Health and Social Care Bill Debate
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Liz Kendall
Main Page: Liz Kendall (Labour - Leicester West)Department Debates - View all Liz Kendall's debates with the Department of Health and Social Care
(12 years, 9 months ago)
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Mr Burns
I hope that my hon. Friend will be reassured by two points. First, the Bill contains far greater duties and responsibilities for integration over the whole provision of care within the NHS, and that will obviously include children’s services. Secondly and more precisely on the narrow issue that he raised, the children’s health outcomes strategy, published some time ago, will ensure that commissioners provide services to improve integration and that there is greater working together between the NHS, public health bodies and commissioners in securing an improved pathway of care and greater integration.
Lords amendment 320 ensures that the NHS continues to provide funds to local government for investment in community services at the interface between health and social care.
Thirdly, amendments in the other place have placed a greater emphasis on the duties of the Secretary of State and commissioners with regard to system-wide issues, such as education, training and research. Amendment 7 ensures that the Secretary of State will remain responsible for securing an effective system of education and training. Amendments 21, 26, 35 and 42 will place duties on the board and CCGs to have regard to the need to promote education and training, and the Government supported the noble Lord Patel’s amendment to ensure that providers of health services were required to participate in the planning, commissioning and delivery of education and training.
The Government have also listened further to concerns that the strength of the research duties on the Secretary of State, the board and CCGs did not properly reflect the importance of the NHS as a world leader in supporting research. Amendments 6, 20 and 34 have strengthened these to a more direct duty to promote research.
Fourthly, concerns were expressed in the other place about the treatment of charities, other voluntary sector organisations and social enterprises that provide or want to provide NHS services. We are committed to a fair playing field for all providers of NHS services, regardless of their size or organisational form. We see voluntary organisations and social enterprises as key to this vision. For example, they can play a key role in understanding the needs of local communities and delivering tailored services.
Amendment 8 commits the Secretary of State to undertake a thorough and impartial statutory review of the whole of the fair playing field for NHS-funded services. I can confirm that it will cover all types and sizes of provider, including charities, social enterprises, mutuals and smaller providers. It will consider the full range of issues that can act as barriers for providers, including access to and cost of capital, access to appropriate insurance and indemnity cover, taxation and access to the NHS pension fund. The Secretary of State will be required to keep consideration of these issues under review. As my noble Friend Earl Howe set out in another place, during preparation of the report there will be full engagement with all provider types, commissioners and other interested stakeholders to ensure their concerns are looked at.
Finally, I turn to the amendments relating to mental health services. I would like to thank my noble Friend Lord Mackay for his work in developing amendment 1, which inserts the words “physical and mental” into clause 1 in order to promote “parity of esteem” between physical and mental health services. In response to the Royal College of Psychiatrists’ concerns, I would like to offer the reassurance that the definition of “illness” in section 275 of the National Health Service Act 2006 would continue to apply to section 1, meaning, for example, that learning disabilities, mental disorders and physical disabilities would continue to be covered by the comprehensive health service.
Although our view is that the most important work in achieving genuine parity of esteem will be non-legislative—for example, through our recent mental health strategy, “No Health without Mental Health”—we recognise the symbolic significance of including these words in clause 1. Mental health is a priority for this Government, so I commit to considering further the role that the mandate, the NHS and public health outcomes frameworks can play in driving improvements in mental health services. Similarly, we decided not to oppose amendment 54 by the noble Lord Patel of Bradford relating to mental health aftercare services provided under section 117 of the Mental Health Act 1983, and tabled a number of consequential technical amendments.
I am grateful for the scrutiny that the Bill has received in another place. There is no doubt that it has been strengthened and improved as a result. It will help to ensure that the Secretary of State will remain accountable overall for the health service and provide a robust framework for holding commissioners to account. I urge hon. Friends and hon. Members to agree to the Lords amendments in this group, but to reject Opposition amendment (a) to Lords amendment 31.
Liz Kendall (Leicester West) (Lab)
There have been 1,000 Government amendments to this disastrous Health and Social Care Bill—374 in the other place alone—and it is unacceptable that elected Members in this House have been given so little time to debate amendments that will affect patients and the public in every constituency in England.
It is essential that we reach the second group of amendments, on parts 3 and 4 of the Bill, which deal with Monitor, foundation trusts and the Government’s plans to raise to 49% the private patient cap in foundation trusts, but I want to start with the Lords amendments to the Secretary of State’s duty to ensure a comprehensive service in the NHS. I will remind hon. Members where this all began.
