Healthcare (International Arrangements) Bill

Lord Lansley Excerpts

Committee: 1st sitting (Hansard): House of Lords
Tuesday 19th February 2019 Lords Chamber

[Lord Wilson of Dinton (CB)]

My Lords, I assure the Minister that my comments, which are very much in support of the noble and learned Lord, Lord Judge, the noble Lords, Lord Lisvane and Lord Cormack, and in fact all noble Lords except the noble Lord, Lord O’Shaughnessy, are in no way a criticism of her. I heard her maiden speech, which was memorable. I think we will all remember it, and we all know that she is not responsible for the problem that she has today.

To the noble Lord, Lord O’Shaughnessy, whom I do not follow, I simply say that I think that accidentally he made a really powerful case for splitting the Bill so that we can deal immediately with the immediate problem and the Government can think more carefully about the legal framework within which new arrangements are brought forward. I thought that he made a very persuasive case; it just happened to be in the opposite direction from the one he intended.

I support the arguments made, which we have heard before. We heard them on Clause 7 of the EU withdrawal Bill, as the noble Lord, Lord Lisvane, reminded us. I still regard the word “appropriate” as objectionable, but we did our best there. We must not let only the noble and learned Lord, Lord Judge, bang on; we must not leave it to him alone. We all have to bang on about this issue because it is of fundamental constitutional importance.

I say to the Minister that this Bill is worse than the EU withdrawal Bill because, as the noble Lord, Lord O’Shaughnessy, admirably demonstrated, it is not confined to Brexit. Let us look at the use of words. The language in Clause 5 is like a red rag to a bull:

“Regulations … may amend, repeal, or revoke primary legislation”.


We cannot accept this practice creeping in general into our legislation. I believe that there is such a thing as good and bad government. I have thought about my career and the years when we were governed well, and when we were governed badly—the years when the machinery worked well, and when it worked badly. Sometimes—in the 1970s, for example—it was really dreadful, and we are in a period of really bad government now.

I remember my first Bill 50 years ago, the Trade Descriptions Bill, which I connect with this Chamber. I was a junior official. We went to see parliamentary counsel who, in those days, were venerable people. You were allowed to see them only with a solicitor present. My assistant secretary was asked why we needed a particular power, and he rather flippantly replied, “Because I thought it might be useful”. Parliamentary counsel gave him a withering look and said, “I am not going to draft a clause for you simply because it might be useful. You have to know what you want it for”. He did not know, and we did not get that power. I read this Bill today and thought, “It has all been thrown in just in case it is useful”. The Government do not know what they want; they are putting it in simply in case it might be useful later on. My goodness, the job of this House is to stand up and say no to that. In Mrs Thatcher’s words: “No, no, no”.

I hope the Minister will accept the amendment of the noble Baroness, Lady Thornton, or that she will at least pause, consider it and come back on Report. I hope that she will also consider the option of a sunset clause, which I believe will be overwhelmingly important. The Bill as drafted breaks all the rules of our constitutional understanding. We have no written constitution. The machinery of government works only because we know where the constraints are and what the rules and behaviours are. We have understandings between ourselves—Governments and Oppositions—about how we run and manage legislation. This Bill tramples on that understanding. It does so in the name of Brexit, but it goes far too wide.

I hope that parliamentary counsel will say no to the Government, in private, and that the machine will say no. I hope the Government will have the wisdom—this is about wisdom—to think again, because the precedent being set here is wholly unacceptable. We have to make a stand.

[Lord Lansley (Con)]

My Lords, I believe it falls to me to be a back-marker. I can be brief, not least because I agreed with much of what my noble friend Lord O’Shaughnessy had to say. However, it might be helpful if I were to explain, purely from my own point of view, why some of the criticisms levelled at the Bill are excessive. First, the structure of the legislation—which provides a power to make payments that are then subject to a number of specific constraints and criteria—is not unusual. One sees this in a lot of legislation. Treating Clause 1 in isolation is therefore a mistake; it must always be treated in the context of the Bill as a whole.

Secondly, on the scope of the Bill, it would have been perfectly possible—I presume; I was not party to the discussion—for Ministers to bring forward legislation with a purpose simply to seek to replicate the existing EU reciprocal healthcare agreements. However, the nature of the agreements we will enter into with our partners across Europe are as yet undetermined. This is not about the transition period. This is effectively about the political declaration and what the future relationship looks like. As my noble friend said—and no doubt the Minister can add more specifics if necessary—the regulations that have been laid separately are intended to deal with the immediate consequences if we leave without any deal and without bilateral agreements with other countries across Europe in place.

