A&E Departments: Winter Pressure

Karin Smyth Excerpts

Thursday 3rd November 2016 Commons Chamber

[Dr Wollaston]

I thank my hon. Friend, and I welcome him to the Health Committee. Yes, he is absolutely right that one of the initiatives that has been put forward is to look at streaming at the front door, but what we heard is that this is quite nuanced. If very senior staff are tied up seeing every single person at the front door, that can be a waste of resources. However, if the patients who are most at risk of needing admission—the sickest individuals —are identified early on and seen by the most senior doctors available, then yes, absolutely, that makes a difference.

[Karin Smyth (Bristol South) (Lab)]

I had a little smile to myself at the Minister’s response. When I was a commissioner, we often said to each other, “It’s another A&E plan—it must be winter again.” On Monday, I asked the Secretary of State about the £2.4 billion protection for general practice, and I am afraid that there was not a satisfactory answer and the money will not plug the hospital deficits. There are very severe general practice problems in south Bristol and very worrying reports about sustainability. I am looking forward to the report, but will the hon. Lady say something about the role of general practice in the winter pressures issue?

[Dr Wollaston]

We have to think of A&E winter pressures as a marker for the whole system. The hon. Lady is absolutely right and I welcome her reference to primary care, because if people cannot get an appointment in primary care, they are more likely to end up in A&E. Luton and Dunstable is now co-locating primary care so that people arriving at the front door who are more appropriately seen there can be seen directly in that setting. There is, however, another viewpoint: co-locating can sometimes end up creating demand, meaning that more people go there directly, so our report calls for better evaluation of the different models. One of the things that Luton and Dunstable does particularly well is apply evaluation at every stage to the changes it makes. The answer is complex, in that co-location may be absolutely the right thing for some systems, but not necessarily the right thing across the board. I absolutely agree with the hon. Lady that people need to have decent, timely access to primary care.

Community Pharmacies

Karin Smyth Excerpts

Wednesday 2nd November 2016 Commons Chamber

[Dr Whitford]

I agree with the Government about looking for more services, but this is not the way to work with the profession, given that they want those in it to do more work and to work differently. Sadly, during my time in the House, we have repeatedly seen the Government not sitting down with a profession and saying, “Why not look for where savings can be made?”, but simply making a cut.

[Karin Smyth (Bristol South) (Lab)]

I was going to intervene on the Minister to follow up the point made by the Chair of the Health Committee. We are looking at bottom-up planning in England for the first time for a number of years with the sustainability and transformation plan process, so this is completely the wrong time to be making these irrational and random cuts.

[Dr Whitford]

We recently debated STPs and the potential they provide. The danger is that at the moment we are seeing finance-centred care, instead of patient-centred care. Going back to place-based planning, which is what we have kept in Scotland, where we still have health boards, means that we can look at integrating services, and pharmacies definitely need to be part of that. They have the potential to be a significant front-line player.

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

Madam Deputy Speaker, if you were to walk along a busy shopping street in Bedminster in my Bristol South constituency today, you would pass seven pharmacies within a mile or so. However, if you were to walk through the Knowle West estate or Hartcliffe, which are two of the most deprived wards in the country, you would see many fewer pharmacies.

I have spent time in pharmacies in Filwood Broadway and Bedminster, and like most hon. Members, I have been contacted by pharmacists and constituents who are worried about the plans. The greatest fear in my constituency, which has a relatively high density of pharmacies, is its severe problem with GP recruitment and with the sustainability of primary care. We stand to lose disproportionately from those twin concerns. As hon. Members have said, we all know the valuable role that pharmacies play in our communities. This is not just about the damage to healthcare as a result of some of the cuts, but about the impact on our wider economy in some of our most deprived areas.

Madam Deputy Speaker, if you were to wander around my constituency in two years’ time, how many pharmacies—and, crucially, which ones—would still exist? As hon. Members are aware, the NHS-wide process of sustainability and transformation planning is currently being undertaken with the aim, finally, of taking a strategic overview of the whole system. This is the first bottom-up, system-wide planning that has taken place since the disastrous Health and Social Care Act 2012. We are bringing back planning to the system, which is long overdue. This is also about saving a lot of money.

In that context, the delayed Government funding announcements on pharmacies, followed by rushed ones, are the opposite of the STP process. It shows an absence of planning, and a failure to include the vital role that the community pharmacy can play. Where is the sense, when communities need stability, in forcing through a cut of this magnitude at this time? The Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston), said that earlier.

In my area, the local pharmacy committee is represented on the STP board. All the local players are working hard, collaboratively, in the best interests of patients, to find a solution to our local healthcare needs. However, as has been said by the chair of the LPC, Lisa Fisher, who runs a pharmacy at Whitchurch in my constituency, this measure is a “devastating blow”. It runs totally counter to the process that Ministers want to succeed.

