quality of the specialised services, and that will not be relinquished if there is no sense that they can be handled any better, because otherwise there is no point. The number of specialised services that are devolved might ultimately be very few. Of course, there is only any point in devolving them if they are going to improve, and that must be demonstrated before they are devolved and moved on.

Let me say a little about the wider concern of the hon. Member for Heywood and Middleton that by devolving these powers and running with the grain of greater devolution, we are losing the “national” in the national health service. We are absolutely determined that that will not be the case. The safeguards that are now in the Bill as a result of concerns expressed elsewhere were never going to be lost, but they are now made more explicit to demonstrate that what she worries about cannot happen. It is not the case that an authority will apply for these powers and they will be handed over without no further consideration, because there is the transfer order that Parliament will be involved in.

What are the Government going to think about when people ask to do this? The Government have invited local areas to develop their own proposals. There is no blueprint for the devolution of health and social care. The substance of devolution deals will be determined on a case-by-case basis, with Government agreeing bespoke deals that correspond to the needs and specific context of each area. There are some important preconditions that we might expect to support the development of local devolution deals, including health and social care. These include a clear vision for the benefits to the local area; a history of successful collaboration and partnership working; support and input from local health and social care organisations for the proposals being put forward; a strong commitment to further engagement with local patients and communities as plans develop; upholding the standards set out in national guidance; and continuing to meet statutory requirements and duties, including the NHS constitution and the Government’s mandate to NHS England. Most importantly, the first overarching principle of any agreement is that all areas will remain part of the NHS. This requirement to adhere to the constitution of the NHS and the ultimate safeguard of the Secretary of State’s responsibilities answers the point about a local area getting hold of NHS money and then deciding to build a new leisure centre. It would not be able to do that because it would not be complying with its duties under the NHS. It would fail and the duties and responsibilities would soon be taken away. That is why the safeguard is there.

To deal with the hon. Lady’s concerns about potential confusion, let me say a little more about the role of NHS England under devolved arrangements. NHS England and CCGs would continue to be bound by their duties under the National Health Service Act 2006 even after devolution of functions. For example, NHS England will remain bound by duties to promote the NHS constitution, and to exercise its functions effectively, efficiently and economically and with a view to securing continuous improvement in the quality of services, including in terms of outcomes.

NHS England must exercise its functions having regard to the need to reduce inequalities in relation to both access to health services and outcomes achieved for patients. When NHS England exercises its functions, it must also promote the involvement of patients and their carers and representatives in decisions made about diagnosis, prevention and care and treatment. It must take appropriate advice and act with a view to enabling patients to make choices with respect to aspects of the health service provided to them.

Those safeguards show that the powers simply cannot be devolved to people who want them without any check or balance on how they would exercise them, even if they persuade people locally that signing a blank cheque for help is in any way acceptable. I cannot see local representatives agreeing to that. That is where the control comes in.

How will the Department of Health and NHS England be involved in agreeing the deals? We have been working closely with other Government Departments to respond to proposals. NHS England has developed its own set of assessment criteria, by which it will assess the potential of proposals from a particular local area. It is not an automatic process: if the deal will not work in terms of the quality of healthcare provided, the House will not pass a transfer order because the proposal will not pass the test set by NHS England and the Department of Health.

Will devolution mean that local areas can set their own strategy for NHS capital estates and management? No, we do not envisage any changes to capital financing and asset ownership.

Finally, I want to address a very important issue raised by the hon. Lady. Who will have the final say over the opening and closing of hospitals and other services? This is issue concerns every single one of us in the Chamber. Reconfiguration of NHS services will continue to be a matter for the local NHS. However, proposals for service change must meet the Government’s four tests: support from local GP commissioners; clarity on the clinical evidence base; robust patient and public engagement; and support for patient choice. The same elements of contest available when reconfiguration has been proposed will remain even after devolution, so nothing is taken away.

I hope that has been helpful. Working with the grain of what people want, we all think this is a better idea, but there are safeguards to make sure that people’s worries will not come to fruition.

Amendment 32 agreed to.

Clause 8, as amended, ordered to stand part of the Bill.

Clause 17

Power to transfer etc. public authority functions to certain local authorities

Amendment made: 33, page 17, line 32, at end insert—

‘( ) See also section 19 (devolving health service functions) which contains further limitations.”—(Alistair Burt.)

This amendment inserts a new subsection into clause 17 which alerts the reader to clause 19 which contains limitations on the power to make regulations under that clause.

Clause 17, as amended, ordered to stand part of the Bill.

Clause 18

Section 17: procedure etc.

Amendment made: 15, page 18, line 6, after “make” insert “incidental, supplementary, consequential,”—(Alistair Burt.)

This amendment provides that the power to make regulations under clause 17 of the Bill includes a power to make incidental, supplementary and consequential provision.

Clause 18, as amended, ordered to stand part of the Bill.

Clause 19

Devolving health service functions

Amendments made: 34, page 18, leave out lines 29 to 33 and insert—

‘(1) Regulations under section 17 of this Act or an order under section 105A of the Local Democracy, Economic Development and Construction Act 2009 (transfer of public authority functions to combined authorities) (“the 2009 Act”)—

(a) must not transfer any of the Secretary of State’s core duties in relation to the health service;”

This amendment confines the limitations contained in clause 19 to the exercise of the power to make regulations under clause 17 or an order under section 105A of Local Democracy, Economic Development and Construction Act 2009. Those powers concern the transfer of public authority functions to local or combined authorities. New clause 19(1)(a) prevents those powers being used to transfer any of the Secretary of State’s core duties in relation to the health service (as defined in clause 19(2) which is inserted by Amendment 38).

Amendment 35, page 18, line 34, leave out “or supervisory”

This amendment removes the prohibition in clause 19(b) on the transfer of health service supervisory functions of national bodies by regulations under clause 17 or an order under section 105A of the Local Democracy, Economic Development and Construction Act 2009.

Amendment 36, page 18, line 36, leave out from “must” to first “the” in line 37 and insert

“, if transferring functions relating to the health service to a local authority or a combined authority, make provision about the standards and duties to be placed on that authority having regard to”

This amendment and Amendment 37 replace the limitation in clause 19(c) with a requirement that regulations under clause 17 or an order under section 105A of the Local Democracy, Economic Development and Construction Act 2009 which transfer functions relating to the health service to a local or combined authority must make provision about the standards and duties to be placed on that authority having regard to certain standards and obligations placed on the authority responsible for the functions being transferred.

Amendment 37, page 18, line 38, leave out from “on” to “being” in line 39 and insert

“the authority responsible for the functions”

See the statement for Amendment 36.