On 10 February last year, my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) challenged the Secretary of State, in his evidence to the Commons Bill Committee, over why he was removing the Secretary of State’s responsibility to provide a comprehensive service in the NHS. He said:
“I have not... It is in the original language. It is reproduced the same way.”––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 166, Q402 and 404.]
On 15 February, my hon. Friend the Member for Halton (Derek Twigg) challenged the Minister of State, Department of Health, the right hon. Member for Chelmsford (Mr Burns) about the removal of the Secretary of State’s duty to provide comprehensive NHS services. Again, this was categorically denied. The Minister said:
“Clause 1 retains the overarching…duty which dates from the original 1946 Act”.––[Official Report, Health and Social Care Public Bill Committee, 15 February 2011; c. 178.]
He also said that any amendments to the clause were “unnecessary”. Today the Government are being forced to eat their words.
For the record, it was the determination of Labour Members in the other place, not Liberal Democrat Members, that forced the Government to place the clauses relating to the Secretary of State’ duties on promoting a comprehensive service and on autonomy within the remit of the Lords Constitution Committee, chaired by the noble Baroness Jay of Paddington. The result of the Committee’s deliberations are the amendments before us today. The amendments do not deliver exactly the same duty as the National Health Service Act 2006, but they are a significant improvement. Pressed on this issue by Labour Members in both Houses and at every stage of the Bill, the Government have been forced to concede.
A similar thing has happened on education and training, which is the subject of Lords amendments 7, 21, 26, 35 and 42.
Liz Kendall
I absolutely concur with my right hon. Friend. For the record in this House, I pay tribute to our colleagues in the Lords for their achievements and their efforts in securing some of the protections for the NHS that we are debating today.
There was absolutely no mention of education and training in the original Bill, despite the fact that the Bill abolishes strategic health authorities, which play a vital role in education and training—for example, by hosting deaneries. Labour Members raised this issue in the first Commons Committee stage. We also tabled an amendment on Report to place a duty on the Secretary of State to ensure a comprehensive education and training system for all professions in the NHS, which would have included continuing professional development. Labour Members in the other place then tabled amendments to address the issue. I should note, again for the record, that it was Labour and Cross-Bench Lords, not Liberal Democrat Lords, who argued for those important amendments and who forced the Government to introduce substantive new clauses placing duties in respect of education and training on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups.
However, the critical issue that I want to focus on is how to deal with conflicts of interest in clinical commissioning groups. Clinical commissioning groups will be responsible for spending around £65 billion of taxpayers’ money. They will be made up of a majority of GPs—professionals who run businesses that are largely, and in many cases wholly, dependent on the NHS for their income. Clinical commissioning groups will commission NHS services, some of which will be provided by GPs who are members of the group, or—as is increasingly envisaged by the Government—by companies in which GP members may have a financial interest. The public must have confidence that clinical commissioning groups are making decisions based on patients’ and taxpayers’ best interests, not the financial interests of GPs.
Liz Kendall
I will finish this point.
However, under the Bill, clinical commissioning groups—the newest bodies in the NHS, and with the least experience—will have the weakest corporate governance of any public body in the country. They are required to have only two lay members. However, there has been no reassurance in this House or another place that those members will be independently appointed. The Government have not even given a reassurance that the chairs of clinical commissioning groups will be lay members. The Government have also failed, at every faltering stage of this Bill, to ensure robust protections against actual or perceived conflicts of interest in clinical commissioning groups.
Liz Kendall
No, I am going to proceed.
Let me remind hon. Members that the Bill started out without any requirement for GP consortia—as they were then called—even to have a board to govern their work, let alone any measures to deal with potential conflicts of interest. On 3 March last year, in the first Commons Committee stage, Labour Members called for effective corporate governance and robust measures to deal with conflicts of interests in clinical commissioning groups.
Liz Kendall
I am going to finish this point.
The Minister of State, the hon. Member for Sutton and Cheam (Paul Burstow), said that all and any changes to those provisions were “unnecessary”, and denied that there was any lack of effective governance. I would remind Liberal Democrat Members that the Minister argued that putting a board in place or dealing with conflicts of interest would mean that clinical commissioning groups would fail to be “liberated”. Those criticisms were among the many issues that were supposed to be dealt with when the Government embarked on their now infamous “pause” in the Bill’s progress last spring, but they were not. The Government were therefore forced to return to the issue in the other place. However, the amendments before us are still weak, incomplete and ineffective.