The Bristol CCG reported earlier this year on the root cause of the waste of medicines, and made recommendations to address the problems in the system. The figures are eye-watering. It estimates that medicine waste amounts to £5.7 million a year in Bristol, and that we can save £2.8 million a year. It made 15 recommendations for such work, but none covers having fewer pharmacies in our community.

The Minister may stand in front of pharmacies and lament the way in which the market has produced clusters in some areas, but will a large supermarket chain housing a pharmacy decide the floor space is better utilised for a café, and will the pharmacy that does the most deliveries in areas of greatest health need and that offers the most self-care advice close? How does he know? He does not. Crucially, how will my constituents know, and how can they influence the service provided to them?

In Ministers’ minds, is any consideration being given to starting from community need, not from market forces at such a time? If they were putting forward a new model that was genuinely built on pharmacies being at the forefront of Government thinking in addressing the challenges of our healthcare system, that would be good, but they are not doing so. This is not a modernisation package, but a fig leaf. It is a missed opportunity, and that is a great shame at this time.

NHS Funding

Karin Smyth Excerpts

Monday 31st October 2016 Commons Chamber

[Mr Hunt]

My hon. Friend is absolutely right. Although I was not personally responsible for the decision in Corby, I am very happy to take credit for it.

[Karin Smyth (Bristol South) (Lab)]

Representatives of the Department of Health and NHS England have appeared before the Public Accounts Committee eight times so far this year. We have taken a detailed look at the Department’s accounts, following the Comptroller and Auditor General’s unprecedented explanatory note, and I am glad that the Health Committee has said that it will examine the issue further.

The Secretary of State said that prevention was better than cure. The “General Practice Forward View” refers to a £2.4 billion increase in investment by 2020. Can the Secretary of State assure us that that crucial investment in primary care will be protected and not used to plug hospital deficits?

[Mr Hunt]

It is a vitally important investment. The first speech that I made as Health Secretary after the last election was made to GPs, and I said then that we wanted to deliver an extra 5,000 doctors working in general practice. It is vital that we eliminate hospital deficits, but we are making good progress in doing so.

Community Pharmacies

Karin Smyth Excerpts

Monday 17th October 2016 Commons Chamber

[David Mowat]

The hon. Gentleman makes a good point: I should not just reach out to pharmacists at posh dinners. In the past three weeks, I have visited a number of pharmacists. I have even opened a new pharmacy. I bow to no one in my view of the value that they can add, but they agree, and I think most Members in the House agree, that the community pharmacy network must move from a model based on dispensing to a model based more on services. We are going to help pharmacies to do that, and these proposals in the round will achieve that.

[Karin Smyth (Bristol South) (Lab)]

As we have said, primary care is the cornerstone, indeed the foundation, of the NHS, and pharmacies represent a successful public-private model. This proposal does seem to be a totally counter-intuitive one. When I, on the Public Accounts Committee, questioned the chief executive of the NHS last month about the Department of Health accounts, he expressed surprise that there may be a reprieve for pharmacies, because the reality is that this is an in-year cut that is already happening; it is part of NHS England’s delivery of savings this year. Can the Minister clarify the reports over the weekend—what are the figures we are talking about? The reports were that the cuts would be £113 million in 2016-17 and £208 million in 2017-18. Are those the correct figures?

[David Mowat]

The figures to which the hon. Lady refers were announced in the consultation in December 2015. The only change since those figures were announced in that consultation in 2015 is that, because of the delay in looking at this again, the in-year saving this year is likely to be lower.

Oral Answers to Questions

Karin Smyth Excerpts

Tuesday 11th October 2016 Commons Chamber

[Mr Hunt]

I am happy to look at that particular funding issue for my hon. Friend. I know that Kettering hospital is under a great deal of pressure. The one thing that it could do to relieve its financial pressures is to look at the number of agency and locum staff that it employs. As with many hospitals, there are big savings to be made in that respect in ways that improve rather than decrease the quality of clinical care.

[Karin Smyth (Bristol South) (Lab)]

The Secretary of State will be aware that the Public Accounts Committee has questioned both the Department of Health and NHS England on the parlous state of NHS accounts this year, following the comments by the Comptroller and Auditor General. It is clear that STPs are the only plan on the table. Will the Secretary of State make clear his support to the NHS to deliver the STPs in the teeth of opposition from his own Back Benchers? If he will not, what is plan B?

[Mr Hunt]

I do not recognise the picture the hon. Lady paints about opposition to STPs. We need to ensure we have good plans that will deliver better care for NHS patients by bringing together and integrating the health and social care system, and improving the quality of out-of-hospital plans. While we are in a period where those plans have not been published there will obviously be a degree of uncertainty, which we will do everything we can to alleviate, but she is right to say that these plans are very important for the future of the NHS. The process has our full support.

NHS Sustainability and Transformation Plans

Karin Smyth Excerpts

Wednesday 14th September 2016 Commons Chamber

[David Mowat]

I shall not take interventions; I now have only five minutes left.