Amendment 38, page 18, line 40, at end insert—

‘(2) For the purposes of subsection (1)(a), “the Secretary of State’s core duties in relation to the health service” means the duties of the Secretary of State under—

(a) sections 1 to 1G of the National Health Service Act 2006 (“the NHSA 2006”) (duty to promote comprehensive health service etc.),

(b) sections 6A to 6BB of that Act (duties regarding the reimbursement of costs of services provided in another EEA state),

(c) section 12E of that Act (duty as respects variation in provision of health services),

(d) sections 13A, 13B, 13U and 223B of that Act (duties regarding mandate to, and annual report and funding of, the NHS Commissioning Board),

(e) section 247C of that Act (duty to keep health service functions under review),

(f) section 247D of that Act (duty to publish annual report on performance of the health service in England),

(g) section 258 of that Act (duty regarding the availability of facilities for university clinical teaching and research), and

(h) sections 3 to 6 of the Health Act 2009 (duties in relation to the NHS Constitution and the Handbook to it),

in so far as those duties would (apart from subsection (1)(a)) be transferable by regulations under section17 or an order under section 105A of the 2009 Act.

(3) For the purposes of subsection (1)(b)—

(a) “health service regulatory function” means a function in relation to the health service which is a regulatory function within the meaning given by section 32 of the Legislative and Regulatory Reform Act 2006,

(b) the functions of the National Health Service Commissioning Board under sections 14Z16 to 14Z22 of the NHSA 2006 (assessment of clinical commissioning groups and intervention powers) are to be treated as “health service regulatory functions” in so far as they do not fall within the definition in paragraph (a), and

(c) functions exercisable by a body by virtue of directions given under section 7 of the NHSA 2006 (functions of Special Health Authorities) are not “vested in” that body.

(4) But subsection (1)(b) does not prevent the transfer of functions of the National Health Service Commissioning Board which—

(a) arise from arrangements under section 1H(3)(a) of the NHSA 2006 (provision of services for the purpose of the health service), and

(b) relate to those providing services under those arrangements.

(5) For the purposes of subsection (1)(c), “national service standards” means the standards contained in any of the following—

(a) the NHS Constitution (within the meaning of Chapter 1 of Part 1 of the Health Act 2009);

(b) the standing rules under section 6E of the NHSA 2006 (regulations as to the exercise of functions by the NHS Commissioning Board or clinical commissioning groups);

(c) the terms as to service delivery required by regulations or directions under the NHSA 2006 for contracts or other arrangements for the provision of primary medical services, primary dental services, primary ophthalmic services or pharmaceutical services under Part 4, 5, 6 or 7 of that Act;

(d) the recommendations or guidance of the National Institute for Health and Care Excellence made or given pursuant to regulations under section 237 of the Health and Social Care Act 2012;

(e) the quality standards prepared by that Institute under section 234 of that Act;

(f) the guidance published under section 14Z8 of the NHSA 2006 (guidance on commissioning by the NHS Commissioning Board);

and such standards are “placed on” a body if the body is required to have regard to or comply with them.

(6) For the purposes of subsection (1)(c)—

(a) “national information obligations” means duties regarding the obtaining, retention, use or disclosure of information, and

(b) “national accountability obligations” means duties (for example, those to keep accounts or records, or to provide or publish reports, plans or other information) which enable the management of a body, or the way in which functions are discharged, to be examined, inspected, reviewed or studied.

(7) For the purposes of this section, a function is transferred by regulations under section 17 or by an order under section 105A of the 2009 Act, if—

(a) provision is made under subsection (1)(a) of the section in question for the function to be the function of a local authority or a combined authority, or

(b) provision is made under subsection (1)(b) of that section for a function corresponding to the function to be conferred on a local authority or a combined authority.

(8) Nothing in this section prevents the conferral on a local authority or a combined authority of duties to have regard to, or to promote or secure, the matters mentioned in sections 1 to 1F of the NHSA 2006 when exercising a function transferred to it by regulations under section 17, or by an order under section 105A of the 2009 Act.

(9) In this section, “the health service” has the meaning given by section 275(1) of the NHSA 2006.”—(Alistair Burt.)

This amendment adds provision to clause 19 which defines terms used in, and clarifies the scope of, the limitations contained in paragraphs (a) to (c) of the clause.

Clause 19, as amended, ordered to stand part of the Bill.

Clause 9 ordered to stand part of the Bill.

Schedule 3 agreed to.

Clause 10

Funding of combined authorities

Amendment made: 9, page 11, line 26, at end insert—

‘( ) In section 105 of the Local Democracy, Economic Development and Construction Act 2009 (constitution and functions of combined authorities: economic development and regeneration), omit subsection (4).”—(Alistair Burt.)

This amendment removes the restriction on orders under section 105 of the Local Democracy, Economic Development and Construction Act 2009 only being able to make provision in relation to the costs of a combined authority that are reasonably attributable to the exercise of its functions relating to economic development and regeneration.

Amendment proposed: 58, page 11, line 26, at end insert—

‘(5) The Secretary of State may by order make provision for conferring powers on a combined authority to set multi-year finance settlements.” —(Jon Trickett.)

This amendment is intended to offer financial stability to city regions, allowing them long-term planning which is something not currently offered by the finance settlement or the funding of local enterprise partnership (LEPs).

NHS Reform

Karin Smyth Excerpts

Thursday 16th July 2015 Commons Chamber

[Mr Hunt]

I thank my hon. Friend for the amazing work he has done in supporting County Hospital through the most unimaginably difficult circumstances. I put on record my thanks to the doctors and nurses working in that hospital who are doing a fantastic job. They have improved care. Many of them were working at the old Mid Staffs hospital and, even during the period of those problems, they were working incredibly hard and doing a very good job for patients. They did not want to be associated with any of the bad things that happened. They are a shining example to all of us. Yes, the independent patient safety investigation service needs to be independent, but I think trusts will welcome this measure. It will mean that a trust has a body, which is completely independent of anyone working in the trust, that it can call in. In a no-blame way, it can find out exactly what happened—a bit like a French juge d’instruction; that kind of principle. I think that will be really welcomed in the NHS, but independence is vital.

[Karin Smyth (Bristol South) (Lab)]

I declare my interest as a former NHS manager, latterly for a clinical commissioning group. I very much welcome the focus on patients, transparency and the use of digital, which will be very helpful for the challenges we will face. As a former NHS manager, I would make the plea that management needs support in facing the challenges ahead. I am afraid that confrontation with local doctors as the first step over the summer period is not helpful. Will the Secretary of State please support NHS managers in this difficult task ahead, across clinical and non-clinical standards? I very much welcome the Rose review, but can we please give managers the support they need?

