Health and Care Bill

Lord Lansley Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

Moved by

[Lord Lansley]

83: Clause 39, page 47, line 37, at end insert—
“(4) A direction under section 13ZC may not be given in relation to a decision about the relative allocation of resources to integrated care boards.(5) A direction under section 13ZC may not be given in relation to a decision about the results of a procurement of goods or services provided for the purposes of the NHS in England.”

[Lord Lansley (Con)]

My Lords, noble Lords will recall from Committee some substantial discussion about whether it was wise for the Secretary of State to take additional powers of direction in relation to NHS England. I suppose I should declare an interest since I gave the NHS commissioning board, or NHS England, the freedoms it currently enjoys. I am probably the person least likely to be persuaded that it is a very good idea to take all that away. After our debate in Committee, I thought it was probably sensible, rather than to seek to remove the powers of direction that the Secretary of State is given under Clause 39, to look at the exceptions to that power in new Section 13ZD and ask: are these all the exceptions that we should have?

On Amendment 83, the conclusion I reached was that there were at least two specific areas which are not mentioned in new Section 13ZD but should be; namely, limitations on the use of this power on the part of the Secretary of State. First, the local allocation of resources to integrated care boards—and the difficult decisions of trying to remedy the inequalities in access to healthcare services through the resource allocation process—is not something which any of us want the Secretary of State to interfere with; otherwise, it is sure to be regarded as being done for a political purpose, even if it might be done for another.

Secondly, there is the question of

“procurement of goods or services”.

After all the experience we have had over recent months, the last thing any of us wants is to go too far in the direction of the Secretary of State having a power in relation to procurement when that can perfectly well be given as a responsibility to NHS England. This is Amendment 83, and I hope that my noble friend, if he cannot accept the amendments, will give us some specific assurances in relation to the Secretary of State not using those powers.

In this group, I also put my name to Amendment 84, which would remove Clause 40—and, by extension, Schedule 6—from the Bill. This is about the Secretary of State coming in and acquiring more powers than was formerly the case. I was shadow Secretary of State for six years or so. During that time, I would have loved it if the then Secretary of State had all these powers to intervene in every reconfiguration, because I went around the country—as people are fond of reminding me—mobilising opposition to some of the ways in which the health service, led by the then Government, was trying to reconfigure services. This is not something that the Secretary of State or the current Government should wish for themselves or for their successors in office. I will not go back into all the arguments, but there are plenty of good examples of where, if the Secretary of State had this power, people would press the Secretary of State to use it—and it would be deeply unwise for a Secretary of State to get involved.

The justification on the part of the Government is that it stops this going on for ever. But there is a reason that these things go on for a long time—because they are intensely difficult, and the balances are very difficult to strike. Sometimes, the processes of consultation and public engagement take a long time. If the Government’s argument is that they are going leap in, intervene and settle it all quickly, both sides will yell when they do that. We can be absolutely certain of this. No one will be happy, and everyone will blame the Secretary of State. This is very firmly in the “be careful what you wish for” category. We would do the Government a great service by deleting Clause 40 from the Bill. If the noble Baroness, Lady Thornton, pursues that, I will certainly support her. I beg to move Amendment 83.

[Baroness Thornton (Lab)]

With the leave of the House, I thought it might be useful if I used my slot to speak right now on leaving out Clause 40. First, I thank the noble Lords, Lord Patel and Lord Lansley, and the noble Baroness, Lady Walmsley, for putting their names to this amendment. The noble Lord, Lord Patel—with whom I spoke this morning, and who is definitely on the mend, so I hope we will see him next week—said how strongly he supports the amendment. I will speak very briefly because we have already said much of what needs to be said about saving the Secretary of State from himself—as the noble Lord, Lord Lansley, said, I think. This is what this amendment is about.