When it comes to funding, we have put in an extra £10 billion, and it is real money. If that money had been available in Wales, some of the points raised in the debate about the interface between us and Wales would have been quite different. This year, the increase in health funding is 4% in real terms—three times the rate of inflation. The real point, however, is not to do with money—however much the Conservatives put in and however much Labour says it might put in, although we have not heard that yet. But however much is put in, it does not detract from the need for the health service to be managed effectively and properly so that it can improve and innovate.

There is a prize from these STPs. At the end of the process, we will have a health service that is more oriented towards primary and community care where people live. The health service will provide better access to GPs, emphasise prevention more than ad hoc responses, properly address long-term conditions such as diabetes and begin to address more quickly our mental health and dementia commitments. I say again that if STPs do not address those things, they will not go forward. Perhaps the most important of all the advantages is that the unacceptable gap that currently exists between healthcare and social care will be breached. That is at the centre of the whole process.

[Karin Smyth (Bristol South) (Lab)]

Will the Minister give way?

[David Mowat]

No, I will not. I have only four minutes left, but the hon. Lady, who worked with me on the Public Accounts Committee, can come and see me.

It is also true to say that if we achieve all those things, there will be lower hospital admissions and more humane and timely discharges. That might save money, but it is not being driven by the need to save money. It is driven by care needs because that is the right thing to do.

Let me deal quickly with the STP process. We have been told that it is a secret process and a Trojan horse for privatisation, and we have heard that we are not going to consult. Well, let us talk about consultation first. The right hon. Member for North Norfolk (Norman Lamb) made some good points about the difficulties involved in change programmes on which proper consultation does not take place. However, we must have something on which to consult that is reasonably agreed and reasonably stable, because if we do not, we shall give rise to expectations that cannot necessarily be fulfilled—in both directions, positive and negative.

When the STPs come back in October after being signed off, they will be consulted on. A document that will be in the House of Commons Library by the end of the week will describe in detail how all the stakeholders will be consulted and what we will do, but in any event—this point was made by my right hon. Friend the Member for Chelmsford (Sir Simon Burns)—no consultation and no engagement will take away the statutory commitments, the need for configurations to be looked at properly, and the requirement for nothing to proceed that has not been locally agreed.

We were told that the plans were secret. In fact, they were so secret that they were announced in December 2015, in the NHS planning guidelines. They were so secret that 38 Degrees, which was responsible for the principal leak, obtained its information from the websites of the organisations that were keeping it all secret. If we ever do something in secret in future, it really will be done better than this.

The STP process is complex. It will not work equally well in all the locations, and there will be issues to resolve. Some plans, if they are not adequate, will not be proceeded with in the same way as others. I say this to Members, however: we need you to engage with the process—

NHS Spending

Karin Smyth Excerpts

Wednesday 6th July 2016 Commons Chamber

[Karin Smyth (Bristol South) (Lab)]

Does my right hon. Friend accept that as well as the £350 million promise, the issue of access to GP primary care appointments caused a lot of anxiety in many communities? That is the fault not only of the funding situation but of the way in which primary care has been run down in the past six years.

[Joan Ryan]

The lack of primary care—particularly in London but also elsewhere—is a key factor behind the huge pressures on our accident and emergency departments and urgent care. No wonder people go there when they cannot get an appointment.

--- Later in debate ---

[Kirsty Blackman (Aberdeen North) (SNP)]

Throughout this referendum campaign, there were numerous times when the campaigns were deceitful. There were numerous times when things that could not be promised were promised. Today, the Vote Leave official Twitter page still has a headline that says:

“We send the EU £350 million a week. Let’s fund our NHS instead.”

That is still on the Vote Leave Twitter page. In fact, they have not posted since the 23rd; I think they have screwed things up and run away.

I was a bit surprised that the Labour party’s motion did not mention the right hon. Member for Birmingham, Edgbaston (Ms Stuart), because when I looked up the £350 million claim, the first quote that came up was:

“Every week we send £350 million to Brussels. I’d rather that we control how to spend that money, and if I had that control I would spend it on the NHS.”

That was said by the right hon. Lady, and it was patently untrue.

BBC Radio 4’s “More or Less” looked at the statistics. For anyone who does not listen to the programme, I should say that it is rather excellent and tends to debunk what politicians say on a regular basis. It does not usually say something is actually false, however; it will say “It’s not quite right.” But with this claim, it said that it was false.

[Karin Smyth (Bristol South) (Lab)]

I hear what the hon. Lady says about my right hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart), but she is not in the Government so does not have the power to transfer that money to the NHS budget, unlike those on the Conservative Benches. Does the hon. Lady agree?

[Kirsty Blackman]

I agree that the right hon. Member for Birmingham, Edgbaston is not in the Government, but she was in the Vote Leave campaign and made those promises.