[Mr Hunt]

I am really grateful to the hon. Lady for making that point. NHS managers have one of the most difficult challenges in the country. Not only do they have to balance revenue and expenditure; they have patients’ lives at risk and public accountability. It is really difficult to run a hospital or a clinical commissioning group. These are some of the most difficult jobs one can imagine. We need to support them. I hope they will agree and welcome a move away from targets as the main way of driving change in the NHS to intelligent transparency and peer review. This is not a confrontation with doctors. Doctors overwhelmingly support a seven-day service. It is, I am afraid, a battle with the BMA, with which we have been trying to negotiate on the matter for nearly three years. It has refused to move. It needs to get in touch with what its members want and what the public want, and then I hope we can make much faster progress.

Operational Productivity in NHS Providers

Karin Smyth Excerpts

Wednesday 1st July 2015 Westminster Hall

[Dr Offord]

I certainly do agree with that point, and I hope to elaborate further on that. I also wish to touch on the use of bank nurses, or bank employees, who periodically work for parts of the NHS. I agree that for patient care it would be best to have full-time permanent staff who not only know the patients and the hospitals, but know the other employees they work with on a day-to-day basis.

Most worryingly, Lord Carter identified the fact that, in some of the 22 hospitals he surveyed, bank nurses are remunerated at a level that does not discourage them from remaining with, or moving to, agencies. I looked at the website of one of the trusts that took part in the review by Lord Carter and was surprised to see the range and number of bank employees—including, ironically, the position of the e-roster co-ordinator. I will not name that particular trust, as this debate is not a “name and shame” exercise, but I raise it to illustrate the point, because if such a role is vacant, what hope can there be to ensure that other clinical positions are staffed suitably?

The e-roster co-ordinator is in the best position to monitor employment and identify irregularities in work patterns to prevent fraudulent practices. The majority of people who work for the NHS are honest, but there are a minority who seek to defraud its resources. I want to highlight the types of fraud that occur. Such fraud involves staff and professionals who claim money for services not provided or more money than they are entitled to, or who divert funds to themselves. It can also involve external organisations that provide false or misleading information, including invoices, to claim money they are not entitled to. Some of these frauds can be fairly low value, but they can often cost the NHS hundreds of thousands of pounds.

One example is Michael Botham, a hospital worker in Stoke-on-Trent who claimed nearly £20,000 for shifts he did not work. He applied for work via a recruitment agency, AMG Nursing and Care Services, in October 2007. He was then assigned as an unqualified healthcare worker to Bucknall hospital in Stoke-on-Trent, where he worked in the complex needs ward. Most worryingly, it took a ward manager to identify an overspend and to report their suspicions about Botham to the trust’s local counter-fraud specialist team. When the team analysed his timesheets, they revealed that he had submitted false claims for work from 1 January to 26 July 2009, complete with forged authorisation. In fact, he had worked only one shift during that period.

Botham also claimed payment for four shifts at Bradwell hospital, part of the same trust, in January 2009. Again, he had not worked those shifts and the authorising signatures were also false. In total, the trust overpaid £19,362 as a result of his false claims to the agency, which invoiced the trust in good faith on a weekly basis, but subsequently, to its credit, offered to pay back its fees of £3,956.50. This is a clear case of an individual deciding to defraud the NHS, but what is concerning is that the problem emerged only as a result of the scrutiny of another member of staff whose role was not to look for fraud.

[Karin Smyth (Bristol South) (Lab)]

I worked for a clinical commissioning group in Bristol. Does the hon. Gentleman accept that one reason why that would have happened is that all members of NHS staff have to undergo mandatory and statutory training to recognise and counter fraud?

[Dr Offord]

I do, but I am saying that this should have been picked up by an individual with a strategic, holistic approach to staffing and staffing budgets, rather than leaving it to one individual on the ward who realised there was a problem with the budgets. There are processes in place to ensure that fraud does not happen, and I would like all hospital trusts to introduce such processes. In his report, Lord Carter highlights a case where one provider identified 20 cases of counter-fraud when they reviewed and strengthened their sickness and annual reporting leave. That prompts the question of why such abuses continue to be left unchecked.

There is another case of fraud that I want to highlight, which has been judged more harshly, although it can be argued that it is certainly not as deceptive because the individual actually undertook the work. Simon Olufemi Ajani was sentenced to 12 months’ imprisonment following a fraud investigation by NHS Protect after he had produced a false passport and certificate of entitlement to the right of abode in the UK. That enabled him to obtain work with patients at East London NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and other London trusts through NHS Professionals, the agency that supplies temporary staff to the NHS. His fraud was first uncovered through a data-matching exercise that highlighted inconsistencies between UK Border Agency records and NHS payroll records.

The difference between those two cases is that Ajani worked the hours that he was paid for, even though he was not entitled to be employed in this country, while Botham was just a crook stealing money directly from the NHS and patient care. These examples lead me to ask the Minister about the employment of those from outside the EU, an issue I have discussed recently with my constituents, as I mentioned. There is some criticism about the use of foreign doctors in the NHS, and some people consider that these jobs have been taken out of the reach of British people. However, we all know that the NHS does not have the numbers of doctors and nurses that it needs and there is not the capacity within the population of the United Kingdom to provide them. That is why some agency staff are required.

For some medical practitioners, however, remaining a locum is an alternative to having a permanent position. Some doctors are able to earn between £1,400 and £1,500 for a 12-hour shift, while the on-costs payable to agencies mean that hundreds of thousands of pounds a year are being charged to health trusts around the country for employment of temporary staff. One alternative to the costly system of locums could be the employment of a permanent doctor from overseas who could earn a salary of between £75,000 and £120,000. I need not ask the Minister whether he feels that this is better value for money than having a locum.

The NHS is an employer of those considered to have skills that are needed in this country, and a tier 2 visa allows “skilled workers” from outside the European economic area with a job offer to enter the UK. However, it has been established that the immigration health surcharge is levied against non-EU citizens. This requires every applicant and their dependents to pay not only their visa fees but a further £200 each year for up to three years. It strikes me as perverse that the very people needed to work in the NHS are being penalised by paying an additional amount that should perhaps be part of their terms and conditions of employment. Can the Minister explain in his summing up how the figure of £200 was reached and whether he feels that levying this tithe against NHS employees is counterproductive?