The Government say that clinical commissioning groups will have to include in their constitutions how they intend to manage conflicts of interest. However, I am afraid the Government are deluded if they think that the national NHS Commissioning Board will be able adequately to scrutinise whether hundreds of clinical commissioning groups are properly implementing the measures in thousands of contracts, particularly when the board has already taken on so many other huge responsibilities for managing the Government’s new system. Giving Monitor powers to scrutinise clinical commissioning groups is inadequate for the same reason. Saying that Monitor can deem a clinical commissioning group’s contract to be ineffective, if it thinks that conflicts of interest have not been dealt with, will in effect mean closing the stable door once the horse has bolted. Indeed, there could be huge problems on the ground, as a provider may have already started delivering services to NHS patients by the time Monitor takes its decision.
Labour’s Front-Bench team in the other place tabled a comprehensive amendment to deal with conflicts of interest in clinical commissioning groups. It would have ensured a code of conduct for how clinical commissioning groups register, manage and report on conflicts of interests among its members and employees, and imposed a duty on CCG members to abide by the code. The amendment would have ensured that no member of a clinical commissioning group could take part in discussion or decisions concerning any provider of services with which that person had a registrable interest, and allowed the Secretary of State to appoint an adjudicator to investigate complaints about any breaches of the code, with a range of financial and other sanctions available, including the ability to suspend or remove a person from the clinical commissioning group. However, the Government rejected that comprehensive amendment, saying that such sanctions were unnecessary.
The Government have agreed to Lords amendment 31, which at least says that there must be a register of interests for a group, along with its governing body, sub-committee and employees, and that the register must be kept up to date, with information updated within 28 days. That change is welcome, but it does not go anywhere near far enough in ensuring that conflicts of interest are robustly dealt with. That is why our amendment (a) to Lords amendment 31 would ensure that members of a clinical commissioning group would not be able to take part in discussions or decisions about services in which they had declared a registered interest, which is the same format as in local government.
Andrew George
Although we welcome Lords amendment 31, which was tabled by my noble Friend Baroness Barker in another place, the hon. Lady’s amendment (a) proposes to go a stage further. I personally welcome that, but did she notice that the Minister, in justifying the Government’s position that it would not practically be applicable, gave the example of a CCG commissioning from all its membership? Does that not fundamentally undermine the argument that clinical commissioning groups cannot be conflicted per se?
Liz Kendall
I am simply arguing in amendment (a) that the same robust mechanisms that exist in local government should apply in this case. The hon. Gentleman will have to have a conversation with his own Ministers about what they have said in response.
The potential for conflicts of interest under the Bill is so great, and the amount of public money being spent by clinical commissioning groups so substantial, that the Government should have put in place far tougher provisions to deal with conflicts of interest. The Deputy Prime Minister has failed to guarantee the integrity of clinical commissioning groups, as he claimed in his joint letter with the noble Baroness Williams to Liberal Democrat Members. The integrity of clinical commissioning groups cannot be guaranteed by having only two lay members who will not even be independently appointed, nor can it be guaranteed through guidance for GPs, which the General Medical Council is currently developing. Indeed, I would argue that the GMC’s role should be to ensure professional integrity in the treatment of individual patients, not with regard to organisational misconduct, which would be a complete change in its current role. Nor can the integrity of clinical commissioning groups be guaranteed by national bodies such as the NHS Commissioning Board and Monitor, which will be too distant, too remote and too busy dealing with the fallout from other aspects of the Government’s Bill to be able effectively to address the potential conflicts of interest that clinical commissioning groups will face every day.
This issue might not have received as much public or media attention as other aspects of the Bill, but it will become significant in future, as patients and taxpayers struggle to determine whether their best interests—not the financial interests of GPs—are at the heart of the NHS. Examples of that have already come to light. In October last year, the Haxby practice in York wrote to its patients to say that a range of minor treatments would no longer be available on the NHS, but that they could be carried out privately at a number of clinics, including one owned by the practice itself. Those treatments included the removal of skin tags, at a cost of £56.30, and the treatment of benign tumours at a charge of £243.20.
Dr Richard Vautrey, of the British Medical Association’s GP committee, has rightly said that
“the direction of travel in NHS policy, particularly combined with the financial situation, does increase the risk of conflicts of interest for GPs which is one of the reasons the BMA is so concerned about the Health and Social Care Bill.”
Similarly, the NHS Confederation and the Royal College of General Practitioners have felt forced to issue guidance to GPs on how they should manage conflicts of interest, because they believe that the arrangements will become more complex under the Government’s plans. The Lords amendments before us are not robust enough to deal with this. It is a real concern for GPs that they will be unable to deal with conflicts of interest. That is what they are saying, and they need to be protected. The Government should support our amendment, because that would enable that to happen.