Going back to “More or Less”, Tim Harford said:

“If we left the EU we wouldn’t have an extra £350 million to spend on the NHS.”

He also talked about the amount of money that we pay to the EU in comparison with the amount that comes back and said that the

“rebate is about £85 million a week. Unless you think we’d continue to get the EU rebate after we left the EU, it’s impossible to make the claim that there would be £350 million a week to spend on the NHS.”

He went on to say:

“We reckon that in the year 2014 the UK paid £280 million a week to the EU and received back £90 million a week in contributions to farmers and poorer regions and another £50 million in spending on British companies.”

Therefore, the most that could possibly have been available is £140 million, and there was no way that anybody in the leave campaign was ever going to spend all that money on the NHS.

It is not unusual, however, for people to be disingenuous. The people of Scotland are actually quite used to people telling untruths during referendums. The article below the now-famous headline, “The Vow”, stated:

“People want to see change.”

Well, they certainly delivered that. The article also said:

“We will honour those principles and values not only before the referendum but after.”

Ruth Davidson, leader of the Conservative party in Scotland, said on 2 September 2014:

“No means we stay in”

the EU. The Conservatives have completely failed to deliver on the promise they made to the people of Scotland. They are trying to drag Scotland out of the EU against our will.

This Conservative Government have a terrible record of making disastrous pledges, mostly because I think they did not expect to have a majority. They thought that they could write anything they wanted into their manifesto and then backslide on it because they were not going to have a majority. They had the fiscal charter, which was disastrous and condemned us to austerity. They had the removal of the subsidy for onshore wind, which was also disastrous. They had the pledge to have an EU referendum and they thought that they could avoid that one because they would not get a majority, but now look at what has happened.

There was also the disastrous, awful, horrendous migration cap. I am faced with constituents most weeks who sit in my office and explain to me what they do for their community and the work that they do in local government or the NHS. They talk about their volunteering and say to me, “Why does this Government want to send me back to another country?” The only answer that I can possibly give them is that this Government signed up to a migration cap and are therefore trying to reduce the number of people here based not on how hard they work, how much they give to their community or how much they put into NHS services, for example, but on trying to reduce the headcount. The Government’s behaviour is absolutely ridiculous.

What does that mean for the future of political campaigning? People across the UK are looking at the pledges, such as the one that is still on the Vote Leave Twitter page saying that £350 million should be spent on the NHS, and their trust in politics and politicians is being eroded further than ever before. If we want to try to bring things back, we are going to have to work incredibly hard and be incredibly truthful. Our campaigning is going to have to be incredibly positive. The fear factor inspires nobody, and we are losing the trust of so much of the population. They do not believe what we say because we constantly present them with fear, which is not good.

The Health Secretary spoke earlier about having to be careful in what he said in case he further damaged the British economy. He did not want to talk down the economy, which I understand, but I hope that that does not mean that the Conservative Government will refuse to be positive about the benefits of migration. The people who come to this country to work in our NHS and in other services provide a huge economic benefit to the UK as a whole and Scotland in particular. It is important to our country’s economy that people are willing to come here. If the Government are scared about damaging the economy and their ability to use people as bargaining chips and are unwilling to talk about the benefits to the British economy of migration, that is a major issue. Things are bad enough already; we do not want to make them any worse.

I want to mention a few other things that people have said. The hon. Member for Uxbridge and South Ruislip (Boris Johnson) said that people would value NHS services more if they had to pay for them. He then said that the £350 million should go to the NHS. Those two things are mutually incompatible. It is a shame that such points were not highlighted a bit more during the campaign.

So many Westminster Governments over so many years, and indeed decades, have been unwilling to do anything other than take part in short-term politics, focusing on what will be of benefit in the next five years in order to try to win elections. The NHS is a prime example, because some of the health measures put in place by the Conservative Government avoid touching on some of the thorniest issues. For example, breast feeding counselling and support, access to which is being reduced, costs money now but will result in a financial benefit—a return to the Treasury—many years later. It would be good if the Government were willing to take such decisions, which may mean they have a smaller budget now, in order to give people health benefits in 20 years’ time.

Earlier this week we had the main debate on the estimates. NHS and health budgets regularly go against HM Treasury guidance by transferring capital to revenue spend, which other Departments are not allowed to do. What I want to know is why that money is not being spent on capital projects. What capital projects on which the money should be spent are being avoided? Why are the Government not funding the NHS revenue spend to the levels they should be? Why does the NHS have to make these transfers between capital and revenue, rather than being adequately funded?

Madam Deputy Speaker, thank you for your indulgence in allowing me to speak in this debate. I really appreciate it.

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

The Public Accounts Committee, of which I am a member, has published seven reports since January on the workings of the Department of Health, including on diabetes, the cancer drugs fund, services for people with neurological conditions, access to GP services, acute hospital trusts, NHS clinical staff and personal budgets in social care. We have had two further hearings, for reports yet to be published, on discharging older people from hospital and specialised services.