Lord Carter’s report goes on to identify opportunities in managing annual leave—what he terms the largest part of non-productive time. There are many ways in which NHS employers can ensure they manage staff leave. I am not going to stand here and say that the Minister should micro-manage the NHS in England, but even simple practices do not appear to be implemented in some NHS trusts. We all agree that, while the needs of patients must be considered when managing annual leave, people do need time off. Introducing a notice period of a month for leave requests of, say, more than three or four days would allow NHS managers the time to plan ahead, but that is not happening uniformly, thereby ensuring that agency staff are needed as an emergency measure.

Can the Minister therefore confirm that measures introduced by the Secretary of State to reduce agency locum spend will include a requirement for trusts to ensure that their employment practices and policies include such conditions as notice periods to book leave, that trusts consider employing e-roster co-ordinators and that trusts examine their employment policies so that they can compare themselves with their peers and undertake a skill mix review, the combination of which would reduce the need for spending on agency staff?

A fear raised with me by my constituents concerns the revalidation of full-time locum doctors. It is well known that locum doctors can experience a variety of challenges with revalidation, largely due to the peripatetic nature of their work, but annual appraisals are the backbone of revalidation and fundamental to demonstrating the fitness of medical professionals to practise. Revalidation should be carried out by the framework suppliers—the agencies that supply staff—but I have heard anecdotal reports that agencies do not revalidate, and it has been alleged that some health professionals are even practising outside their qualifications and skill range. Can the Minister tell us how the Department will ensure that the revalidation of all full-time locum medical professionals is carried out by the framework suppliers?

The final issue about the use of agency staff I want to raise is the use of master vendor contracts between health trusts and employment agencies. The use of this practice creates an opportunity for collusion within the employment industry to seek maximum financial gain through the use of exclusive contracts. While such contracts may be an easy option for the employer—in this case, the health trust—the agency can ask premium prices for a service that could be provided more cheaply if it were opened up to competition. Such a practice effectively introduces a closed shop and prevents smaller employment agencies from being able to enter the health market. Can the Minister advise us how the Department can ensure that the use of master vendors does not result in tacit collusion in the employment industry for exclusive contracts that cost the NHS more than it might pay for the services elsewhere?

In conclusion, this debate is not a negative criticism of employment agencies or the work of people in the NHS; in fact, it is the opposite. I congratulate the people who work in the NHS and I want to ensure that more people are employed in the NHS. I am framing this debate as an opportunity to assist the Government in ensuring that the resources needed by the NHS and identified by the Stevens review are made available. It is an opportunity to start the process by recognising where we can work smarter to ensure a better NHS for all and identify opportunities to achieve economies that do not undermine patient care, but in fact achieve the opposite, by ensuring the correct number of appropriately qualified staff in the NHS, working confidently, diligently and at a pace that ensures the best care for patients.

[Karin Smyth (Bristol South) (Lab)]

Thank you, Mr Pritchard, for calling me to speak.

I agree with the hon. Member for Hendon (Dr Offord) that of course there are always efficiencies to be made, and ways of considering how they can be made; NHS managers and staff, including clinical staff, spend a great deal of their time doing that. My intervention about counter-fraud was meant to suggest that that work becomes part of the way that people start thinking about their work as public servants. However, this debate needs to be widened out beyond the individual savings that have been mentioned. As the King’s Fund has said, the greatest savings achieved in the NHS since 1948 were made since 2010, largely through reductions to pay and central budgets, and some restructuring. Having said that, I am slightly sceptical about the savings that can be made through restructuring.

We need to move this debate on to a discussion about quality in its widest sense, because quality is an organising principle of the NHS; ultimately, quality will deliver greater savings and contribute towards the £22 billion target. It will also involve people much more in the management of their healthcare, so that we save money that is currently spent on public health interventions. We must also ensure that when people use the health service, they understand where savings can be made. If we were able to involve patients and others much more in that debate, we would find more good examples of what we have been discussing. There are some great examples from Bristol, particularly around environmental savings. There have been some fantastic projects to reduce consumption of energy, both at Universities Hospital Bristol NHS Foundation Trust, and at North Bristol NHS Trust. There is also the reskilling that takes place within the community services organisations, to make better use of the highly skilled community nurses and to help people with the flow in and out of hospital.

However, all these measures require the system to be stable and require some transitional support to allow the transformation to happen. At the moment, I am not sure that the NHS feels it has the support to make that happen, as individual examples that will not yield overall results are being picked out. I welcome this debate about productivity, but I hope that we can have a degree of political honesty about the scale of the challenge of the £22 billion cuts.

[Mr Jim Cunningham]

The hon. Member for Hendon (Dr Offord) talked about efficiency, which is one thing; productivity is something totally different. Productivity is what the individual produces, whereas efficiency is really about how the individual works. Does my hon. Frind agree?

[Karin Smyth]

I agree with my hon. Friend. It is the environment in which an individual works and is supported into work that helps to boost productivity. I think we would all agree that generally people want to be as productive in the service as they can be, and they are very cognisant of their role as public servants. As I say, I would like to see political honesty and discussion about the scale of the £22 billion cuts. It is hard to see where they will come from, regardless of pay restraint, cuts to services and major reconfigurations. Those changes may need to happen, but there needs to be honesty across all parties in the House to support their introduction.

There is wide-scale agreement about the problems that the NHS faces, beyond the items that the hon. Member for Hendon mentioned, but now that the election has passed it is time for us to consider the solutions that can be achieved to support staff in making that transformation, and in making the NHS highly productive, as well as one of the most efficient services in the world.

--- Later in debate ---

[Andrew Gwynne (Denton and Reddish) (Lab)]

It is a pleasure to see you in the Chair, Mr Pritchard. I congratulate the hon. Member for Hendon (Dr Offord) on securing this important debate. We have had a good debate, although fairly brief, and some important issues have been raised.

I formally welcome the Minister. We have had Health Questions and an Opposition day debate on health since he assumed his role, but this is my first opportunity to welcome him. I trust that his time at the Department of Health will be enjoyable and successful.

I am pleased to respond to the debate on behalf of the Opposition. The hon. Member for Hendon is right: the efficiency challenge for the coming years will dominate the debate about healthcare and shape our NHS in England for decades. As Members know—indeed, several referred to it specifically—the Government are committed to seeing £22 billion of efficiency savings in the NHS by 2020 to meet the £30 billion funding challenge. We have not yet heard any details of where the £8 billion in funding will come from; perhaps I can tease some of the detail out of the Minister. I do not wish to prejudge what may or may not be in the Budget, but it would be nice to have some indication, aside from the usual spin about a growing economy, of where he thinks the £8 billion will come from. Setting aside that question, we need to think carefully about how to meet the £22 billion gap that will remain once that £8 billion is found. To achieve savings on that scale would be a huge ask at any time, but when NHS trusts have huge deficits to tackle and providers say they are experiencing the biggest financial pressures they have ever seen, making these efficiencies will be a huge challenge.