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[Lord Marks of Henley-on-Thames]

Does the noble Lord accept that all Parliament can do to treaties is withhold agreement in the House of Commons? Is he seriously arguing that that is sufficient scrutiny of potential healthcare treaties and that this House should not persist in its objection?

[Lord Lansley]

The noble Lord invites me to go on about a subject that I anticipate Report stage of the Trade Bill will discuss in considerable detail. I do not propose to discuss it now, if he will forgive me, because this is a wide debate that raises broader issues that will have to be addressed. Quite properly, they might be better addressed in the Trade Bill, which is actually about large-scale international treaties that we are likely to enter into in short order. I am not aware of any proposals for an international healthcare agreement that will be presented in the form of a treaty that we will have to ratify in any immediate timescale. I would rather think about it under those circumstances.

I will say one more thing about sunset clauses. Because of their nature, I am rather sympathetic to the idea that, if we know legislation has a limited shelf life, we should put one into the legislation, otherwise the temptation to go on and on will be irresistible to Ministers. But I do not understand that this Bill has such a limited shelf life. We want to enter into healthcare agreements that might or might not be agreed by December 2020; they might be agreed in 2021 or 2022. In so far as they relate to non-European Economic Area countries, they might arise at any time. There is no immediate prospect of them doing so. To have a sunset clause of this kind would be potentially unduly restrictive, especially expressed as a two-year limit, as it is.

For all those reasons, the debate has been useful. I absolutely understand its importance, because I have future amendments, as the noble and learned Lord, Lord Judge, said, about the ability to amend retained EU law and the question of whether there should be different arrangements relating to agreements that replicate an EU agreement or do something different. As my noble friend Lord O’Shaughnessy rightly said, I raised that at Second Reading and I have amendments that will allow us to debate it later. Those are practical steps where we can question the structure of scrutiny and control that Parliament will exercise in relation to these regulations. A future group that I hope we will get to this evening questions the extent of the Secretary of State’s power to pay money—to whom and how much. That is important. All of us want to set down in legislation how we think Ministers’ use of this power should be structured in the agreements they might consider with other countries. Those debates will be useful, not least in terms of the Minister’s response—which I very much look forward to.

[Baroness Brinton (LD)]

My Lords, I will comment on a couple of points from a political perspective. We have heard from a significant constitutional expert during the course of the last hour and a half. I thank the Minister for her letter following Second Reading and for her response at Second Reading. But what has become clear in the past hour is that for most of us who have been engaging in the debate this has clearly been a Brexit Bill. Indeed, the Minister says at the beginning of her letter:

“Although this Bill is being brought forward as a result of the UK’s exit from the EU, it is not intended to only deal with EU exit”.


However, it is one of the series of Bills that must be passed by 29 March, regardless of whether there is a deal, because we do not yet have the detail. As far as this House is concerned, it is in the list of Bills that we have been told must go through by that date. For that reason, I am afraid that I take issue with the noble Lord, Lord O’Shaughnessy, who says that it is not being rushed through. We have been waiting for this Bill and others for some time. We now have to rush it through because we are 39 days away from 29 March and time is extremely limited.

Some of the allegations that some of us made at Second Reading that this was all about future trade deals have become much clearer to us. I raised concerns then about TTIP. In her letter, the Minister appears to contradict herself. She says on page 2:

“Should the Government wish to enter into new comprehensive arrangements, this Bill provides the framework to implement these”.


Two paragraphs later she says:

“This Bill is not about negotiating new agreements, but to ensure … appropriate mechanisms … to implement them”.


It seems from everything that the noble Lords, Lord Lansley and Lord O’Shaughnessy, said that this provides the framework that will influence the Trade Bill and any future trade agreements. That is one of the most important reasons why a Bill that we understood was coming before us in order to replicate health arrangements with the EU, whatever our relationship is with it after 29 March, is now moving into a much broader political arena that deserves more than one and a half days in Committee to discuss it—let alone whatever time we are going to be allowed at Report.

I want to leave it there at this point, except to say to the noble Baroness—because I do not think there is another point at which I can do so without laying down an amendment that does not particularly have reference to the scope—that she tried to reassure me and others, both in Hansard in what she said winding up the Second Reading debate and in her letter, that the NHS was safe in the hands of this Government, and that the Government basically agree with the principle of the service of the NHS being free at the point of need. But the question that I asked has not been answered, either in her letter or in her response on the Bill. I am concerned about the replication of the EU directive on public procurement that provides many of the protections that we are seeking for the NHS in its entirety as we continue in the future.