I recommend those reports to those on the Government Front Bench—I have a few copies with me, just in case they do not wish to watch the football tonight. Taken together, they paint a bleak picture of a system under immense pressure, with commitments undelivered, a massive increase in complexity as a result of the Health and Social Care Act 2012 and, above all for the Public Accounts Committee, continuing poor data upon which to make decisions and manage performance, as well as a complete lack of clarity about accountability for delivery on the areas we have investigated.

The concerns outlined in our reports include: on staffing, that trusts have been set unrealistic efficiency targets, and that the shortage of nurses is expected to continue for the next three years; on funding, that the financial performance of trusts has deteriorated sharply, and that this trend is not sustainable; and that the data used to estimate trusts’ potential cost savings targets are seriously flawed.

[Melanie Onn (Great Grimsby) (Lab)]

Northern Lincolnshire and Goole NHS Foundation Trust has only just been taken out of special measures, but last week’s Care Quality Commission report highlights a concerning dip in standards at Diana, Princess of Wales hospital. The bosses have said that that is because they struggled to recruit quality staff. Does my hon. Friend agree that removing the NHS nursing bursary is long-term pain for short-term gain?

[Karin Smyth]

I agree with my hon. Friend. In fact, one of the reports I have with me is the one we published in December about the work of the Care Quality Commission and some of the concerns that have already been issued about the work it does to uncover issues such as the ones she has highlighted in her constituency.

[Catherine West (Hornsey and Wood Green) (Lab)]

Does my hon. Friend agree that a worrying number of trusts are now in deficit, whereas 10 years ago they were simply bubbling along well—in fact, they were getting more money for their budgets? Even for North Middlesex hospital, which we have heard about extensively tonight, the situation is increasingly worrying, as it is now in deficit for the first time in 10 years.

[Karin Smyth]

I agree and I will talk about some of the issues with trusts.

Hon. Members have provided examples that highlight our concerns about how the Department is managing to do what Parliament intended with the funds voted to it. They highlight the importance of giving the Public Accounts Committee and Parliament the opportunity to review the departmental accounts properly.

The Department of Health annual accounts cover more than 20 arm’s-length bodies and delivery partners, not only NHS England, but the Care Quality Commission, NHS Improvement, the National Institute for Health and Care Excellence, the Human Tissue Authority, Health Education England, the NHS Litigation Authority and—one of my and, I am sure, many hon. Members’ favourite organisations—NHS Property Services Ltd.

Within NHS England, NHS trusts reported a record deficit of £2.45 billion in 2015-16—almost £500 million worse than planned, and triple the size of the 2014-15 deficit. As my hon. Friend the Member for Hornsey and Wood Green (Catherine West) said, a record 121 out of 138 acute trusts ended 2015-16 in deficit. Analysis by the King’s Fund and the Health Foundation has challenged the Secretary of State’s claim that, in the 2016-17 Budget, the NHS will receive the sixth biggest funding increase in its history. The chief economist at the King’s Fund concluded that this year’s total real spend increase of 1.6% is the 28th largest increase since 1975-76.

The Health Foundation noted:

“The health budget has been protected from cuts but spending growth is substantially below the growing pressures on the service…In exchange for this protection, the NHS has been asked to absorb these pressures through improved efficiency. There are opportunities to improve the efficiency and effectiveness of the NHS but realising these savings is proving to be a huge challenge—particularly against a backdrop of staffing shortage.”

Given the size of the trust deficit and the implications for the budget of NHS England, which takes up by far the greatest part of the Department’s budget, there are widespread concerns about how the Department might stay within its departmental expenditure limit. Failure to do so would be an exceptional breach of control. As my friend, the hon. Member for Aberdeen North (Kirsty Blackman) said, there are issues about the way in which capital has been transferred to revenue and so on.

The Public Accounts Committee understands that the accounts will be available before the recess—perhaps next week, which would be very welcome. We need to look at not only NHS England’s spend, but that of the other 20 or so bodies that make up the Department of Health. I know that you, Madam Deputy Speaker, and Parliament will take a dim view if the Department’s accounts are not subject to proper scrutiny when the Committee, which had some additional training this year to review the accounts, is ready to undertake such scrutiny.

In addition to my concerns about last year’s accounts and this year’s departmental budget, I believe that Brexit now poses huge risks. My major concerns are about staffing, procurement and medicines, but there are many others. In my NHS career as a non-executive director on a trust board and as a manager, I read and indeed compiled many a risk register. It is truly a joyful task. The Department requires all its bodies to identify, assess and mitigate risks. As anyone in any business knows, risk registers are an essential part of the planning process. Few if any risks to business could be greater than Brexit. I would expect the Department to have a robust Department-wide risk assessment process, and I would expect it to include Brexit.