Andrew George
I congratulate my noble Friends Baroness Jolly, Baroness Barker, Lord Marks, Baroness Williams, Baroness Tyler and Baroness Northover on putting in a tremendous amount of work during the Bill’s various stages to negotiate and table amendments to advance the arguments that my Liberal Democrat Friends and I have expressed concern about. I have already put on record the fact that, although some of those amendments represent important strides towards making the Bill less bad, the changes still do not satisfy me to the extent that I feel that the Bill should be entitled to go forward from this, the elected House, as a piece of legislation. Unfortunately, that is not an argument that I am going to win, but I wanted to put the point on record.
Lords amendment 31 represents an important step forward, but it will merely provide a sticking plaster in what will be a fundamentally challenging scenario. The clinical commissioning groups represent a crumbling pillar in the edifice of the legislation. The big weakness at the centre of the CCGs is the fact that their members will, collectively and individually, be conflicted in almost all circumstances, and they will be unable to escape from that.
The Minister emphasised that point further when he told the House why he could not accept the amendment tabled by those on the Labour Front Bench. He told us that members of a CCG should not take part in certain discussions and decisions, even though they had declared an interest, because the groups would, on occasion, be commissioning for all their members. In those circumstances, a CCG would be incapable of making a decision because none of its board members or general members could be brought in to help because they would all be conflicted. That demonstrates a fundamental weakness in the legislation. My noble Friend Baroness Barker tabled an excellently drafted amendment to deal with that problem, but she was working within very limited parameters. The amendment would simply provide a sticking plaster for a crumbling edifice that will be unable to hold up this policy. I have a fundamental concern about the way in which the legislation will work in this regard.
Liz Kendall
The fundamental difference is that under the Bill only two lay people will be appointed as members of clinical commissioning groups, and no independence will be involved. Under the old system, lay members of primary care trusts were independently appointed. The degree of independence that provided checks and balances has gone.
Paul Burstow
Despite the noises off, the fact is that there is considerable scope for that sort of public shaping.
Let me talk my right hon. Friend through some of those changes. We are establishing local health and wellbeing boards, which are made up of clinical commissioning groups, elected local authority members, the various directors to which I just referred, and, importantly, local healthwatch organisations. They have the statutory responsibility for identifying population need for their area and for then framing the strategy to meet those needs. The local commissioner must evidence that the strategies for delivering that—the local commissioning plans—reflect the commissioning strategy that has been produced by the health and wellbeing board. That is the first opportunity to intervene and to help shape the nature of services that are being commissioned for a local population. Indeed, we made amendments that make it clear that health and wellbeing boards must involve their population in that work.
The next stage when people can be involved is when the clinical commissioning group produces its commissioning intentions and plan. CCGs have obligations to consult on their plans and to involve the public in their formulation. That is a further opportunity, but beyond it there is a role in commissioning decisions, or decisions to change or reconfigure a service, for the local authority’s health and overview scrutiny committee, which we are retaining and enhancing, so that, for the first time, NHS providers in the public sector or private providers providing NHS-contracted services can be held accountable for their decisions. That is a change from the arrangements under the previous Administration.
Those are just a few of the steps, but ultimately we have retained the provisions for a reference by the local authority to the Secretary of State to make decisions regarding major reconfigurations. There are a number of steps. I hope that that reassures my right hon. Friend and gives the lie to those who suggest that the provisions have been watered down—the contrary is the case.
We have committed to use the Secretary of State’s powers to specify the criteria that local healthwatch organisations must satisfy when it comes to strong involvement by volunteers and lay members, including in their governance and leadership. We want to ensure that local healthwatch organisations break out of existing models and find ways of reaching and involving far wider and more representative populations than hitherto.
I can confirm that there are a number of amendments, the majority of which are technical in nature, relating to the Health and Care Professions Council, NICE, and the NHS Information Centre. Part 7 of the Bill relates to the regulation of health and social care workers. The Government have made a technical alteration to the provisions amending article 12 of the Health Professions Order 2001 to enable the Health Professions Council to recognise training undertaken in Wales, Scotland and Northern Ireland as sufficient for admission to its register as a social worker. The amendments also give the council the power to assess training or professional expertise and experience in social work gained outside England but within the UK.