I went on to the NHS Confederation website to look at what advice the Government were providing for the NHS in the event of a no-deal Brexit, and found that all the bullet points relating to public procurement were about emergency supplies running out. There is nothing about the intrinsic changes that are provided for in the current EU directive about not having to go out to competitive tender for certain parts of NHS procurement. We have used those as a protection over recent years, including during the coalition Government, to say that the NHS is safe in our hands. So I ask the Minister specifically if she can point me to where the replication of that EU directive on public procurement will appear before us prior to 29 March this year, because I am having trouble finding it.

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[Lord Marks of Henley-on-Thames]

My Lords, I am grateful for that intervention: I did not know the facts about the involvement of certain members of our political establishment in healthcare arrangements. I agree that we are right to be suspicious and I shall come to that later in my contribution, but for now I will go on to the second fundamental fault with the Bill, which is that the proposed powers would enable the Secretary of State not only to make healthcare arrangements with countries across the world but to make such arrangements on whatever terms he or she chooses. That is a dangerous concept.

Many noble Lords, including me, quoted the Delegated Powers Committee’s powerful first report on the Bill at Second Reading. We have now had its second report, published on 14 February. It is in similarly strong terms, speaking, for example, of,

“unprecedented powers for Ministers to make law by statutory instrument”.

The powers are described as far too wide and,

“drafted in far wider terms than are necessary to give effect to the Department’s limited aims”.

I agree with the noble Baroness, Lady Andrews, that the Government ought to be listening more carefully to that committee and to the Constitution Committee. I agree that it is frankly outrageous that, on receipt of the first report of a committee that, when I was a member of it, generally expected its reports to be accepted by the Government, instead of that report being accepted, the Government came back with a response that stuck by every word in the Bill, made no real amendments to it, and provoked the second, outraged report of the committee. That, in my experience, is unprecedented. The committee chose, on this occasion, to deal with the Bill before the Commons had finished dealing it, rather than between Second Reading and Committee in the House of Lords, and the Government, frankly, took no notice.

The Constitution Committee said:

“We agree with the Delegated Powers and Regulatory Reform Committee that the powers in clause 2 are ‘inappropriately wide and have not been adequately justified’”.


I went through the powers in outline at Second Reading. The committees have been through the powers in detail, but the Bill puts absolutely no limit on the Government’s power to enter such deals. The Secretary of State would be empowered to authorise payments and claim reimbursement at any level he or she chooses and for any kinds of healthcare arrangements. Parliament would have no effective scrutiny or control. I urge the Committee to remember the Delegated Powers Committee’s central point, which it repeated in its second report, that,

“we assess powers by how they are capable of being used, not by how governments say that they propose to use them”.

The Government now profess entirely innocuous motivations for taking the powers contained in the Bill to make international healthcare arrangements outside the European context. Indeed, the noble Lords, Lord O’Shaughnessy and Lord Lansley, almost suggested that this was an exciting prospect. In closing the Second Reading debate, the Minister spoke of,

“a natural opportunity to consider how we can best support Britons in an increasingly global world … Global reciprocal healthcare agreements have the potential to protect public health by supporting international visitors to access emergency and needs-arising treatment when they need it”.—[Official Report, 5/2/19; col. 1488.]

She may be right. She repeats all those points in her long and detailed letter—a well-drafted, well-written and impressive letter that she sent to all of us yesterday or the day before. However, I am afraid that what she envisages as the use of the powers misses the point, as her answer to the noble Lord, Lord Brooke, on the possibility of a healthcare arrangement with the United States, illustrated. It is the powers that count, not what Ministers of the day might envisage for their use. The powers are not limited to such benign purposes.

I am not generally a cynic, but if we leave without a deal, then the day after Brexit one can foresee this Government, battered by the failure to reach an agreement, being desperately keen to make all kinds of trade deals with third countries across the world, in an effort to protect a vision of our future as “global Britain”, and no doubt to give the Department for International Trade a purpose to fulfil at the same time. There is a serious risk, in such a climate, of the Government offering third countries health deals in return for trade deals. The terms of such health deals could be seriously detrimental to the United Kingdom. Access to the NHS could be sold cheaply, and across wide and populous markets. UK taxpayers could be committed to unreasonable payments to foreign countries for offering treatment to UK citizens, and all as sweeteners to secure free trade deals. This is why I share the suspicions of the noble Lord, Lord Foulkes, and all this in an attempt to rescue an economy in difficulties—

[Lord Lansley]

I am sorry, but I am getting a bit confused here. By what mechanism does the Bill, which provides a power to make payments in respect of healthcare outside the United Kingdom, give power to access the NHS? It simply does not, does it?