It is probably appropriate at this stage for me to place on record my appreciation of and thanks to those who work in our national health service—at every level. It is not always popular to praise managers, but to meet the challenge the NHS will need a great deal of expert management. We therefore need to praise the work of not just the doctors, nurses, clinicians, porters and support staff, but the good managers, because they will face the real challenge of finding these efficiencies.

It is vital, not just for us but for all those who work in the NHS, that the Minister is as open and honest as he can be today about where the efficiencies will come from. One of the few people who has seen the detail of the planned efficiency savings is the former Care Minister, the right hon. Member for North Norfolk (Norman Lamb). Just last week, he said that the £22 billion efficiency savings in the five-year forward view are “virtually impossible” to achieve—words that will not fill people with confidence.

As the Minister knows, the Opposition have pressed the Government on a number of occasions to publish the assumptions underlying the £22 billion figure. I hope he will take that message back to the Secretary of State today, because we need to have a properly informed debate about the NHS’s long-term funding requirements. That is true not just of England, because the proposals will have knock-on consequences for the NHS in all the constituent parts of the United Kingdom, including Scotland and Northern Ireland, which have been represented in the debate.

We need to be honest about the fact that, whatever the scale of the efficiencies that need to be found, there will be no quick fix—a point eloquently made by my hon. Friend the Member for Bristol South (Karin Smyth). However, when budgets are tight, it is right that we debate how money can be better spent to meet the growing cost of delivering world-class healthcare.

With that in mind, let me cover a couple of pertinent areas. The first is procurement. Any doctor will tell us of sales representatives pushing every bit of kit and course of medicine under the sun—that is just the nature of salespeople, and that is what they do. In the NHS, there are around 500,000 product lines for everyday consumables, with cost variances of sometimes more than 35%, which is massive. The Carter review suggested that a catalogue of 6,000 to 9,000 product lines represents best practice. In part, the huge variety of products is a symptom of a more fragmented NHS. These days, we do not have the opportunity to use the NHS’s national purchasing muscle as much as we did, which is a shame and a wasted opportunity. However, having a reduced range of products—perhaps set out in a national catalogue, but definitely coming through the NHS supply chain—would be good for cost-effectiveness. I hope the Minister can take that point on board.

Part of the problem is the army of sales representatives, who are proliferating at all levels of the NHS. Their very existence represents a large dead-weight cost to providers. They can provide a useful service when it comes to selecting the best product for practitioners’ needs, but it is obviously not in their interests to provide products at the lowest practical cost; nor is it in their interests to promote other products or to give practitioners more information about the choices that may be available to them and their patients. It is, to some extent, an imperfect market, with smaller suppliers pushed out from the very beginning. There will always be a need for companies to provide high-end support and advice, but while representatives have a big influence on buying decisions, we must ensure that that influence is at least partly tracked.

Let me talk briefly about the cost of competition. The Minister is new to his post, but he will have paid close attention to the many debates we had on these issues before the election, so he will be aware of the Opposition’s concerns about the competition rules introduced in the Health and Social Care Act 2012. We know that the new competition framework is causing

“significant cost to the system”—

not my words, but those of the former chief executive of the NHS. Last year, we identified at least £100 million that in trusts and clinical commissioning groups alone was being spent on staff and lawyers to analyse tenders and to administer the tendering process. If the Minister is serious about making substantial savings, may I gently advise him that it would be a good start to look at the waste generated by the Act’s competition provisions?

One crucial area to analyse is the poor workflow in hospitals, and specifically the lack of adequate sub-acute services. At the moment, many discharged patients, particularly elderly ones, have nowhere to go. That is attributable mainly to the drastic cuts to adult social care we have seen in recent years. Sadly, I can only anticipate that those pressures will remain, and perhaps become more acute with coming spending reviews. We all know that if patients are not discharged, hospital beds are wasted and hospital workflow is disrupted, which costs the system an absolute fortune. That is to leave aside the fact that hospital is not the best or most appropriate place for such patients to be or for their care to be delivered.

[Karin Smyth]

The consequences of the 2012 Act included fragmentation of responsibility for the flow of patients through the system. Different commissioning organisations now commission primary care to support the patient outside hospital, there is separate provision of community services, and NHS England has an oversight role as well as a role in commissioning specialised services. In Bristol there are two major acute trusts that are largely commissioned by three different clinical commissioning groups, supported by NHS England and involving the Trust Development Authority and Monitor. A large room is needed for people to get around the table at meetings to consider things such as flow, and it is very complicated.

[Andrew Gwynne]

My hon. Friend hits the nail on the head, describing the complexities of the NHS in England. We have talked for several years in the House of Commons about the need for a properly integrated health and social care system. My hon. Friend has set out a prime example of the reason we need that.

I anticipate that the Minister will argue that some of the inefficiencies we have discussed will be addressed through integration. My problem is that many of the competition rules and requirements in the 2012 Act work against such an integrated health and social care system, even though both sides of the House want it. The Government will have to look carefully at the role of some of the rules and regulations they introduced, when local health economies reach the point of developing integrated care models. It is clear that representatives of a hospital trust, local authority adult social care and children’s care services, and the clinical commissioning group cannot sit around a table to plan an integrated health and social care system while many of the requirements placed on the NHS by the 2012 Act continue to apply.

To return to the issue of transfer and delays in hospitals, we all know that the NHS operates something of a just-in-time system. Such systems are used in industry, particularly for international stock control, and they make sure that nothing is wasted. There is little room for slack: if a patient is admitted for longer than necessary because of avoidable shortfalls elsewhere in the system, that can lead to the atrocious scenes that happen when desperately sick and injured people are left lying in corridors. I think that on one occasion, somewhere near the constituency of my hon. Friend the Member for Bristol South, someone was treated in a tent in a hospital car park. We hoped such images had long gone from the NHS.

I want to say politely but firmly to the Minister that the NHS is affected by what goes on in the social care system. Social care cuts are to all intents and purposes NHS cuts. I hope that he will get that message loudly and clearly and that the Prime Minister will stop insisting otherwise. All that demonstrates, as my hon. Friend the Member for Bristol South eloquently stated in her intervention, the need for a properly joined-up service. Labour Front Benchers have argued for that for some time and the previous Government were moving towards it. I am happy to provide guidance to the Minister on what we think should happen to that end, and to provide stern criticism if Ministers do not deliver.

