NHS Care of Older People

Paul Burstow Excerpts

Thursday 27th October 2011 Westminster Hall

[The Minister of State, Department of Health (Paul Burstow)]

I start by thanking the Backbench Business Committee for scheduling the debate and the hon. Member for Stourbridge (Margot James) for securing it. We have heard personal testimonies and powerful speeches today. There have been thoughtful contributions and I want to make sure that the debate is seen by colleagues at the CQC. The relevant national clinical directors, the chief nursing officer and the chief executive of the NHS ought to read the report of the debate because it encapsulates in a very powerful way the challenges, as well as the opportunities to move on and make a difference for the people we are here to serve.

I want to address the problem and then describe some of the things that are happening and discuss what more needs to happen. Whether in the NHS or in our wider care and support system, poor quality care can never be acceptable and should find no hiding-place in our country. Many hon. Members have rightly expressed their serious concerns that such shocking and neglectful care can be—or appear to be—tolerated within our NHS, and that kindness and compassion can go missing on some wards. The hon. Member for Bolton West (Julie Hilling) described her journey and the way the system almost seems to have imprisoned people with good intentions and disempowered them. The point about empowering staff to live their values in their practice is an incredibly important one.

I will not speak to the social care piece of the debate in great detail today. The Backbench Business Committee has scheduled a debate on social care on 10 November, and I look forward to that broader debate. I will talk about the problem that we have been wrestling with today. Sadly, it is not a new issue. The ombudsman report, “Care and Compassion”, is just one in a long line. Evidence of poor or variable care for older people can be found in major clinical audits on continence care or falls and bone health undertaken by the Royal College of Physicians; in the work of NCEPOD—the national confidential enquiry into patient outcome and death—and its inquiry into pre-operative care for the over-80s, chillingly titled “an age old problem”; in the findings from the national hip fracture database; in the parliamentary inquiry into the human rights of older people in health and social care; in the many reports by charities such as Age UK and the Alzheimer’s Society on acute care and nutrition; or in the Mid Staffs inquiry. Taken together, those reports, audits and inquiries, which go back years not months, paint a disturbing picture that quite rightly has been rehearsed here today. They demand action.

Some people try to reduce the issues to problems that need simplistic solutions, of which there are none. Some people see the issue as an opportunity to make criticisms of modern nursing or the role of health care assistants, which misses the point of so many of the reports I just listed. Such issues do not have a single cause, so there cannot be a single magic bullet solution. However, I am clear that we have to move on from merely describing the problem. There is an almost constant cycle of revisiting the problem, but never actually solving it. We need to identify steps to solve it.

I shall outline some of the steps the Government are taking in concert with others—it cannot just be governmental action—to stamp out poor care and to embed a culture of quality care, and zero tolerance of behaviours and systems that do not facilitate that care. I cannot cover all the actions that are taking place; only some. The level of non-compliance uncovered by the CQC inspections in 100 hospitals was inexcusable; in my view, there are no mitigating circumstances that can relieve medical staff of the duty they owe their patients. I agree with the hon. Member for Leicester West (Liz Kendall), who said that follow-ups by the CQC need to be rapid and proportionate. Matters cannot be left unanswered. Once concerns have been identified, they need to be properly followed up to ensure they are addressed.

My hon. Friends the Members for Suffolk Coastal (Dr Coffey) and for Waveney (Peter Aldous) mentioned the James Paget hospital. I shall not usurp the role of the CQC, but its report has made it clear that the trust could face prosecution or suspension of services for the failures that have been identified. We must now await the next report, and expect speedy and timely action from the CQC as it discharges its responsibilities.

As part of the next wave of inspections announced yesterday by the Secretary of State, the CQC will carry out inspections not only on a nine-to-five, Monday to Friday basis, but outside normal hours so that we get the fullest possible picture. That is essential and it is right for that point to be raised. The CQC will undertake 500 inspections, also outside normal hours, to look at residential care for elderly people. It will look at the care and welfare of service users and their nutritional needs, which will shine an important light on issues of dignity and care in the sector. The CQC will not only highlight care homes that are not performing well; it will put those that are as they should be into the spotlight to take the applause they deserve when they get it right.

Let me put the debate into context. There is nothing inevitable about illness and disability in old age. Dementia or falling over are not normal parts of ageing; illness and ageing are not synonymous, and we must get that point across when designing our systems. That does not mean that an ageing population poses no challenges to our health care system because it does, but it is also a cause for celebration. The age shift taking place in our society is one of the biggest challenges we face, and it is right that Parliament should spend more time debating it.

Caring for older people is the everyday business of the NHS and a core part of what it does. People over 65 account for 65% of hospital admissions and 70% of bed days. We must, therefore, look carefully, critically and constructively at how the model of care needs to adapt to address those needs. We have an episodic model but we need one that reflects co-morbidities, complexity and long-term conditions. That is the challenge, and it requires the debate that we shall have on social care, which is the other side of the same coin.