Clearly, this is not what the NHS asked for in the Bill. It did not ask for this power. It has been added to the Bill—by a previous Secretary of State, I suspect—and I hear rumours that even the current Secretary of State is not a great fan. Why would any Secretary of State want to have this power—to be lobbied and drawn into any minor local dispute, particularly as we head towards a general election?

I have a small anecdote. A small coastal town had a small hospital with an accident and emergency department. It could not be properly staffed, it regularly closed for random periods, and far too often patients arrived there only to be moved to the larger A&E 20 miles down the road. Proposals were made to close it—and of course, outrage ensued. “Save our A&E”, people said, even though it was unsafe. Local politics were poisonous, and the blame for the closure was thrown on opponents, whichever side they were on.

However, over time, good communications, clinical leadership and, eventually, bringing local people into the team, got the proposal moving. People understood what was needed and why, and the reconfiguration process went through its stages, with external reviews and analysis by the national clinical advisory team, which all gave reassurance. The clincher came when a distinguished clinician leading the review told a meeting that he would personally go and paint over the road signs for the A&E, because it was so unsuitable. It shut, which probably means that lives were saved.

The process of rational argument and proper analysis works, and on this occasion we should not just leave it to local politics to decide what reconfiguration means. The Secretary of State has enough powers to direct the whole NHS in its fullness, but should not be involved in what may be very small reconfigurations indeed. We agree, and many people in the NHS and its organisations agree, that this clause should be removed from the Bill.

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[Lord Kamall (Con)]

The noble Baroness raises some important points, but I remind her that, alongside those, she should consider safeguards and limitations that are being put in place to address these concerns and the importance of ensuring due accountability for health service delivery. I understand the strong feeling among noble Lords and have tried to go as far as I can in addressing those concerns. I once again, perhaps in vain, ask noble Lords to think about the assurances that have been given and not to move their amendments when they are reached.

[Lord Lansley (Con)]

My Lords, I am grateful to my noble friend. In particular I am grateful for his specific assurances on the powers of procurement and the question of resource allocation. We can be pretty confident that the Secretary of State would not interfere with the Advisory Committee on Resource Allocation or the NHS England response to it. If the Secretary of State were to start messing with the formula, we would get into a very difficult place.

I am still of the view that there was a very good reason we gave NHS England greater freedoms. I think it would not have been possible for NHS England to have published its Five Year Forward View in 2014 or even more so the Long Term Plan in 2019, in circumstances where it had occupied the same relationship with the Secretary of State as it did in the past.

This is taking NHS England from its current degree of independence to something that it was not in the past, but is a little more ambiguous. It will be difficult, for precisely the reasons the noble Lord, Lord Hunt of Kings Heath, explained, for the NHS to feel that, when the successor to the long-term plan is published by the successor to the noble Lord, Lord Stevens of Birmingham, it is the NHS’s own plan. That has been very important; Ministers have said it a thousand times. Why do we not let that happen? The measures in Clause 39 take a real risk of infringing on the idea that it is the NHS’s own plan.

It does not mean that the Secretary of State is not accountable, but that they are accountable in ways that they can legitimately control: the resource allocation and an expectation of the priorities and outcomes. That is where the Secretary of State should be putting the weight of the Government, not in trying to decide how outcomes in the NHS are best achieved. I do not agree in principle with what is proposed in Clause 39, but I am not going to press that point.

I will, however, if the noble Baroness, Lady Thornton, pushes it, support her on Clause 40. I say to my noble friend: look at Schedule 6. The structure of it does not even mention the Independent Reconfiguration Panel. As soon as there is a proposal for a reconfiguration from any of the NHS bodies, it quite clearly places in the hands of the Secretary of State the responsibility to decide whether to go ahead with it or not. That will be exactly the moment when the Secretary of State is drawn in and is not able to be extricated from it.

My noble friend has simply to look at the example of the reconfiguration of congenital paediatric cardiac services to realise that no sensible Minister would have been drawn into that debate at an early stage with any confidence of being able to make a decision that would have been accepted by any of the parties to that debate.