[Lord Marks of Henley-on-Thames]

It simply does: you can make a healthcare arrangement with countries outside the United Kingdom in return for access to healthcare within the United Kingdom, on the same basis as the EU reciprocal arrangements do at the moment.

[Lord Lansley]

I do not mean to badger the noble Lord, but this is simply not true. The power in the Bill relates to payments for healthcare outside the United Kingdom. Governments make agreements with other Governments all the time, including trade agreements, but this Bill does not provide for what is in a trade agreement. It provides for the power to make payments outside the United Kingdom. That has no bearing on access to the NHS inside the United Kingdom.

[Lord Marks of Henley-on-Thames]

That does not, as I understand it, prevent the Government offering other countries access to the NHS on terms that are sweet for them.

[Lord Foulkes of Cumnock]

Clause 3(b) concerns,

“healthcare provided in the United Kingdom, payments in respect of which may be made by a country or territory outside the United Kingdom”.

So it is reciprocal and the noble Lord, Lord Lansley, who is one of the people involved with private healthcare, is trying to mislead the House by intervening.

[Lord Lansley]

I object to what the noble Lord has said: I am not involved in private healthcare in any sense. Not now nor at any time in the past have I acted in any way as a representative of the private healthcare sector. I think the noble Lord should simply withdraw that.

[Lord Marks of Henley-on-Thames]

My Lords, I make no aspersions on either the motivation or the interests of the noble Lord, Lord Lansley, but I think the noble Lord, Lord Foulkes, was right to draw attention to the definition of “healthcare agreement” in Clause 3, which provides that,

“‘healthcare agreement’ means an agreement made between the government of the United Kingdom and either the government of a country or territory outside the United Kingdom or an international organisation, concerning either or both of the following— (a) healthcare provided outside the United Kingdom, payments in respect of which may be made by the government of the United Kingdom; (b) healthcare provided in the United Kingdom, payments in respect of which may be made by a country or territory outside the United Kingdom”.

That makes the point I am trying to make about the danger. If the noble Lord, Lord Lansley, disagrees with me about that, perhaps we could discuss it outside the Chamber, but for the moment I regard it as a serious danger.

[Lord Lansley]

With respect to the noble Lord, we are having the debate now. I have read the Bill, and reading it out does not make his point. The Bill simply defines what a healthcare agreement is. The Government have the power to make healthcare agreements now. He is objecting to the Bill. The only power it gives the Government that they do not presently have is to make payments in respect of healthcare outside the United Kingdom.

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Moved by

[Lord Lansley]

7: Clause 2, page 2, line 3, at end insert—
“( ) Regulations under subsection (1) may not specify or describe persons who are not—(a) United Kingdom citizens;(b) in receipt of a United Kingdom state pension; or(c) eligible at the relevant time for free NHS treatment because they are ordinarily resident in the United Kingdom.”

[Lord Lansley]

My Lords, perhaps it is my turn now to try to mark the Government’s card on the use of these powers.

We are dealing with Clause 2 and the implementing regulations. There are a number of respects in the regulations under which the Government will have to specify to whom they apply, under what circumstances and what payments will be made. For example, in Clause 2(2)(a) and (e), provision is expected to be made about the levels of payment and how they are to be calculated, and the reimbursement levels. Under subsection (2)(b) the regulations may specify or describe persons in respect of whom payments and provision may be made. Who are these persons and what is the extent of the payment?

I freely acknowledge that the amendments are intended to draw out the Government rather than for final inclusion in the Bill. I think this will be useful in two respects. Amendment 7 seeks to discover who we intend to provide payments for outside the United Kingdom. I have included United Kingdom citizens but not all United Kingdom citizens. I remember that when I was in the Natal province of South Africa there were 250,000 UK passport holders; I am not sure what proportion of them are UK citizens but it may be a relatively large number, so being a UK citizen is clearly not a sufficient criterion.

What else does the amendment require? It requires too that a person is in receipt of the United Kingdom state pension. It is not intended to be UK citizens who are also in receipt of the United Kingdom state pension because the state pension is a consideration in itself. This is what the EU reciprocal healthcare agreement presently provides. If one is a UK pensioner living in Spain, France or the Republic of Ireland, one has access to healthcare in that country as if one was a resident of that country. The UK is regarded as the competent member state and the Government of that country can seek reimbursement from the United Kingdom Government, and do so. So receiving a state pension is a sufficient consideration in itself.