I also want to talk briefly about the cost of agency workers, which the hon. Member for Angus (Mike Weir) touched on. The Health Secretary has belatedly sought to address that issue, but it has been years in the making. Ministers will know that hospitals have consistently cited recruitment difficulties, particularly for qualified nursing and medical staff and in accident and emergency departments. It is welcome that the number of training places has been increased in recent years, but it was a short-sighted mistake to cut the number of those places early in the previous Parliament. That has led in part to the present recruitment issues.

The Minister will know that the rising number of staff suffering from work-related stress has resulted in even more workforce pressures in the NHS. He will also know that the decision to cut nurse training posts has meant that many hospitals must either recruit from overseas or hire expensive agency workers. Health Ministers must make strong representations to Home Office Ministers, because if there was ever a sign of disjointed Government decisions, it was the recent announcement of changes to immigration policy. As we have already discussed, those changes may cause massive problems to some NHS trusts across the United Kingdom that already face challenges and have recruited from overseas.

The savings that the NHS will need to make in coming years are far more difficult than the low-hanging fruit or quick wins that some may think are available. All of us across the parties and across the constituent parts of the United Kingdom need to acknowledge that there will be no quick fixes to the challenge. There should be no mistaking how difficult things have been for many trusts in the past few years. The coming years will be just as difficult for them, if not more so. I hope that the Minister will agree in that context that we need a proper open debate, with all the facts, figures and information before us about where we can make the savings, and how we can ensure that more of the NHS’s funding is spent on what it does best—delivering high-quality patient care across the United Kingdom.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. It is indeed my first appearance in this role in Westminster Hall and, therefore, under your chairmanship here.

I congratulate my hon. Friend the Member for Hendon (Dr Offord) on securing this important debate. I suspect that, in raising the important matters that he took up in his speech, he did not anticipate the glimpse of the promised land that the debate would give us. I have never sat in a debate on the NHS in this House—I have only been here for five years—when there was such a productive, interesting and bipartisan approach to such an important matter. I hope that it will be a model for things to come.

In seriousness, the differences between us, across the Floor, are far fewer than the things we agree on when we consider the NHS. A new Member, the hon. Member for Bristol South (Karin Smyth), said in her speech that now the election is over we have a fantastic opportunity to forge a greater consensus on the NHS, which will be better for the service and patients, and especially, in the present context, for the people who work in it. They get fed up with the politicisation of the NHS, which has happened since its creation in 1948.

The hon. Lady hit the nail on the head in her excellent speech: efficiency really comes from quality. We begin to get an NHS system that is truly efficient in using the resources that the taxpayer puts at its disposal and the hard work of those who work in it when the first consideration is care quality and safety. If we try to build a system around quality and safety, the efficiencies will flow from that and excessive costs will start to fall out. Part of the problem with trying to find efficiency savings in the NHS—indeed, in any public body or private organisation—is that a purely cost-cutting approach will almost certainly fail, in terms of not only the quality of the product being delivered, but the efficiencies being sought. I very much welcome the hon. Lady’s intervention on that point, because that is where we need to begin.

All of that lies at the heart of Lord Carter’s excellent report. It is an interim report—he will publish his final report, with a great deal more detail, in the autumn—but he has understood that it is the patient who feels the effects of inefficiency first and foremost. Their experience of care is not what it should be, because of how rostering is arranged or medicines are dispensed and administered. He gave specific instances in his interim report—for example, the range of products available for hip replacements—of where choosing one product over another can mean dramatic differences in the occurrence of revisions. As the hon. Member for Strangford (Jim Shannon) said in his speech, cheapest is not always best. Sometimes, a slightly more expensive hip replacement joint can mean a much higher chance that someone does not have to come back for surgery again in a few years’ time. Such decisions about balance lie at the heart of patient care. If we get the balance right, we have a huge prize: better patient care and a more efficient, cost-effective service.

I want to run through the main points of Lord Carter’s report and reflect on them in the terms raised by my hon. Friend the Member for Hendon. The NHS provides a varied picture of efficiency. The service has some of the most efficient hospitals in the world, but also some fantastically inefficient ones. That variation lies at the heart of the problem that we have to square in the next few years, which I will come to shortly when I address the specific points about the £22 billion target. As MPs, we all have anecdotal impressions from speaking to chief executives and managers in the NHS: they have come up with great ideas locally, but one knows immediately that no one is learning from that across the system. That was the case before the 2012 reorganisation, and it was case before all the previous reorganisations; it has been problem in the NHS since its inception.

We must also learn from best practice around the world. There is some fantastic practice around, and not only in France, Spain—specifically Valencia—and Germany; some of the best practice in the world for creating efficient healthcare is in American hospitals. I find it very exciting that there is some fantastic practice coming from Indian hospitals, because it shows how the world is changing. If we can draw in that expertise, we will do better for the NHS. I hope that, at the same time, we will export some of the best practice we have developed here—much of which has come from places not a million miles from the shadow Minister’s constituency—to hospitals and health systems around the world.

The changes in efficiency and productivity gains in the past few years have been considerable. Traditionally, the NHS has lagged behind in productivity improvements, but in the past few years it has overtaken productivity gains in the rest of the economy. Some of that has come from wage restraint, but there has been a genuine improvement in productivity, although it is not as much as we hope, anticipate and need to come over the next five years from system change, rather that just from wage restraint.

Lord Carter’s review covers some of the efficiency savings that can be made, especially in the provider sector. He has identified £5 billion of savings, of which £2 billion can come from improving workflow and workforce costs and £3 billion from static costs related to pharmacies, estates and procurement. As has been mentioned already, he has identified the fact that although there is much dispersed good practice, it is not shared, and there is no common understanding of what a good hospital looks like. On the back of Lord Carter’s principal recommendation, we are going to construct a good hospital. It will be a virtual hospital, so people will not be able to visit it, but they will be able to go to parts of it, because we are going to take the best practice and codify it.

Lord Carter has created a system called the adjusted treatment index, which is a rather dry term for an exciting idea. We will say, “This index is the best that the NHS is doing and we’re going to measure you all against it.” Every chief executive, manager and clinician will be able to see where their particular unit sits against the very best in the country. That will immediately prompt some questions: “Why are we not the best? Why are we a third or half of the way down? What can we do to close the gap?”

The second output from Lord Carter’s report is to provide a suggestion, in base terms, of how the poorest performing hospitals, along with those in the middle and those near the top, can improve and become the best. His final report will give far more detail, but this is of course a living process. We want to create a manual that will help clinicians to constantly improve their performance, measured against the very best—and the very best in the NHS will be measured against the very best in the world, so that our target keeps moving upward.