Part 8 of the Bill establishes the National Institute for Health and Care Excellence—I emphasise the word “care”—and extends its remit to adults’ and children’s social care. NICE will play a central role in driving quality improvement through the production of robust, evidence-based quality standards and other guidance across the NHS, social care and public health. That is yet another measure in the Bill that supports and drives greater integration of health and social care than has existed in the past. The Government have made minor and technical amendments to part 8 to avoid the potential for misinterpretation and to ensure that NICE’s functions can be exercised effectively in practice.
It is important that patients continue to have access to NICE-approved drugs and treatments in line with the NHS constitution and accompanying handbook, whether those fall within the future responsibilities of the NHS or of local authorities. We have therefore amended the regulation-making power in clause 234 of part 8 so that the provision in regulations to replicate the effect of the current funding direction for NICE technology appraisal recommendations may also be applied to local authorities in respect of the drugs and treatments that they may prescribe for public health purposes, such as smoking cessation aids.
Part 9 establishes for the first time the NHS Information Centre in primary legislation, setting out its powers in relation to the collection, analysis, publication or dissemination of information. The Government have made a number of amendments—to clauses 255 and 257—and inserted new clauses after clauses 252 and 257 that further strengthen the protection of individuals’ confidential personal information while ensuring that the wider benefits of safely and securely sharing information, which include improvements in the quality of services and treatments, can be realised.
The amendments will, for example, restrict the people who can require the centre to collect confidential, personal, identifiable information; clarify the circumstances in which the centre may require others to provide it with confidential, personal, identifiable information; and require a code of practice to be published, setting out how confidential information must be handled. That provides an essential safe haven that can provide a powerful driver to support research and quality improvement in the NHS.
To support these amendments, we have made a number of minor and technical amendments to part 9 and to schedule 19. Finally, we made a minor and technical amendment in part 11 relating to the transfer scheme, which is set out in clause 294. That provision allows for flexibility in how the Secretary of State holds his shares in any property company. That is normal for company structures and is in a form already used by the Secretary of State with his other companies.
I urge hon. Members to support these amendments, including amendment 181.
Liz Kendall
I start by sharing with hon. Members a letter to the Prime Minister on 13 March from Malcolm Alexander, who is the chair of the National Association of LINks Members, the national body representing 150 statutory independent local involvement networks that promote the public and patient voice in health and social care. The letter is about the amendments to HealthWatch that were made in the other place and are before us now. He wrote to register his
“strong objections to the government’s major policy change on Healthwatch—specifically your decision to abandon plans to establish statutory Local Healthwatch bodies…Instead of creating independent statutory bodies led by local people who can monitor, influence, involve the public, hold the local authority and NHS to account; the government plan to create weak bodies that will not be independent, but will be funded by and accountable to the local authority they are monitoring. There will be no genuine accountability to the public.”
He then makes this rather perceptive comment:
“Plans for a statutory Healthwatch body were probably the only part of the Health and Social Care Bill that had any public support.”
He continues:
“Your government’s ambition”—
not your Government, Mr Deputy Speaker, but the Prime Minister’s—
“to establish independent, statutory Healthwatch organisations that would help achieve equity and empowerment in relation to access to NHS and social care services, has been diminished to such a degree, that Healthwatch will have little impact…The aspiration to achieve equity and excellence in public involvement in health and social care, especially for the most vulnerable people, has been replaced by a model that has lost its central purpose of building effective patient and user led bodies that can influence the planning of health and social care.”
Andrew George
I am listening carefully to the hon. Lady’s arguments about the structure and funding of local healthwatch bodies and HealthWatch England. I ask this question not to be deliberately mischievous, but in view of her comments and criticisms: what is the preferred option of the Labour party for those scrutiny bodies?
Liz Kendall
I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords, which set out how we could have a separate independent, body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.
National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK, Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.
Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.
The risk register says that there is a high risk that
“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”
because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities
“will not invest in establishing effective relationships with existing LINks and other community organisations”
because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch
“doesn’t work effectively with providers and commissioners. HW is not fully representative.”
It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:
“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”
The cause is identified:
“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”
Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.
Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[Interruption.] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified
“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”
The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.
Simon Hughes
These are important issues, but I hope the hon. Lady recognises that on the public health agenda, which Labour Members regularly say is so important, there is now—I think for the first time—written into legislation an obligation on the Secretary of State, and therefore on the NHS, to secure
“continuous improvement in the quality of services provided to individuals for or in connection with…the protection or improvement of public health.”
That must be reflected all the way down the tree; it will not stay only in the Department of Health office.