The hon. Member for Nottingham South (Lilian Greenwood) referred to dementia. We estimate that a quarter of people in every adult acute hospital suffer from dementia or confusion that is often undiagnosed and too often ignored. That failure to diagnose can add days to the length of a person’s stay in hospital, and create additional distress for the patient and their family. The hon. Member for Waveney spoke of a sense of déjà-vu, which I feel that I have shared for many years. In opposition, I repeatedly raised the issues under discussion and argued that at their root lie ageist assumptions and practices. Time and time again, I pressed for a systematic approach to ageism in the NHS, and for the law to state beyond doubt that ageism is unacceptable; one of my first acts as a Minister was to rule out any exemptions from the age discrimination duty for the NHS. In future, the arbitrary use of age cannot be used in the NHS as a means of limiting the care and treatment that older people receive.

The introduction of the equality delivery system across the NHS, involving leadership at all levels, means that for the first time a mechanism is in place to challenge and change the culture and behaviours that allow ageism to prosper. I greatly welcome the initiative led by the NHS Confederation, the Local Government Association and Age UK to look at issues of dignity, and the Department is working closely with them on that. We expect, however, that the work will look beyond analysing problems; we have done too much of that and there are too many reports sitting on shelves. The problem has been analysed but we now need practical steps to deliver change.

A debate such as this must go beyond discussing the problems; we must highlight the stories that are told less often. In many places, care is exceptional and excellent, and 45 of the hospitals inspected were fully compliant with the essential standards. Many NHS trusts take care seriously and want to get it right for older people. At University Hospital Southampton NHS Trust, for example, the Southampton meal-time assistance study is evaluating the effectiveness of additional help from volunteers at meal times on acute medical wards for older people. University Hospitals Birmingham NHS Trust is implementing a systematic trust-wide approach to improve dignity, which includes using the stories of carers and patients—the story related by the hon. Member for Bolton West would be relevant—in its clinical governance arrangements and regular dignity rounds. The Department has funded work by the Royal College of Nursing on improving dementia care in general hospitals. That initiative was launched in September, and the RCN spelt out its commitment to the care of people with dementia and noted the critical factors essential to delivering good quality care.

There is, therefore, no shortage of tools, guidance, ideas or initiatives that can be taken to tackle these issues. If we get safe and dignified care right for older people, we will get it right for the majority of those who use our health service. It is not always about money but about attitude, approach and doing things differently. Often, it can be something simple such as putting ourselves in the patient’s position and looking at the service through their eyes. At Sheffield’s Northern General hospital, for example, patients and carers were concerned because they could not tell the difference between different types of staff on the ward, so staff put up colourful and simple posters around the hospital that identified them by the colour of their clothing. That suddenly lifted a barrier to patients’ understanding of what was going on around them, and made a real difference.

Several hon. Members have mentioned staffing levels, which is an important matter. The CQC expects registered organisations to ensure that they have enough skilled and trained staff to deliver the care expected of them, and failure to comply carries all the relevant enforcement powers and consequences. The RCN has published guidance on staffing ratios, and we expect that to be consulted and used by nurse leaders, who should have the freedom to agree staff profiles for their organisations. We all recognise, however, that it is not an exact science, which returns us to the quality of leadership and culture, which many hon. Members mentioned.

The role of nurses and health care assistants has been mentioned by several hon. Members. At the heart of good nursing lie values of compassion, respect for the rights of the individual, empathy and kindness. The principles of nursing practice are clear and the Government believe that nurses must be recruited for their values, trained for their skills and empowered to practise their values in their work. That means that universities and NHS organisations must work together on the selection of students to ensure that requirements for education and practice are met, not least because the pace of technological and pharmacological change demands higher levels of knowledge and skills to deliver high-quality patient care. Having a degree-educated work force does not mean placing technical competence ahead of values; that is a key point in ensuring that caring does not turn into the specialist service that some hon. Members fear it is becoming.

Caring demands high standards, leadership, and a readiness to challenge poor practice and demonstrate good practice. I will follow up the suggestion about meeting the Nursing and Midwifery Council, and I will ask my officials to discuss the matter with the Minister responsible for nursing, my hon. Friend the Member for Guildford (Anne Milton), who I know takes a close interest in such issues.

The role of health care assistants has been raised, and it is worth noting that the Government have put into legislation for the first time the power to regulate health care assistants. We are breaking new ground, although I am sure some will feel that we are not doing so quickly enough. We are taking a measured approach, however, by legislating for the Council for Healthcare Regulatory Excellence to establish a voluntary registration scheme that will set a benchmark for training, conduct and competence. However, it is our view that it is right to place responsibility fully and squarely on employers to decide whether to select staff on the basis of their registration. They must ensure that staff have received the necessary training for the role that they are undertaking.

The hon. Member for Wirral South (Alison McGovern) made a very important point, which I encapsulate in this way. We have an NHS that all too often can be described in industrial process terms. We need an NHS that is all about personalisation and that is personalised to the individual. That is an important part of the transformation that we need.