Yesterday at Health questions, I asked what was being done across the Department, including the NHS, to assess and mitigate the risks to its current year budget of Brexit’s huge impact on staffing, procurement and medicines. I received a far from satisfactory reply—although he tried to be helpful—from the Under-Secretary of State for Life Sciences. I therefore pose three key questions to Ministers: what are the risks of Brexit that the Department must surely have already identified through its risk register or by other means? How are they to be mitigated? When will they be debated and discussed in Parliament?

Oral Answers to Questions

Karin Smyth Excerpts

Tuesday 5th July 2016 Commons Chamber

[Mr Speaker]

Order. Progress has been rather slow today, but I want to accommodate one further inquiry. I call Karin Smyth.

[Karin Smyth (Bristol South) (Lab)]

14. What steps he is taking to ensure that forward budget planning in his Department is robust.

[The Parliamentary Under-Secretary of State for Life Sciences (George Freeman)]

In the autumn statement and the Budget the Government fully funded NHS England’s five year forward view. We have committed to an extra £10 billion in-year by the end of this Parliament. Furthermore, we have frontloaded it, as we were asked to do by NHS England, with £6 billion extra by the end of 2016-17 with an extra £4 billion for technology funding.

[Karin Smyth]

I thank the Minister for his answer. Having published reports on seven areas of the Department’s work since January, members of the Public Accounts Committee, of whom I am one, were looking forward to the publication of the annual accounts with some anticipation. It is becoming clear that Brexit’s impact on staffing, procurement and medicines will be huge, so what is the Minister doing to assess and mitigate the risk to the 2016-17 budget and will this be made clear in this year’s published accounts?

[George Freeman]

May I first make it clear, as the Prime Minister has done, that nothing immediately changes? We are still full voting-right members of the European Union, and nobody in the system needs to worry about any immediate changes. The Government are putting together a plan for handling the negotiations that now need to be taken forward, and for my own part I as a Minister in the Department have convened a workforce to look at the issues around medicines access. There are three things we need to do: first, to reassure people that this country has a very strong life science and healthcare research system and economy; secondly, to make sure that we negotiate our new relationship with the EU in a way that works; and thirdly, to take advantage of the regulatory freedoms that we now have to make sure that this country is the very best country in the world in which to develop those innovations.

Digital Records in the NHS

Karin Smyth Excerpts

Thursday 28th April 2016 Westminster Hall

[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Wilson. I congratulate the hon. Member for The Cotswolds (Geoffrey Clifton-Brown) on securing this important debate and I thank the Backbench Business Committee for granting it. It has been interesting. I am a new Member of this House and it is true, and a great pleasure, that every day brings new insight into the working of the House and its rules and procedures. I am grateful to have seen some of that today.

We have heard some valuable contributions. The hon. Member for Twickenham (Dr Mathias) used her practical experience as a clinician to talk about patient control data and her dream, which I share, of co-ordination on behalf of her constituents. The hon. Member for Bury St Edmunds (Jo Churchill) emphasised the value of research and the role of charities and other non-NHS bodies in driving this agenda forward and having the time to understand diseases. I was particularly glad to hear her mention health economics in this sort of work.

The hon. Member for South Basildon and East Thurrock (Stephen Metcalfe) heroically used his experience of large data in another Department and I look forward to his accelerated political career through the Government ranks. The perspectives of all hon. Members have enriched this debate not just today, but previously. Let us hope that we can move the discussion on digital health records forward for the benefit of patients across the country.

This subject is dear to the heart of the hon. Member for The Cotswolds. He talked about his constituent’s experience and referred to four ways in which the digitisation of data can be transformational for the health service by speeding up new developments, improving co-ordination of care, giving patients control over information about their health and driving whole processes forward. He has been a powerful advocate for his constituents. I often say that patients are assets to be utilised for their knowledge and experience, not nuisances to be ignored. The potential for people to look for hope, not just for themselves but using their experience for others, is an inspiration and at the heart of much of this debate.

I want to talk about the benefits of the data. This debate is important because the NHS, which provides a large population with universal coverage that is free at the point of use, is uniquely placed to be a world leader in innovation.

I started my career as an NHS manager in 1988 without access to a computer and finished as a manager of a patient referral service, so I know how far we have come but also how far we need to go. The NHS must be one of the last remaining organisations that still communicate with people via letter. Extending the use of technology to patient records is not just about using taxpayers’ money more effectively, important though that is. The effective use of the right data has huge benefits as yet unseen and unknown, such as how such data can be used to help tackle inequalities, particularly health inequalities?

With a growing and ageing population, more and more people are living with different combinations of illnesses and conditions. None of us here knows the huge potential healthcare benefits that the wise use of data could bring to the population we serve in years to come. The principles of the Government’s proposals are worthy of our support. As members of the party that founded and nurtured the NHS, we want to find ways of delivering high-quality, personalised and cost-effective care. I assure the Minister that we will support in principle the Government’s plans to roll the agenda forward, as long as there is scrutiny and challenge in a number of areas.