[Lord Stevens of Birmingham (CB)]

The noble Lord raises the congenital paediatric cardiac case, and the noble Baroness, Lady Cumberlege, raised the Kent stroke question. On that question, the estimate was that 40 to 50 people will have died or lost their ability to live independently as a result of that two-year delay. Is it not the case that, for the very reasons that the noble Lord, Lord Lansley, has just set out, those kinds of delays will now be invisible to the naked eye because these proposals will never get off the ground due to the self-censoring of necessary clinical change that would save lives, precisely as the noble Lord, Lord Hunt of Kings Heath described?

[Lord Lansley (Con)]

We all know that when these proposals come forward, there is a lot of local pressure. In many cases, it will be local pressure that is transmitted to the Secretary of State by Members of Parliament who are—

[Baroness Penn (Con)]

My Lords, it might be worth reminding noble Lords that on Report, noble Lords only speak twice for short questions of elucidation.

[Lord Lansley (Con)]

I am responding to the debate, am I not?

[Noble Lords]

You are.

[Lord Lansley (Con)]

The noble Lord was elucidating something to which I was responding. That is my view. Anyway, I was not planning to go on at any length. My point is very straightforward. As the noble Lord, Lord Hunt, said, that will be transmitted to the Secretary of State at an early stage, before the point where the Secretary of State can, in any practical way, distance himself or herself from the decision by giving it to the independent reconfiguration panel. There is a process out there. I am a Conservative, and we do not change things that are not broken. This is not yet broken. It is a system that has been used tolerably well and we should stick with it, so I support leaving out Clause 40. However, I beg leave to withdraw Amendment 83.

Amendment 83 withdrawn.

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Moved by

[Lord Lansley]

98: Schedule 10, page 223, line 21, at end insert—
“(5A) Rules under subsection (1) may not be framed by reference to whether the provider is in the public or, as the case may be, private sector.”

[Lord Lansley (Con)]

My Lords, I will not go on at great length because noble Lords have heard more than sufficient from me today, but this group brings us to what is known in the trade as the provider selection regime: that is, how the NHS goes about the process of commissioning services from a range of providers and the relationship between that and the choice that is available to patients. I am going to refer to my amendments, Amendments 98 and 99, and, without going on about it, I commend Amendment 80 in the name of the noble Lord, Lord Warner. Finding out whether people have actually experienced choice and whether that is helpful to them is a useful thing to do, and I am not sure whether it features in the current electronic referral system. It would be useful to add it in.

The words of Amendment 98 are in fact already in the regulations that the NHS currently lives by because, born of the previous experience when there were discriminatory payment arrangements for private sector providers relative to public sector providers—ie, more advantageous payment arrangements for the private sector than the public sector—in the 2012 legislation we legislated to prevent that happening in the future. The current Bill removes said prohibition on discrimination on the basis of the ownership, public or private ownership, of a provider.

Noble Lords might think, “Ah, this is trying to avoid us discriminating against the private sector.” This was actually included in order to prevent the Government or the NHS discriminating in favour of the private sector. There may be arguments for it in certain circumstances because NHS bodies often have, as it were, fully depreciated assets and to create additional capacity the private sector very often has to invest capital and has to meet the costs of capital as well as the revenue costs of providing services. None the less, we addressed all that and took the view that we did not want any discrimination: we wanted no competition on price, but we wanted competition on quality. That is why, to be perfectly frank, I am testing the Government’s intentions in omitting something that was a central plank of policy for the 2012 legislation.