Liz Kendall
The right hon. Gentleman might think that that on its own will protect the system, but as he well knows, I am pointing out what public health professionals are saying. [Interruption.] What I am saying is that the Secretary of State’s interpretation of the Bill is not shared by those who work in public health who think that there are huge risks in it. I was also making the point that when it comes to the fundamental issue of the control or powers of the health and wellbeing boards, we should be very clear that they do not have sign-off. That was my point.
Steve Brine (Winchester) (Con)
I was unfairly chuntering from a sedentary position a minute ago, and I thought I would like to place something on the record. The hon. Lady refers to the Faculty of Public Health, and I have obviously heard its public comments about the Bill. However, it is right there in new section 1B in clause 3 that the Secretary of State has a duty “to reduce inequalities”. I heard an Opposition Member chuntering from a sedentary position earlier, too, to the effect that this is a matter of faith and trust, but this House’s job is to scrutinise and enact legislation. There it is in the Bill in black and white—on green —[Interruption.] Yes, for the first time in 13 years, as I do not recall seeing it in any national health Bill before.
Liz Kendall
The point is that the rest of the Bill absolutely trumps that. That is the concern of others—[Interruption.] Conservative Members groan, but people who work in the system say that the Bill—[Interruption.] The hon. Member for Winchester (Steve Brine)has not stumped me. He said that one phrase in a Bill is supposedly going to outweigh the rest of the implications in the Bill, which the Faculty of Public Health says will increase the postcode lottery and widen inequalities, without providing value for money or improving the quality of services. Conservative Members should listen to the concerns of the people who work in the system.
Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)
Does my hon. Friend agree with me—
Ms Abbott
She will, you know. Does she agree that it is apparent over the years that it is one thing to see an intention built into a Bill, but quite another to see it implemented on the ground? It is the contention of Opposition Members that, worthwhile as the statements in the Bill are, in the context of this particular car crash of a Bill, some of those intentions around public health will be dead on arrival.
Liz Kendall
I thank my hon. Friend for her, as always, powerful and eloquent description of the realities of the Bill.
Liz Kendall
No, I am not giving way to the Minister.
Although I have said that a number of amendments in the group make minor improvements regarding NICE and the functioning of the information centre, they are overwhelmingly—
Liz Kendall
I have told the Minister that I am not giving way to him.
These amendments are overwhelmingly outweighed by the huge change put forward by the Government in abolishing an effective statutory model for healthwatch bodies locally, which was supposed to give patients and the public a strong and independent voice in the NHS. Labour Members cannot accept the Government’s removal of that statutory body, which they promised and have now betrayed. The amendments make a mockery of the Deputy Prime Minister’s claim in the letter he wrote with Baroness Williams to Liberal Democrat Members that the Bill will ensure “proper accountability” to the public. It makes a mockery, too, of the claims made by the Secretary of State and the Prime Minister that this Bill will put real power into the hands of patients and the public, and that there will be “No decision about me without me.” And, as the national body that represents patients and public involvement in the NHS has said, it is
“a betrayal of public trust”.
This is what has happened throughout the proceedings on a Bill for which the Government—Conservatives and Liberal Democrats—have no mandate, and for which they know they have no mandate. They promised that there would be no top-down reorganisation, but did not present any proposals for an independent regulator on the basis of the system that exists in the privatised utilities because they were worried about what people would say. Above all, on this fundamental issue, which concerns the say that the public and patients have in the NHS, the Government have—as the National Association of LINks Members said—betrayed people’s trust in what they promised, and for that reason we will not support the amendments.
Simon Hughes
These amendments—the last group that we shall consider tonight—contain important issues, including that of local community involvement, which was raised by the hon. Member for Leicester West (Liz Kendall). Like other Members, I have an interest in the subject, and have had throughout my time in politics. I happen to know Malcolm Alexander—who was cited by the hon. Lady—very well, because he was once secretary of Southwark community health council.
Let me present my honest opinion of the Bill to my friends on the Government Front Bench. It is not the Bill that I would have presented to Parliament. I think that it has gone much too far in its efforts to introduce top-down reorganisation, which is not what we told the public we would give them; and although there was a fine balance between the arguments in favour of primary care trusts and those in favour of the new structure that we have created, I believe that by changing what we said we would do we have caused more uncertainty, not least among health professionals.
Nevertheless, I am convinced that the process to which the Bill has been subjected has improved it hugely. I am convinced that a year ago my party colleagues performed a public service by setting out an agenda for change, and that we have helped to persuade the Government to amend the Bill in 2,000 different ways. That is not my figure, but one given by the Library in a note with which it provided us before the debate. Since the Bill returned to Committee about a year ago, 2,000 amendments have been tabled, many of them in the House of Commons after the Future Forum had done its work. Today we are considering—technically—374 amendments, all of which are going in the right direction.