As with everything, there is a vital balance to be struck, particularly on privacy, protection and penalties for the misuse of data, which the hon. Member for The Cotswolds highlighted. I hope the Minister will agree that public confidence in the integrity of the programme is pivotal to its success. I also hope he will assure us today that the Government will take on board important lessons from the shambles surrounding the roll-out of care.data. At the heart of that was lack of public trust about possible misuse of data and a perception that the Government were trying to make changes on the quiet. This must not happen again. I agree with the hon. Member for The Cotswolds that we need a public information campaign that brings patients with us on this journey.

The efficient and effective use of data and technology plays an increasing role in many areas of our lives. The public, perhaps rightly, expect the NHS to catch up and to make for an easier and better-quality patient experience. It can be hard to convince a sceptical public and worried patients that sharing data about their health conditions and treatment will benefit them and their families.

Examples from years past can help and we have heard some powerful examples today. Data played a vital role in tracking and establishing a link between smoking and lung cancer. As a result, earlier diagnosis and swifter treatments were made possible. I am sure that people who have felt the frustration of putting themselves under the care of healthcare professionals who, for whatever reason, have not had access to their health records and so are not always best placed to move treatment forward can be readily convinced of the programme’s benefits.

In my city of Bristol, GPs collaborate on a web-based platform with well-established sharing agreements for data that includes community providers. There is good practice across the country. Bristol is a high-tech, savvy digital city, but I have learned during my time in this place that many hon. Members have constituencies that do not even have good broadband coverage. If this project helps to bring the benefits of shared platforms to people nationwide, it will be a good thing, but it will require a lot of work. If patients can be helped to understand the interoperability of patient data, that promises to improve the quality of experience for the patient, and the programme will receive widespread public support.

I hope the Minister will be able to explain what plans the Government have to educate the public at large about the benefits of this important project, to ensure that concerns that are bound to be expressed by some about privacy and security are tackled before they can multiply. There will be concern that such a major programme of digitisation with an ambitious timeline could run into glitches of the type that many governmental IT projects across different types of government have suffered in the past. What degree of confidence does the Minister have in the deliverability of the timeline and the budget overview? What guarantee can he give that it will be met and who can the taxpayer hold to account if it is not? What confidence does the Minister have in the safeguards that will be put in place to ensure the credibility of confidential data? Is he confident that the requirements of the National Data Guardian will be met?

I now want to turn to a few other concerns that I hope the Minster will address this afternoon, first about money. I have mentioned taxpayer value, as have other hon. Members, so let me turn to some elements of the financial side of this project. Like other hon. Members, I have seen the headlines proclaiming the additional money that is supposedly being allocated to these projects as part of the “General Practice Forward View”, but with the Department of Health struggling to remain within its expenditure limit, 80% of trusts in deficit and the well-documented pressures on primary care, will the Minister be crystal clear, not just about the money allocation he will want to tell us about but, crucially, what pot or pots it will come from and how it will be allocated to support this work?

The Secretary of State has referred to the so-called extra investment of £45 million being dependent on uptake. Will he outline how he sees this dependency shaping up over the coming years? If digitisation of medical records is about improving patient health and genuinely bringing healthcare into the 21st century and speeding up patient care, it will be worthy of support, but we do need to know how it will be implemented.

There are serious questions about capacity and ability to deliver, not just the capacity of the Department of Health and NHS England but, crucially, the capacity of GP surgeries and other providers to deliver a credible digitised service. How will GP practices, which are already hard-pressed by soaring patient demand, be supported to implement this project? What level of engagement in the process to shape the roll-out can GP practices expect? If the Government are keen to limit piling additional pressure on busy GPs, how will they ensure that digitisation processes do not simply add to the burdens? I look forward to reassurance from the Minister to take back to GPs in my constituency, and for colleagues to take back to theirs, because I know that the latest announcements will, with other pressures, bear heavily on their current and projected workload.

Finally, I turn to accountability, which was of concern in my professional experience during the structural changes of 2010-2015. The source of responsibility for change and delivery remains a concern to me and others and is a problem that permeates many aspects of our healthcare system. Throughout the digitisation programme, who will be accountable for its delivery? In the realigned structures of the NHS, we are well used to having difficulty navigating a complex web of accountability for various elements of various programmes. When it comes to patient data, Governments of all persuasions do not have a glowing track record. I suspect that if this project goes to plan, the Minister will claim credit, but if it goes wrong, who will carry the can?

I again thank the Backbench Business Committee for granting this important debate. I hope this will be the start of many more discussions with hon. Members on both sides of the House about this very important issue.

[Phil Wilson (in the Chair)]

Before I call the Minister, let me say that I am really disappointed that he could not be here from the start of the debate. I know that the agenda for this afternoon was changed, but that was on the Order Paper; it was known. I am sure that the change would also have been communicated to the Department, in ample time for this afternoon’s debate. Bearing that in mind, I call the Minister to respond to the debate.