Lord Carter also identified issues with staffing, agency spend and locums, which formed the meat of the speech by my hon. Friend the Member for Hendon. I will quickly go through what we plan to do. In the long term, it is clear that the expansion of nursing recruitment places will meet our objective to improve staffing ratios and the quality of care in hospitals, but we do have a backlog to fill. I do not want to break the bipartisan consensus, but the fall-off in recruitment places did begin before 2010. It picked up again in 2012-13, partly in response to the recommendations of the Francis report, but we still have some way to go to ensure that we are up to pace.

It has become clear that although there was a need for agency staffing to plug the shortfall, some have been abusing that position. Now that we are getting more and more nurses into the system, it is the right time to bear down on agency costs, which is why the measures outlined by my right hon. Friend the Secretary of State a couple of weeks ago will make such a difference, by giving chief executives the tools to ensure that they are not paying over the odds on agency spend.

[Karin Smyth]

On agency recruitment, does the Minister agree that we should encourage more young people to see the NHS as a good career? Young people such as those in my constituency, Bristol South, do not always get the advantages of university and further and higher education qualifications, and they do not see working for the NHS as a good and positive career. It is still a very good career—well paid and well remunerated by pensions and so on—but it is no one’s job, directly, to sell a career in the NHS in order to bring through the next generation of young people in places such as Bristol South to work in the NHS. That is not a hospital’s direct role. Health Education England is a new organisation and has that responsibility, but, in the spirit of bipartisanship and cross-departmental working, will the Minister take our advice and talk to colleagues in skills and development and support apprenticeships to encourage young people to come through and fill the gap currently filled by agencies?

[Ben Gummer]

I do not want to ruin the hon. Lady’s nascent reputation by agreeing with her again—happily, there are very few Opposition Members present to notice, although that is not an implied criticism—but she is absolutely right. We are lucky that nursing places are quite significantly over-subscribed. The position is popular, but she is absolutely right that we need to not only make far greater use of apprenticeships but widen the skills base in nursing full stop. We are actively working on that in the Department—I have spent much of the day on it, and I am sure there will be more to come.

To help chief executives in this interim period, we have forced all agencies that want to offer their services to ensure that they are doing so through framework contracts, and we are ensuring that there is an hourly cap on the rate that can be charged. We have also taken additional measures on managerial salaries, along with a few other measures, to ensure that managers have the opportunity to be able to manage costs as they wish. We understand, however, that this is the first stage of a much deeper programme of reform that is needed. Lord Carter’s report points in that direction by suggesting that we use our existing workforce far better, so that people are doing the job that they are suited to and qualified for and that their time is not wasted. That is the great win, not only for efficiency and patient care, but for staff enjoyment of their jobs.

The hon. Member for Coventry South (Mr Cunningham) made some helpful interventions about NHS workers’ quality of life. It has been a sad but persistent truth of the NHS for many years—decades, in fact—that staff-reported incidents of harassment and bullying have been higher than the national average and that workforce stress and illness is higher than average. Some of that is to be expected—parts of the NHS are extremely stressful working environments—but we can do much more. Part of that is about ensuring, when people turn up to work, that they are doing the job they wanted to do, with a suitable but not excessive degree of pressure, and that the system is not wasting their time. If we make them happier in their jobs, their patient care will improve and their commitment to the service will be even greater. I am therefore aware of the prize, not just in pounds, shillings and pence, but in an improvement to staff morale and therefore patient care.

A&E Services

Karin Smyth Excerpts

Wednesday 24th June 2015 Commons Chamber

[Dr Whitford]

The problem with moving patients into hospitals is being exacerbated by the reduction in in-patient facilities. Every new hospital seems to have fewer beds than the old hospital it replaces. The Scottish Government finally accepted the view of clinical staff that that could not go on. We now treat people in a different way. People used to get a hernia done and lie there for a week. My breast cancer patients used to come in and stay for 10 days. That has changed, which is great for those patients, but there is an inexorable rise in the number of older patients who have complex needs. The problem is not that we are living longer. I get quite upset at the phrase, “the catastrophe of living longer”. I suggest that Members think about what the alternative is. At medical school, I was definitely given the impression that people living longer was the point.

People are surviving their first major illness and, actually, their second major illness. They may present with breast cancer in their mid-70s to someone like me and have four co-morbidities. Such patients do not get in and out quickly for elective surgery, and they do not get out quickly when something major goes wrong, such as pneumonia or a chest infection. We therefore need to stop the downward trajectory in the number of beds, because we will not get the flow of patients if we go on cutting beds.

For me, the key things that we need are the co-location of GPs; an out-of-hours service for out-of-hours issues that are better dealt with in primary care; and enough beds in the right places. Finally, we need to smooth the way of our patients to get back to their homes. In Scotland, we have free personal care that allows us to keep more people at home and stop them going into hospital and to get more people back out of hospital.

I commend the “Five Year Forward View”. Much of it is taken from something that was written in Scotland several years ago called “2020 Vision”, which was about integrating health and social care.

[Karin Smyth (Bristol South) (Lab)]

I am not aware of the position on co-location in Scotland, but one barrier to the successful implementation of co-location in England is that the tariff and the funding mechanism mean that is it not efficient. Will the hon. Lady say what the position is in Scotland, because perhaps we can learn from that in England?

[Dr Whitford]

As I am sure the hon. Lady is aware, we have a totally separate system, for which I am grateful. We do not have a system of tariffs. We have a single NHS, so we can sit around a table and try to work out a solution. That is one of my concerns about the situation that the NHS in England faces and it is where I would veer away from the “Five Year Forward View”.

The principle of working together and integrating health and social care is commendable. The integration boards in Scotland started work in April because “2020 Vision” is a few years older than the “Five Year Forward View”, but we face the same challenge: local authorities are struggling with their budgets, which can end up eating away at the health side.

The four-hour target is still useful as a weekly target to provide a quick response to what is going on in our hospitals. However, it should not be used as a stick to beat staff or to beat ourselves in this House and make public capital. The NHS is too precious for that.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

I congratulate the hon. Member for Dewsbury (Paula Sherriff) on her eloquent maiden speech. It is great to see another strong woman in the House.

I am mindful of the time constraints in the debate and, although I would love to talk about GP access and hospital finances, I shall concentrate on accident and emergency targets and, in particular, the target of 95% of patients being seen within four hours. I speak as a nurse who has worked in A&E under the last Labour Government when the four-hour target was introduced. I hope that my clinical experience will be used to inform the debate and take it forward.