Leadership has rightly been talked about a lot in the debate. It is critical. Directors of nursing, medical directors and other health professionals must deal with the issues raised in the CQC report. Just as the CQC has turned a spotlight on dignity and nutrition, so too must every NHS trust look at the report and take a long hard look at itself and the stories that this debate has highlighted. Too often after things have gone wrong, we learn time and time again—sadly, the debate has underlined that point—about the staff who tried to alert senior clinical colleagues or managers only to be ignored or, even worse, victimised, or about the patients and families who have been on the sharp end of appalling care and who are marginalised, with their experience not being used to challenge and change poor practice.

We all have such cases in our mailbags. We have all had constituents in our surgeries who feel let down because they have not been listened to and who do not feel that there has been any learning as a consequence of their experience. There can be no place in the NHS where staff feel unable to speak up when patients are being put at risk, and no place in the NHS where the voice of patients and carers is not heard loud and clear.

When the hon. Member for Worsley and Eccles South (Barbara Keeley) talked about complaints handling, she made very important points. Getting redress or an apology should not be a battle. People should not have to feel that the lessons are not being learned. It must be staff on the front line who work on the wards every day and see poor care—patients not being fed properly, privacy neglected, poor continence care or, as the hon. Lady said, pain relief overlooked—who change things for the better. That is why we are placing all providers under a duty of candour and why we are strengthening the NHS constitution to put beyond doubt the duty on managers to support staff who raise concerns about the quality of care. That point was touched on in the debate. We need to send a clear message that managers must support staff who raise concerns about the quality of care. It is also why we are establishing HealthWatch England and local HealthWatch to champion the interests of patients and carers.

There can be and should be no hiding place for poor care. The CQC inspections that the Government ordered are part of the work to take that agenda forward, but are by no means all of it. There is no magic bullet solution to this problem. We need a wide range of things: an effective inspection and regulation regime, which measures what matters to patients and carers and then takes action; guidance on what good practice looks like—for instance, the range of National Institute for Health and Clinical Excellence quality standards and guidelines on older people’s care; and the systematic involvement of older people and carers in the design of services from the outset.

We need greater transparency on complaints. We must ensure that we get it right the first time and that we value complaints as a way of learning and changing the way organisations and leaders in organisations behave. Feedback is needed to improve services. People must seek continuously to improve services. Another element is use of the law. We sometimes debate human rights in a very negative way. In this area, human rights are central, and we must deliver them for older people. We must use our equalities duty legislation as well.

Another requirement is effective advocacy and leadership from professions at every level—at ward level, at institution level and at the level of the Royal Colleges and specialist societies. We need a work force supported with the training and skills to make them fit to care for an ageing population. That is a new challenge, and we need to adapt to meet it. Other requirements are advocacy and support from the voluntary sector and—notwithstanding some of our debates about system change—system incentives, such as outcome indicators and best practice tariffs to drive the right behaviours. We need much more transparency around performance data, such as those provided by CQC inspections, audits and satisfaction surveys. We need a greater focus on integration—many hon. Members touched on this—so that older people are in hospital only when they need to be. Hospital is not the right place for most older people in most circumstances.

This is about culture and systems. The Government recognise that. We know that we cannot do it on our own. We are working with others to make the changes that are needed. Yes, there has to be action now. The Government are taking immediate action by casting the spotlight where it needs to be. We must then sustain the action to get the transformation that is essential to delivering quality of care and the dignity and rights of older people in the NHS and anywhere else they need care.

National Health Service

Paul Burstow Excerpts

Wednesday 26th October 2011 Commons Chamber

[The Secretary of State for Health (Mr Andrew Lansley)]

indicated dissent.

[The Minister of State, Department of Health (Paul Burstow)]

indicated dissent.

[Andy Burnham]

Ministers are shaking their heads, but I will read them the Treasury figures published in July this year, and let them tell me then that what I have just said is not true. The public expenditure statistical analyses from this year provide official confirmation of what I have just said. They show that in 2009-10 health spending was £102,751 million. That was in the last year of the Labour Government. In 2010-11, health spending was £101,985 million. There we have it in black and white—the first real-terms cut in health spending for 14 years. In fact, it is the first real-terms cut since the last year of the last Tory Government in 1996-97.

Response to Offender Personality Disorder Consultation

Paul Burstow Excerpts

Friday 21st October 2011 Written Statements

[The Minister of State, Department of Health (Paul Burstow)]

I am publishing today a joint Department of Health and Ministry of Justice response to the public consultation on an offender personality disorder pathway implementation plan, which was completed on 17 May 2011.

The consultation set out the Government’s plans to reshape services, interventions and treatments for offenders with severe personality disorders. There were 91 responses to the consultation almost all of which supported the proposed approach.

The Government will now begin to take forward the pathway approach, which will enable the complex needs of high-risk offenders to be addressed more effectively. We will start to decommission the dangerous and severe personality disorder (DSPD) pilot sites in the NHS, the first being the unit based in Broadmoor high secure psychiatric hospital. The patients currently being held in these facilities will continue to be treated in the level of security necessary for the risk they present and no individual will be moved to a lower-level of security as a result of these changes. Professional judgments on an individual’s appropriate level of security will continue to be made as part of the normal assessment arrangements.