Interestingly, as I understand it, one does not have to be a UK citizen in order for that to be the case. This is one of the reasons why there is a relatively large number of UK-insured registered pensioners in Ireland. The Explanatory Notes state that the most recent number, for 2018, is 45,000. They are principally citizens of the Republic of Ireland who have worked in the United Kingdom, acquired a United Kingdom state pension and subsequently retired to the Republic of Ireland. They are covered by virtue of that.

The third consideration is whether the person in respect of whom the payment is made is eligible for free NHS treatment because they are ordinarily resident in the United Kingdom. In these bilateral agreements there is a certain discontinuity between the way in which healthcare is provided in this country and for whom, compared with how and for whom it is provided in other countries. Therefore, although the structure of the EU regulation looks straightforward—it is that wherever people go they should be treated as though they were resident in that country—in practice that does not mean that in every EU country everything is free in the way that it is in the United Kingdom.

This means that those who are ordinarily resident in the United Kingdom can apply, as I understand it—the Minister will doubtless correct me if I am wrong—for a European health insurance card. By virtue of possessing that—it gives them eligibility for NHS treatment—they can secure access to healthcare in the country they are visiting. I presume that that explains the figure in the Explanatory Notes, in the table on page 4, which says that there were 55,000 UK residents using EHIC in Poland in 2016. These are not by and large people who were born and brought up in the United Kingdom but people who have moved to the United Kingdom from Poland and are now visiting Poland with their European health insurance card.

When we are considering who we are paying for we probably have to think in terms of those people who are eligible for NHS treatment. When they go somewhere else, they should have access to the support that the United Kingdom Government give them. Amendment 7 seeks to show who we are describing and, by implication, to say that it would not extend to other people. We do not have responsibility for them so why would we not limit the regulation-making power to those people?

Amendment 8, also in my name, concerns the amount of payment. Proposed new paragraph (a) would not permit the payment to exceed what the cost of the healthcare would be in the country or territory where the healthcare was being provided. For example, if a country would expect to pay £1,000 for a treatment, it would not be permissible for it to charge the United Kingdom £2,000.

There is an issue here in relation to the Republic of Ireland, which I will briefly mention. My noble friend may wish to refer to it. I am not sure of the current situation but it used to be the case when I was Secretary of State that the amount we paid the Republic of Ireland, when averaged across the number of pensioners we paid for there, significantly exceeded two- or threefold—rather than an order of magnitude—the amount that we paid on average for pensioners in England. This begged the question: was healthcare in the Republic of Ireland that much more expensive? I do not think the answer was yes. The answer was that an agreement had been reached that had acquired a certain character over time. I initiated further discussions with our Republic of Ireland colleagues on this matter, which may or may not have led to a conclusion.

[Lord Cormack]

Or a backstop.

[Lord Lansley]

Yes. It might have been part of the backstop agreement in the old days, I do not know.

The second limb of Amendment 8 is to say that although care is free to NHS patients in the United Kingdom, the object of the support is to put people in the same position in other countries as if they were residents of that country. Of course, care is not free in other countries. In a significant number of EU countries—I think about half—some out-of-pocket expenses are required in relation to their healthcare provision, which would not necessarily be reimbursed. We should not expect to pay more than would be the case if somebody were a resident of that country. The expectation should not be that because the NHS is a free service here, there should be a free service everywhere.

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[Baroness Blackwood of North Oxford]

I simply said that two amendments on devolution have been tabled, so we will be discussing that issue in a lot of detail when we reach Amendment 42.

I hope that my noble friend will feel able to withdraw his amendment.

[Lord Lansley]

I am very grateful to my noble friend. Her response has given reassurance. She is quite right to say that it will not be until such agreements are negotiated and entered into that we will have absolute clarity, but the commitment to the equal treatment principle is clear. I just hope that, equally, other countries recognise that. There is an awful temptation for them to think that healthcare is delivered in the United Kingdom on the basis of ordinary residence and that therefore a significant proportion of the citizens of those countries who go to live and work in the United Kingdom become eligible for NHS care. It might suit them to choose not to be the competent member state when it comes to the purposes of the agreement and paying for their healthcare in the United Kingdom. I hope that they will not be tempted in that direction but there is a potential discontinuity and indeed an imbalance between what we provide in the United Kingdom and what is provided in other countries. I suppose that, if I say nothing else, I should say that we should always guard against that and ensure that agreements are, as far as we can make them, properly bilateral and reciprocal. However, on the basis of the reassurance that my noble friend has been able to give me, I am happy to beg leave to withdraw the amendment.

Amendment 7 withdrawn.