On Amendment 99, if I recall there is language in the original White Paper from last year, which set the provisions for the Bill, which referred to “any qualified provider” and made it clear that it was the Government’s intention to maintain the existing choice arrangements and access to any qualified provider. Indeed, I think it said that it would “bolster” the system, although I am not sure whether that is happening anywhere. The amendment is really intended to test a particular issue that arose. I am a very sad person, and I was looking at the service conditions for the NHS standard contract; the noble Lord, Lord Stevens of Birmingham, will know them intimately. There is a point at which commissioners who are presented with people who wish to access other providers, who have a contract with another commissioner, are not required to extend that service to them. The way in which it was written in the standard contract was to talk about circumstances where the originating contract does not refer to the address—I think it said the postal address—included in the originating contract. My point to the Government is that this is absurd. There can be geographic limitations, but we should aim not to make them as limiting as the reference to a postal address in the originating contract would have made them.

The wider point is that, if one looks at the new provider selection regime, one sees that there is a process by which commissioners—the decision-making bodies commissioning services—go through a process of saying, “What are the circumstances of commissioning providers?” They ask whether it is circumstance 1, extending the existing arrangement; circumstance 2, going to a different provider; or circumstance 3, going to competition. The language of circumstance 2 is:

“where the decision-making body wants to use a different provider and the decision-making body considers it can identify a suitable provider without running a competitive procurement process”.

This is something that it will be readily able to do in many cases. A commissioner can say, “This is the circumstance. We want to go to a different provider and we know who we want to go to—that’s fine, we’ll give them the contract.”

Circumstance 3 is

“where the decision-making body cannot identify a single provider or group of providers that is most suitable without running a competitive process; or to test the market”.

The body could choose to test the market, but of course more than subtly. Whereas, in the past, the NHS tended to think that it needed to test the market in circumstances in which the legislation did not actually require it to, there is no such thing as compulsory competitive tendering in the 2012 legislation, or the regulations made under it. But now it has shifted completely the other way, and NHS bodies will be able broadly speaking to choose not to use competition at all. The question is whether that will really be sustainable. In the short run, access to the private sector may well be quite widespread, and there may well be a significant element of choice available to patients through the electronic referral service, but that may be closed down in years ahead, if these provisions are implemented in the way in which they are set out.

I issue a further warning to my noble friends. If you are a provider of services to the NHS and you believe that a decision has been made unfairly or inappropriately by the NHS, there is a standstill on the contract, you have 30 days, and you can send in a complaint, in effect, to the decision-making body, which then decides whether it has done the right thing. There is no independent process whatever, so it seems that the chances of providers resorting to law to challenge what they regard as unfair decisions on the part of decision-making bodies in the NHS rise dramatically with the implementation of these processes.

All that said, I hope what I can hear from my noble friends on the Front Bench is that what they said in the White Paper a year ago in February 2021 remains true: that they are going to sustain patient choice, that they will use the resources of NHS providers and beyond to enable us to fulfil our very demanding recovery programme, that they will think hard about whether the precise language in some of the respects that I have outlined is fair to providers, and that commissioners in the NHS will use their procurement capabilities to deliver best value for patients. I beg to move Amendment 98.

[The Deputy Speaker (Baroness McIntosh of Hudnall) (Lab)]

The noble Baroness, Lady Brinton, is contributing remotely.

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I hope that my responses have served to reassure the noble Lords, Lord Hendy and Lord Warner, and my noble friend Lord Lansley, that the Government are very much in tune with their thinking on these matters and that the points they have sensibly raised through the amendments have been addressed in one way or another. I hope, too, that the Government’s amendments, to which I have spoken, will have allayed the specific concerns voiced at earlier stages about the regulation-making power in Clause 70. Accordingly, I would invite my noble friend to withdraw his Amendment 98.

[Lord Lansley (Con)]

My Lords, I am most grateful to my noble friend, in particular for the helpful explanation of the impact of the response to the consultation published yesterday, which I think moves us in the right direction on the service conditions in the standard contract on that point. I am grateful for my noble friend’s assurance on Amendment 98 as well. Clearly the power is available in the regulations to make sure that the non-discriminatory element of the procurement regulations can be brought forward in due course, so it need not be in the Bill. I beg leave to withdraw Amendment 98.

Amendment 98 withdrawn.