The new pathway will enable the complex needs of high-risk offenders to be addressed more effectively. Interventions and treatment will be provided earlier and in the most suitable locations, additional support will be given to those who have completed programmes and ongoing supervision will be enhanced. These plans strengthen public protection arrangements and improvements in psychological health outcomes through new collaborative services across the national health service and national offender management service.

“Response to Offender Personality Disorder Consultation” has been placed in the Library. Copies are available to hon. Members from the Vote Office and to noble Lords from the Printed Paper Office.

Oral Answers to Questions

Paul Burstow Excerpts

Tuesday 18th October 2011 Commons Chamber

[Helen Jones (Warrington North) (Lab)]

6. What steps he is taking to ensure that patients receive accurate and unbiased information on treatment options.

[The Minister of State, Department of Health (Paul Burstow)]

The NHS constitution gives people a right to information about their treatment options. I want everyone to get timely, trustworthy information such as patient decision aids, so that they are involved in their care decisions. The Health and Social Care Bill will ensure that the commissioning board and clinical commissioning groups secure that.

[Helen Jones]

In the light of that answer, will the Minister condemn the decision by GPs in Haxby to use NHS data to tout the services of their own private company and give wrong information to patients? Or is that simply a foretaste of what will happen under the Health and Social Care Bill when clinical commissioning groups decide what services are necessary, leaving private companies in which they may have an interest to pick up the slack in a privatised, marketised NHS in which patients come last?

[Paul Burstow]

The hon. Lady is spreading yet more myths and misconceptions about the reforms that this Government are making. If she had researched the matter more thoroughly, she would know that there is a code of conduct for the promotion of NHS-funded services, which makes it clear that providers of primary medical services cannot directly or indirectly seek or accept from any of their patients payment or other remuneration for any treatment. As a result, the PCT is questioning that clinic about how it has used patient information and will continue to pursue the matter.

[David Tredinnick (Bosworth) (Con)]

Does my hon. Friend agree that many patients look to NHS Choices for accurate and unbiased information? Is he aware that its site on homeopathy is both biased and inaccurate? As the Department has had a long-standing review that has not reported, will he—

[Mr Speaker]

Order. I call the Minister.

[Paul Burstow]

If the hon. Gentleman would care to write to me setting out where he believes there are inaccuracies, we will examine them.

[Andy Burnham (Leigh) (Lab)]

It is good to be back. I see that in my absence, the Secretary of State has at last made some progress with his plans for a US-style health care system.

I have a letter sent by the practice that my hon. Friend the Member for Warrington North (Helen Jones) mentioned a moment ago, in which it wrote that

“we can no longer offer your procedure as one of our NHS services…I am writing to make you aware of some of the options that you have to have the procedure completed as a private patient.”

Helpfully, it enclosed a leaflet announcing the practice’s new private minor operations service. Can the Minister point me to any part of the Health and Social Care Bill that will prevent that practice in future?

[Paul Burstow]

I wonder whether the right hon. Gentleman could have pointed me to any such arrangements in current legislation. There is none. However, Dr David Geddes, the medical director of NHS North Yorkshire and York, has stated:

“We have some concerns about the activities of the Haxby and Wigginton health centre in York and we will be discussing these issues with them directly as a matter of urgency. These concerns are around possible breaches of the Data Protection Act and the accuracy of the information sent to patients. For example, of the eight procedures they list, three are routinely funded by NHS North Yorkshire and York”.

Let us be clear that when he was Secretary of State, that PCT was in a worse financial state.

[Andy Burnham]

That is total bluster, because that vision is precisely what the Government want to do to our NHS. As my hon. Friend the Member for Warrington North said, it is a terrifying glimpse of a Tory NHS in future—not a national health service but a postcode lottery writ large, in which, as we read today, random rationing is taking place around the country. The NHS is in chaos because the Secretary of State made the mistake of combining a £2.5 billion reorganisation, at a time when every ounce of energy should be focused on the NHS front line. This Secretary of State has placed our national health service in the danger zone, and he has lost the confidence of GPs, nurses and midwives. Is it not time that he stopped digging in, listened to NHS staff and dropped this damaging Bill?

[Paul Burstow]

That was a good example of bluster—perhaps that is what we will see from the Opposition under the right hon. Gentleman’s stewardship.

The right hon. Gentleman ought to be aware, because it happened on his watch, that primary care trusts and strategic health authorities have seen their management costs increase by more than £1 billion. There was a 120% increase from 2002 to when this Government took office. That is why we are determined to cut overhead costs in the NHS, so that we can reinvest every penny in the front line.

[Adam Afriyie (Windsor) (Con)]

7. What recent representations he has received from Berkshire East primary care trust on the future of Heatherwood hospital in Ascot.