It is interesting to observe that only three Labour amendments have been tabled today to the changes proposed by the House of Lords, and that two of them dealt with the same issue. Effectively, that means that the Labour Front Bench has sought to change only three of the many proposals made by the Lords. Of course the 374 amendments are not all substantive—some are consequential, and some are small—but we should not undermine or understate the substantive changes that have been made since the Bill left this place.
Many outside the House believe that there is an opportunity for Members of Parliament to vote on every Bill at the end of all its proceedings, and to deliver a final yes or no decision. There is not, although I think that there should be. I hope to persuade colleagues that we can change our procedure so that all public legislation, whether it starts in the Lords or the Commons, ends up in the Commons for Third Reading. I think that that would make for more democratically accountable decisions. We could then examine the Bill as amended by the Lords, and take a final view. However, we are not there yet; tonight we are considering all these amendments, and with them I thoroughly concur.
I have listened to the debate about accountability, and I accept that there is real disagreement on whether the new system proposed by the Government, at short notice, is an adequate substitute for the statutory HealthWatch. I remember a time—the hon. Member for Leicester West was not in the House then—when, from the Opposition Benches, I ferociously opposed the Labour Government’s proposal to abolish community health councils. I thought that it was a move in the wrong direction, as did my constituents. I still believe that any measure that does not empower my constituents— and the hon. Lady’s in Leicester—and enable them to become involved in decisions, consultations and processes will not be a good thing.
Ministers have been asked some perfectly proper questions today, and I am not 100% persuaded that their answers suggest that we will have the best possible system. Let me be absolutely honest: I believe that although, by and large, the amendments contain huge improvements, there is a great deal of unfinished business. Some will be dealt with in regulations, which will enable us to return to these matters, while some will be judged on the basis of experience.
I asked my hon. Friend the Minister of State to put on record the way in which the public can be more involved, because I am clear that there are significant additional opportunities for the public to become involved. That is why, in those areas, it is a good Bill. I am clear that local councils should have more involvement. He may remember that, as my party’s representative when the Bill setting up the Greater London authority was introduced, I argued that the GLA should have the power of the London strategic health authority, so that there would be a democratically accountable strategic health authority. I have always believed in more accountable local health services and in local councillors and councils having more say.
Liz Kendall
The right hon. Gentleman says that there is more to do and that that can be done in regulations, but that is not the case on the amendment that we are being asked to agree, which will abolish local healthwatch organisations as statutory bodies. That cannot be changed in regulations. Will he vote against that?
Simon Hughes
I understand that. I was not pretending that everything could be dealt with in regulations. I said to the hon. Lady, I hope fairly—I am trying to be fair—that I thought she made a good point that the proposal has come late in the day and does not have the support of the people leading the community involvement at the moment, one of whom she cited and whom I have known for many years. I do not think that the Government have yet given a full explanation of why the new proposals are better than the old ones. I understand why they have suggested that there should not be a one-size-fits-all approach, but I hope that in his winding-up speech the Minister will explain, because I think that Ministers have a case to answer.
John Healey
My hon. Friend hits right at the heart of the flaws in the arrangements proposed tonight, which I was going to move on to. I am sure that Who Cares has its ear to the ground, good local connections and strong representation, and I want to see that continue, as I am sure he does. The real question is whether those organisations can go beyond hard-hitting reports, and who then will be accountable for the action that might need to be taken to follow them up. Where are the enforcement powers that could ensure that any problems they identify on behalf of patients are properly dealt with? I will move on to that point in a moment.
In a sense, that links to the point I wish to put to Ministers now. In the arrangements before us it seems that if a local healthwatch organisation is not up to standard, is not doing the job and is somehow failing patients in an area or falling short of what is expected, we will be offered a new provision, a new power introduced by the Government through an amendment in the other place, for HealthWatch England to write a letter to the local authority, telling it that it must do better. Thinking of the two local authority leaders in the area that I am privileged to represent—Steve Houghton, the leader of Barnsley metropolitan borough council, and Roger Stone, the leader of Rotherham metropolitan borough council—I could not use language in this House that is likely to reflect their reaction. If I think of them, as elected local government leaders, receiving a letter from a sub-committee of a national quango responsible for regulating things that their local authorities have little or no responsibility for, telling them that they are not doing their job properly, I can just imagine their reaction. Quite frankly, “You’re having a laugh.” That is simply not a serious power of, or provision for, redress on behalf of patients when a local patients’ representative organisation is failing to do the job properly. So, no enforcement powers and no intervention powers, only the power to write a letter to the local authority.