I want to make four key points on A&E targets and the four-hour wait. First, like the hon. Member for Central Ayrshire (Dr Whitford) and my hon. Friend the Member for Totnes (Dr Wollaston), I am not a fan of targets. As a healthcare professional, I found them increasingly frustrating. They are great as a tool, but they are being used as a political stick with which to beat healthcare workers and the system. There was no clinical rationale for choosing the four-hour target. There is no evidence that the morbidity or mortality of someone who waits for four hours and 30 minutes is compromised. Similarly, there is no evidence that the healthcare received by someone who has waited for three hours and 30 minutes is any better than that received by someone who has waited for four hours. The four-hour target is actually not that helpful.

[Karin Smyth]

Will the hon. Lady give way?

[Maria Caulfield]

I will not take any interventions owing to the restriction on time.

I shall give the House an example. When I worked as a nurse in A&E—under the Labour Government—an elderly gentleman was brought in during a busy night shift. He had fallen at home and broken his hip, and he was put in a corridor to wait. After three hours and 30 minutes, he called me over, saying, “Nurse, I desperately need to go to the toilet.” I had nowhere to put him. The best thing I could do was to wheel a curtain around his trolley, and there, in the middle of a busy hospital corridor, that elderly gentleman with war medals on his chest went to the toilet. He was seen within four hours. That box was ticked and he was deemed to have had good healthcare, but I was not particularly impressed with that care. Let us not kid ourselves that meeting that target always means that the patient experience is good or that the outcome is any better.

My second point, which relates to my worry that this debate is being used as a political football, is that the four-hour target is not being seen in the context of the bigger picture. Other targets show that, even with the increased numbers attending A&E, more and more patients are getting their treatment within four hours. Similarly, the clinical outcomes—surely the most important factor—relating to diseases such as heart attacks show that morbidity and mortality rates have improved. There have also been better outcomes for people who have had strokes and for trauma victims. So outcomes for patients are improving despite the four-hour target not having been met during the past 100 weeks. We should welcome that and congratulate our NHS staff on achieving it.

Thirdly, if this is a serious debate about A&E services throughout the whole of the United Kingdom, which we are surely all here to represent, why are we not looking at the rate in Scotland of only 87%, in Labour-run Wales of 83% and in Northern Ireland of 79%? This debate is a political one, and as a healthcare worker, I find that distressing. It is interesting that those Members who have worked in the NHS believe that the four-hour target is a useful tool but that it should not be used as a political stick.

--- Later in debate ---

[Andrea Jenkyns (Morley and Outwood) (Con)]

I congratulate the hon. Member for Dumfries and Galloway (Richard Arkless) on his passionate maiden speech. I know how nerve-wracking it can be to speak here.

I have experienced the good and the bad of the NHS. I have lost a loved one, but also seen the excellent care that my mum received when she had a knee replacement recently, and that my sister has received for her multiple sclerosis. For my university research dissertation, I looked at healthcare systems around the world, their per capita spend and outcomes. I can honestly say that my research showed that no country and no Government get it right 100% of the time, but I for one am proud of our NHS and I urge Labour Members to stop talking it down and to drop their selective amnesia. Every Member of this House has something to learn from our party history and I would like us all to pull together for the NHS.

We all have lessons to learn, so let us look at the UK statistics on A&E services. NHS England has a 95% A&E target and achieves 93%; the figure for Labour-controlled Wales is 83%, and for SNP-controlled Scotland, 87%. [Interruption.] Those are the figures from NHS Scotland, so perhaps hon. Members should check that out.

[Karin Smyth]

Will the hon. Lady give way?

[Andrea Jenkyns]

No, as I have only three minutes.

My point is that every Member of this House has lessons to learn. I think we should be critical friends, looking honestly at what works and what does not, and sharing best practice. If we look at our record, we see that NHS England has the best emergency care of any western nation. We should celebrate that fact. In Yorkshire and Humber alone, we have 582 more doctors and nurses than in 2010, and I celebrate that. I have worked for healthcare charities for the last four years. Today I met a patients’ association and, together, we are setting up an all-party parliamentary group on patient care. We need to do things in a constructive manner, rather than using this issue for political means. It is only through collective working, including working with patients’ groups and healthcare charities, and by looking at strong local leadership on a ward-by-ward basis, that change can happen.

I welcome the Government’s decision to have a seven-day NHS. We will need to look at how that is managed, but it will take pressure off our A&E services. I will finish by saying that we need to be a critical friend. We need to be honest and make sure there are consequences when things go wrong, and that lessons are learned. We also need to celebrate our fantastic NHS, in which we are still investing. I urge every Member in the House to support that.

NHS Success Regime

Karin Smyth Excerpts

Thursday 4th June 2015 Commons Chamber

[Ben Gummer]

I do not at this stage anticipate—I have received no indication from NHS England—that the success regime will be extended in any way. I repeat that this is a particular intervention by local people, in co-ordination with NHS bodies, to fix local NHS problems. It they arise elsewhere in the country, I am sure that local people will want to look at them too.

[Karin Smyth (Bristol South) (Lab)]

I congratulate the Minister on what is possibly the fastest reorganisation the NHS has ever seen. Which of those local organisations is in charge, and who will be accountable for deciding what constitutes success?

[Ben Gummer]

I welcome the hon. Lady to her place. We are now repeating discussions we had in the previous Parliament, because I am afraid that the Labour party still does not understand that these decisions are not being directed from Whitehall. I know that is uncomfortable for them, because what they want to do is pull a lever and hope that something happens at the other end, but that does not work. The only way to get success is by having local clinicians, supported by national bodies, providing the solutions that local people deserve.

Oral Answers to Questions

Karin Smyth Excerpts

Tuesday 2nd June 2015 Commons Chamber

[Alistair Burt]

I thank my hon. Friend for his question, and the Secretary of State will have picked up his thanks for the visit. Seeing GPs is really important. I will let the House into something that I am likely to say again, which is that my dad is a GP. I pay tribute to him, as he has just passed his 93rd birthday. I thank him and all other GPs for their devotion to practice and to looking after people so well. They are a vital part of the service. I will be keen and rather soft on GPs. I want to see them enjoy their profession as much as my father has enjoyed his.

[Karin Smyth (Bristol South) (Lab)]

What is the Minister’s plan to make GP premises fit for the 21st century?

[Alistair Burt]

I welcome the hon. Lady to her place. Briefly, there is a £1 billion fund to improve, over the next five years, GP surgeries and premises and access to GP practices. It is an important part of the process of improving access to GPs, which is good not only for patients but for GPs, who can feel fully engaged in their work without being overburdened. This support should certainly help.