--- Later in debate ---

[Mark Pawsey (Rugby) (Con)]

10. What representations he has received on the need for effective and clear distinction in uniforms worn by fully trained nurses and other workers in the care sector.

[The Minister of State, Department of Health (Paul Burstow)]

The Department receives occasional representations from individuals and groups about uniforms, including the need to distinguish between staff groups. Guidance is available to help employers set sensible policies and, in line with Government policy to reduce central control, we expect decisions on uniforms to be made locally.

[Mark Pawsey]

There is real concern about the lack of distinction between the uniforms worn by qualified nurses and care workers. The latter are free to wear whatever uniform they like and often give the impression that they are medically qualified. This presents a risk to patients, especially because more and more vulnerable elderly patients are being treated in their homes. Will the Minister look again at this to see what action could be taken to clarify the situation?

[Paul Burstow]

My hon. Friend has written to me about this matter on behalf of a constituent. The responsibility sits in three places: first, providers have a responsibility to provide clear information to people receiving services from them about who is providing that service; secondly, commissioners have a responsibility for how they contract for those services; and thirdly the Care Quality Commission has a responsibility to regulate those services. Undoubtedly, however, I would be more than happy to look further at the points he makes.

[Karl MᶜCartney (Lincoln) (Con)]

11. What assessment he has of the provision of ventilation machines and related equipment for patients with muscle-wasting diseases who experience respiratory difficulties; and if he will make a statement.

[The Minister of State, Department of Health (Paul Burstow)]

Local health bodies have responsibility for ensuring that adequate provision of health services is made available to those living with neuromuscular conditions. All specialised commissioning groups have now completed their reviews of neuromuscular services, which are a priority in the annual work plans of each of the specialised commissioning groups in 2011-12.

[Karl MᶜCartney]

I thank the Minister for that answer, but will he also outline the steps being taken to ensure that there is adequate knowledge about neuromuscular conditions among general practitioners and health professionals in Lincoln, so that referrals to the specialist respiratory service in Nottingham can be provided as appropriate?

[Paul Burstow]

My hon. Friend is right to raise the issue of ensuring sufficient awareness of the pathways that exist for people to gain access to those services. I understand that the east midlands specialised commissioning group has recently carried out a review of non-invasive ventilation services. I shall ask the group to write to him in more detail.

[Alec Shelbrooke (Elmet and Rothwell) (Con)]

12. What steps he is taking to assist patients to access a greater range of NHS services.

--- Later in debate ---

[Stephen Gilbert (St Austell and Newquay) (LD)]

Mr Paul Eccles is a constituent of mine. He is a qualified care assistant who wants to go freelance and set up his own business, helping people in their own homes. However, the annual up-front £1,000 charge of the Care Quality Commission is preventing him from starting this new venture. Will the Secretary of State meet me so we can find a way to help my constituent get his business off the ground?

[The Minister of State, Department of Health (Paul Burstow)]

My hon. Friend is absolutely right to highlight how well-intended regulation can sometimes be a way of blocking effective growth and the opportunities available for new people to set up businesses in the care sector. I would be very happy to meet my hon. Friend to discuss that matter.

[Ann Coffey (Stockport) (Lab)]

Stockport is one of only five PCTs in the country that does not provide any in vitro fertilisation treatment—in spite of recommendations from the National Institute for Health and Clinical Excellence. Does the Secretary of State think it fair that my constituents, who pay the same taxes as everybody else, do not get the same access to this treatment as people living elsewhere?

[Dr Julian Lewis (New Forest East) (Con)]

The news that the Woodhaven hospital in my constituency is threatened with closure only eight years after it was opened as a state-of-the-art mental health facility is causing great concern. Will my right hon. Friend endeavour to look into what is proposed for the closure of acute in-patient beds because the “hospital at home” alternative is simply not good enough?

[Paul Burstow]

I am grateful for the hon. Gentleman’s question and I would certainly be happy to look further into the matter and write to him accordingly.

[Tony Lloyd (Manchester Central) (Lab)]

When the Minister responsible for care services wrote to me about the closure of the Edale unit in Manchester, why did he not address the issue that the closure would cost more money than it saved or the fact that the police had expressed concerns about their access in emergency times, particularly during the weekend?

[Paul Burstow]

I am sorry if the hon. Gentleman feels that all the issues have not been dealt with following our telephone conversation and subsequent correspondence. I will check the correspondence again, and if I find that something is missing, I will certainly provide an answer.

[Andrew Bridgen (North West Leicestershire) (Con)]

I welcome the policy review of the entitlement of foreign nationals to free NHS care, but will my right hon. Friend assure the House that it will examine the options relating to charges for GP as well as hospital services?

--- Later in debate ---

[Barbara Keeley (Worsley and Eccles South) (Lab)]

My right hon. Friend the Leader of the Opposition and the officers of 12 all-party groups associated with care have urged the Government to commit themselves to the urgent reform recommended by Dilnot. Will the Minister update the House on the Government’s response to the Dilnot recommendations, and tell us when the cross-party talks will begin?