In the end, that brings us to the point. At this stage, in the final hour, at the end of this extraordinary Bill’s passage through Parliament, we can see very clearly the truths at the heart of it. There is provision for an independent national commissioning board, an independent market regulator and independent hospital foundation trusts, but there is no provision for an independent patients’ organisation.
In this Bill there are powers to ensure strong action to guarantee competition, strong action to guarantee financial efficiency and strong action to guarantee professional concerns, but there are no powers to guarantee any sort of action, let alone strong action, on behalf of patients.
I listened very carefully to my hon. Friend the Member for Leicester West (Liz Kendall), who made a very good speech from our Front Bench. When she notes that the representative body, National Voices, says on behalf of patients and interests groups, “You’re setting us up to fail,” and reads the letter from Malcolm Alexander, the chair of the National Association of LINks Members, who says, “You’re creating weak bodies that will not be independent,” I think that we in this House should be worried. Such action is, to borrow a phrase, pennywise, pound foolish. The Government are cutting what to Ministers and civil servants might seem to be small corners, but there could be big consequences for patients.
I see a link—a common characteristic—between this debate and our earlier debate on the risk register. The Government will live to regret at length poor judgments and decisions made in haste and under pressure now. The Secretary of State will face the question of whether to release the transition risk register. If he insists on remaining resolute in refusing to disclose, and if he insists on keeping it secret, patients will ask, “What are they hiding from us?” In the future, in the months ahead, long after the Bill has received Royal Assent and is on the statute book, patients will rightly ask when things go wrong, “Did they know these risks were there, and why didn’t they tell us?”
The same applies to HealthWatch. When things go wrong, patients will find that they do not have the recourse and the representation that they may need to act and intervene on their behalf, and they may well find that the arrangements that we are invited to pass tonight are too weak to help them. I say to the Health Secretary, who is now on his own on the Front Bench, that this is likely to reinforce that lack of confidence and lack of trust in the notion that the Government’s huge upheaval in our NHS, and this huge piece of legislation before the House, really is in the best interests of the NHS and NHS patients.
Liz Kendall
On a point of order, Mr Deputy Speaker. Is it in order for the Minister who moved these particularly important amendments, which will abolish a statutory organisation, HealthWatch, to be absent from the debate? If it is in order, is it not a huge discourtesy to Members on both sides of the House?
Mr Deputy Speaker (Mr Nigel Evans)
I thank the hon. Lady for her point of order. It is in order for the Minister not to be here at this moment in time, and it is up to each Member’s judgment as to what to make of that.
Andrew George
I shall sidestep that question at present and return to it later, because I first want to listen to the Minister’s winding-up speech. As I want to ensure that he has adequate time, I shall conclude my remarks as swiftly as possible.
I could, however, initiate a brief yah-boo interlude, such as by saying that the previous Government got rid of community health councils. Many people look back at the era of CHCs as the halcyon days of independent scrutiny of local provision. In creating local healthwatch, we should as far as possible mirror, and learn from, the excellent services provided by the CHCs.
Liz Kendall
On 26 October 2006, when the Secretary of State was the shadow Secretary of State, he set out his policies on HealthWatch. He said:
“I envisage it as an independent body with a separate funding stream and the right to decide its own agenda of work.”
Does the hon. Gentleman agree that that has been completely changed under this Bill?
Andrew George
Earlier, I asked a question about the rationale behind the last-minute change from having independent bodies to the situation now, under which, as a result of both a proposal we are debating this evening and an amendment tabled in the Lords, we are allowing local authorities to commission community interest companies or others to provide the healthwatch function in their areas. That ties the local healthwatch into the local authority. I believe we should devolve and localise, and empower local communities as far as possible, but this change does not achieve that. Instead, it empowers the local authority. If there is a genuine intention to ensure that we have integrated health and social care, then there is a problem here. If the local authority provides both the social care and the local scrutiny, I fear we may not have effective scrutiny of the work of the local authority in this regard.
Liberal Democrats in the Lords have done excellent work in advancing a large number of amendments to improve the Bill, and I am perplexed that the proposal before us tonight appears, in effect, to backpedal from that progress made in other areas. That is why I hope the Minister will reassure us on the rationale for this proposal, and assure us that the new body will be genuinely independent and genuinely effective. I shall therefore reserve judgment on the question of which way to vote tonight.