--- Later in debate ---

[George Freeman]

My hon. Friend makes an interesting point, as did my hon. Friend the Member for Twickenham. As part of this quiet revolution of patient empowerment, the clinicians I speak to actively want their patients to have the data and are encouraging them to have it. This is where the apps revolution comes into play, because that is one of the ways in which we are putting this information in the hands, laptops and phones of patients. He is absolutely right that care is improved, but we want to improve patients’ understanding of their condition and improve patient empowerment.

The other example I want to cite is an inspiring example set up at King’s College London by Professor Simon Lovestone: the case register information system in mental health and psychiatry, which is a difficult area of research, as colleagues know. It puts together patient records from across the 250,000-patient catchment area of South London and Maudsley and combines them with MRI brain scans, the digitisation of patient medical records and very complex drug histories in mental health, to build the world’s first reference database for trying to understand the causal mechanisms for complex psychiatric disorders. It has attracted phenomenal industry co-investment alongside the NIHR centre of excellence and is a shining example of how we can use information and data to drive both research and improved care.

On electronic health records, which are important and which this debate was focused on, the ultimate goal is to have a system in which our individual health records flow seamlessly across the system in advance of patients. That is the goal of the paperless NHS. We have set out a series of specific commitments—I can write to the hon. Members here about them—for this year, next year, 2018, 2019 and 2020. They set out clear targets for how the electronic health record will be used and brought to bear—percentages of penetration in A&E, in the ambulance service and then mainstream across the service.

My hon. Friend the Member for The Cotswolds makes an important point. We need to identify some early uses of electronic health records, which may not be comprehensive and universal, and put this benefit in the hands of patients as quickly as possible. One of my missions is to ensure that we get some basic but powerful uses of electronic health records in iPads, phones and devices, so that patients can see their experience beginning to improve today.

[Karin Smyth]

I appreciate the Minister’s enthusiasm and his great knowledge of this sphere. He is probably one of the people who has benefited in his career from the Labour Government’s reversal of the brain drain in the 1980s and 1990s, when they invested heavily in research and technology in the great institutions that he has talked about, which has led us to this point. I look forward to the timeline. He has highlighted how we have Dame Fiona Caldicott, the CQC and—forgive me; I missed the name of the gentleman from America—the practitioner who is coming to talk to us about the culture of patient data. We have CCGs reporting into NHS England and NHS England’s capability on the ground to deliver and support providers to make this deliverable. I do not wish to make a party political point on that, but the frustration shared by those of us who understand how those systems work on the ground will not be helped by having a plurality of people. Who will be in charge of the work plan with its 26 workstreams to make this happen?

[George Freeman]

The hon. Lady makes an important point. It is being driven by the National Information Board, which is NHS-led and involves all the key stakeholders within the service. It is a shining example. I recently spoke at its annual conference, and NHS clinicians will tell you that they are setting the protocols and programmes through the NIB. I genuinely do not believe that the establishment of Dame Fiona Caldicott and the CQC and Wachter reviews are distractions. They are intended to try to support clinical pioneers in the service.

I understand the point that the hon. Lady makes about the service being under pressure, which it is. The demand for healthcare is exploding, and NHS England has set out in the “Five Year Forward View” that digitisation and the greater use of technology is essential to reducing unnecessary pressure on the system. It has forecast that in 2020 we will be looking at £22 billion of avoidable costs from hospital admissions, from bureaucracy, and from paperwork. How many of us have had a diagnosis and received three or four, sometimes five, letters all saying slightly different things? That is incredibly wasteful and expensive.

NHS England itself has identified the fact that if that technology is properly implemented it can play a part in driving efficiency. However, I do not underestimate the extent to which that requires investment—which is why we have front-loaded it—as well as capacity and the ability to integrate. That is a challenge. When those systems are put in place in the private sector, huge numbers of people and huge amounts of resources are devoted to driving the integration properly. I would expect Dame Fiona’s review to touch on that, particularly in relation to training, and organisations’ culture and capacity.

However, things are happening. I want to share the data. More than 55 million people in England now have a summary care record. That is 96% of the population. As to how many are aware of that, it is an excellent question. How many of us have obtained access to our summary care record? That is important. Eighty-five per cent. of NHS 111 services, 73% of ambulance trusts and 63% of A&E departments now use the summary care record, and by April next year more than 95% of pharmacies will have access to it. By 2018 clinicians in primary care, urgent and emergency care, and other key transitions of care context will operate without paper, using the summary care record.

Several colleagues have touched on the question of apps today. We have clearly set out, through the National Information Board, a commitment to ensure that there are high-quality appointment-booking apps, with access to full medical records, from this year. NHS England and NHS Digital are working with GP system suppliers and third-party app developers.

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.

--- Later in debate ---

[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.

--- Later in debate ---

[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.

--- Later in debate ---

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.

--- Later in debate ---

[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).