[Paul Burstow]

I know that the hon. Lady follows these issues closely. In September we published a plan for consultation on the proposals, which includes looking beyond the Dilnot commission’s recommendations at issues of quality, regulation, and many other aspects of how we can secure a comprehensive reform of social care. Today my right hon. Friend the Secretary of State wrote to Opposition Front Benchers with the aim of resuming the discussions across parties to ensure that we get the conversation going with the new Opposition Front-Bench team as soon as possible.

[Mr David Ward (Bradford East) (LD)]

In a recent ministerial response, I was informed that public health services were a matter for the local NHS and that it would not be appropriate for Ministers to become involved or intervene. The transfer of staff from PCTs to local authorities excludes staff delivering services relating to weight management, smoking cessation, physical activity promotion, sexual health, community development and diabetes awareness-raising. How on earth can local authorities pick up the responsibilities without being given the staff who would enable them to do it?

Strategic Vision for Volunteering

Paul Burstow Excerpts

Monday 17th October 2011 Written Statements

[The Minister of State, Department of Health (Paul Burstow)]

The Government have today announced the launch of a strategic vision for volunteering for health and care. “Social action for health and well-being: building co-operative communities” has been placed in the Library. Copies are available for hon. Members from the Vote Office and to noble Lords from the Printed Paper Office.

The Government recognise that volunteers already make a tremendous contribution towards the health and care services and support within their communities, improving the quality and choice of services available in our country. We want to ensure that this wealth of activity is recognised, celebrated and strengthened and that we nurture and release the capability and capacity that exists within our communities.

This strategic vision for volunteering sets out the Government’s long-term vision for social action, and in particular volunteering, in support of health and well-being. It replaces “Volunteering: involving people and communities in delivering and developing health and social care services”, published in March 2010 and refreshes it to reflect health, public health and social care reforms and the coalition Government’s big society agenda.

The vision highlights the valuable contribution volunteering and wider social action makes to every sphere of health, public health and social care, including prevention, the creation of people-centred and relationship-based services and improved patient and service user experience. It demonstrates how greater involvement of members of the public can help to develop support mechanisms and services that genuinely meet people’s needs, are more personal, strength-based and community-owned.

The strategic vision aims to:

embed a deeper understanding, genuine appreciation and awareness of volunteering and its benefits across all of health, public health and social care;

recognise the enormous voluntary effort that contributes to health and well-being and to health, public health and care services in this country and ensure that this is recognised, celebrated and strengthened in the process of system and service reform;

ensure that services are built around the strengths and assets that people (including those with health and care needs, carers and communities) can bring to them, through volunteering as well as co-production and shared decision making; and

encourage the various parts of the health, public health and social care systems to recognise the value of volunteering in relation to their respective priorities and consider, from a more informed stance, where a more strategic approach and coherent investment in volunteering would lead to improved quality, equity and outcomes.

As part of the overarching approach of Government outlined in the “Giving” White Paper, Cm 8084 the Department will take a facilitative and enabling role in pursuing this vision, working with partners inside and outside Government to: raise awareness of the potential and added value of volunteering in health and care; improve the evidence base for investment in volunteering in this field; and improve access to best practice and opportunities for shared learning.

Ovarian Cancer

Paul Burstow Excerpts

Wednesday 12th October 2011 Westminster Hall

[The Minister of State, Department of Health (Paul Burstow)]

Thank you very much, Mr Rosindell, for calling me to speak.

I assure the hon. Member for Hackney North and Stoke Newington (Ms Abbott) that I have not found my last 12 months “humdrum” at all and I agree entirely with the comment by the hon. Member for Cardiff West (Kevin Brennan) that being a Minister is a privilege, and a privilege that one should use fully to serve the common good and the purposes that our constituents send us here for.

I want to try to do justice to the debate, and if I do not cover any issues that have been raised, that will purely be because of time and I will write to hon. Members about those issues. However, I will try to cover as much ground as I can.

I congratulate the hon. Member for Pudsey (Stuart Andrew) on securing the debate and congratulate all those who have taken part. I particularly congratulate the all-party group on ovarian cancer, which has done an excellent job in mobilising colleagues to be here in Westminster Hall today and to be persistent and persuasive in their arguments on the issue.

As others have rightly said, the speech by the hon. Member for Slough (Fiona Mactaggart) was typically powerful and typically persuasive. I think that I have served in the House as long as the hon. Lady, and during the time that she fought her cancer I certainly admired the way that she did so, while continuing to provide the service that she gives to her constituents and the House. She made a very powerful set of points today.

I think that everyone who has spoken in the debate has been touched by ovarian cancer. I had not planned to refer to my own experience, but, given that others have talked about their experiences, I will say that my aunt died of ovarian cancer some years ago. Having fought the disease for some time, she sadly died at the Royal Marsden hospital, despite receiving excellent treatment there. Ovarian cancer touches many of us.

I thank Target Ovarian Cancer, Ovarian Cancer Action, Ovacome and the Eve Appeal, which have all done an excellent job in raising MPs’ awareness of ovarian cancer, in the ways that the hon. Member for Pudsey and others have described today. That work has done a lot, not only to initiate debates in this place, but to assist us as MPs to play our part in our communities to help to raise awareness of those issues.

I could rehearse the statistics again, but will not do so because they have already been well rehearsed and powerfully illustrated with personal stories. I certainly recognise the urgency that we need to attach to our fight against cancers and I particularly note the points that have been made today about ovarian cancer. That is why we urgently came forward with the strategy that we published in January and why we have been fast in trialling and rolling out awareness campaigns. I will say more about those awareness campaigns shortly.

As has been pointed out, late diagnosis is one of the main reasons for the relatively poor cancer survival rates in England. I must crave the forgiveness of those colleagues who have spoken today from the perspective of Northern Ireland, Scotland and Wales. They all made important points and they need to continue, as I know they will, to raise them with their colleagues in the devolved Administrations who have responsibility for health.

Research by the National Cancer Intelligence Network showed that nearly a quarter of all cancers are diagnosed through an emergency route, as my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron) said. That is at a stage when the cancer is very advanced. The research also showed that one in five patients did not visit their GP before being diagnosed with cancer. Diagnosis of ovarian cancer often comes late because the symptoms in the early stages—they have been powerfully set out—are often ignored or thought to be something else.

The hon. Member for Slough talked about volunteers, and about the volunteer who did the manicure on that day when her head was in another place. I have visited hospitals where Macmillan Cancer Support and other voluntary organisations play a part. Such volunteers bring back the key human dimension, which the hon. Lady was absolutely right to underline. We will ensure that the role of volunteers in the NHS is valued by including that point in the Department of Health’s message to the NHS in its soon-to-be-published updated volunteer strategy.

Reference has been made to the £450 million for early diagnosis work that the Government have put in as part of the spending review. The funds will support campaigns to raise public awareness of the symptoms of cancers, encouraging people to present with persistent symptoms. They will also support GPs in more effectively assessing people with possible cancer symptoms and improve access to diagnostic tests. In 2010-11, we ran local cancer awareness campaigns and a regional pilot campaign for bowel cancer, and in 2011-12 we are running a national campaign on bowel cancer, a regional campaign on lung cancer and 18 local campaigns to raise awareness of breast cancer among women over 70 and of the symptoms of some less common cancers.

A question that has been rightly put is, why, so far, have we not addressed ourselves to ovarian cancer? Understandably, Members want answers, not least because of the evidence that if we were performing at, I believe, just the average of our European neighbours—certainly if we were matching the best of them—500 additional lives would be saved every year. We are considering whether there is scope for piloting ovarian cancer awareness campaigns, drawing on the experience of our more generic campaigns on blood in urine, which can be a marker for bladder and kidney cancers, and on the evaluations of awareness campaigns on specific disease sites. That will inform us how we can most effectively roll out further campaigns. I give that undertaking, and I am more than happy to meet with members of the all-party group.

The hon. Member for Romsey and Southampton North (Caroline Nokes) spoke very persuasively about the scope for using existing screening programmes to deliver awareness-raising messages about other cancers, and ovarian cancer in particular, and we will consider how we might implement such a practical solution. Nevertheless, I hope that hon. Members appreciate that awareness raising is just one of a range of actions and that we need to look at the other aspects of the strategy that we set out earlier this year. We are working on other fronts to try to drive up earlier diagnosis and treatment.

A key focus of the cancer outcome strategy is primary care, which is why we are investing in providing GPs with practical tools for assessing patients who might have cancer. In addition, some of the cancer networks are reviewing referral pathways to help to shorten the time taken for patients to access diagnostic tests. I welcome the contribution of the cancer charities that have been working with primary care professionals to promote early diagnosis of cancer, and I specifically pay tribute to Target Ovarian Cancer, which, in partnership with BMJ Learning, has produced an online GP learning tool that covers the signs and symptoms of ovarian cancer, and diagnostic tests based on the latest evidence.

[Ms Abbott]

Will the hon. Gentleman give way?

[Paul Burstow]

I want to try to do justice to the debate and ensure that I get to answer a couple more of the questions posed, but I will give way in a moment if I can.

If a GP suspects cancer, it is vital that they can refer people urgently for further tests, using the two-week referral pathway. For women who do not meet the criteria for that pathway for suspected cancer but have symptoms that require investigation, we are providing additional funds over the next four years to support the diagnosis of ovarian cancer by giving GPs direct access to four key diagnostic tests, including non-obstetric ultrasound. Questions have been asked about what data are collected. We plan routinely to collect data on GP usage of the four tests and to publish them alongside data on GP usage of the two-week referral pathway, so that we can benchmark performance and expose areas that are not performing as well as others.

Several hon. Members asked about the CA 125 test and suggested that there are restrictions. I can assure Members that if there were restrictions we would challenge them. Just last month, Bruce Keogh, NHS medical director, wrote to strategic health authorities to raise questions about general access to diagnostics, and David Flory, deputy NHS chief executive, reiterated in the September edition of The Quarter that there must be no “arbitrary restrictions on access”. That would apply to the CA 125 test, not least because it is clearly covered in NICE guidance.

Hon. Members referred to the two ongoing trials, which are evidence of the research taking place. The UK collaborative trial of ovarian cancer screening offers real prospects for a screening tool, but on screening the Government of the day take the advice of the UK National Screening Committee, which considers the evidence from trials of the sort going on at the moment. A randomised control trial of 200,000 post-menopausal women aged between 50 and 74 is studying the use of annual CA 125 blood tests as a way to identify—along with annual trans-vaginal ultrasound—which women are most at risk of ovarian cancer. The results of the study will be available in 2015, and the Government will then respond to the recommendations that the UK National Screening Committee makes on the basis of the evidence. I hope that there will be a positive recommendation that enables us to roll out such a screening programme.

Familial ovarian cancer screening was referred to early in the debate, and a study has shown that up to 10% of ovarian cancers can be attributed to an inherited genetic predisposition. It was mentioned that the results of that research would be available in 2012, but we understand that the study will close in 2013. We would want to act on the evidence from that study.

Research, therefore, is taking place in those two fields. High-quality applications are the key to getting research funding; we do not fund solely on the basis of something being a priority. The hon. Member for Hackney North and Stoke Newington asked about Ovarian Cancer Action’s nine recommendations, and I will respond to her in writing, with copies to colleagues.

National measurement was mentioned. The NHS operating framework for England for 2011-12 requires that cancer registries record the stage of cancer, which is a key proxy for predicting outcomes, and publish one-year, as well as five-year, survival rates. We are benchmarking, providing a useful way to see who is performing well and who is not, and, as the hon. Lady mentioned, we are in the international benchmarking partnership with other nations. Would she like to make her intervention in the remaining time?

[Ms Abbott]

indicated dissent.

[Paul Burstow]

In conclusion, I hope that I have responded positively to the debate. We must make progress on a broad front in this area to improve early diagnosis and get the treatment that people need, so that we can cut the death toll in this country from all cancers. Ovarian cancer is, and will continue to be, a priority for this Government.

Southern Cross Healthcare and Social Care Market

Paul Burstow Excerpts

Monday 10th October 2011 Written Statements

[The Minister of State, Department of Health (Paul Burstow)]

I wish to update the House on Southern Cross and the Government’s wider response to the issues which this case has raised.

On 30 September, Southern Cross announced that 250 of the care homes in which it operates have been transferred to new care operators. This represents one third of all of Southern Cross’s homes, involving 249 homes in England and one in Scotland. In each case, the transfer was scrutinised and approved by the relevant national regulator. For the time being, Southern Cross will continue to provide care services in the remainder of its homes.

Two further transfers of homes are expected in October and when the transfers are concluded Southern Cross will no longer be a provider of care services.

The Association of Directors of Adult Social Services is maintaining a list of Southern Cross’s care homes with information on plans for transfer to alternative providers, as well as contact information for residents, relatives and any other interested parties. This is updated weekly and is available at:

www.dh.gov.uk/health/2011/09/transfer-of-southern-cross-healthcare-to-new-operators/

This first set of transfers is an important step towards the consensual and orderly winding down of the company. Throughout, it has been the Government’s overriding concern to secure the welfare and safety of the residents in Southern Cross’s care. This transfer and the ones to follow should ensure that this is achieved, with minimal impact on the residents of these homes and clear arrangements to ensure continuity of care.

We will continue to monitor closely the remaining steps to the full transfer of all homes, and will work closely with all interested parties, but I am encouraged that those involved in the restructuring negotiations have put in place the necessary agreements to secure a successful outcome.

As noted by the National Audit Office in its recent report on the social care market “Oversight of user choice and provider competition in care markets”, the case of Southern Cross has highlighted the risks associated with a large care provider facing financial difficulty.

In my previous written ministerial statement to Parliament, I said the Government would shortly be publishing a discussion paper on the issue. This paper has been published today, and forms a part of the Government’s wider engagement exercise on care and support reform, as reported to the House on 15 September 2011.

The paper considers the issues raised by the risk of financial failure in large providers and seeks views on service continuity and/or whether new measures are necessary. It sets out what the Government think is the key objective of any reform, and outlines the key considerations which need to be balanced when coming to a view on what measures may be appropriate. It then lists a range of possible options that could be pursued, drawing on experience in other sectors and considering both regulatory and non-regulatory approaches. This includes possible roles for Monitor, as allowed for in the Health and Social Care Bill currently before the House. The paper invites comments on these options, but also welcomes other ideas. At this stage the Government have not formed a firm view on what would be the best approach. They want to take this opportunity to hear different views, before settling their position ahead of next year’s White Paper.

“Oversight of the Social Care Market; Discussion Paper” has been placed in the Library. Copies are available to hon. Members from the Vote Office and to noble Lords from the Printed Paper office.

Health and Social Care (Re-committed) Bill

Paul Burstow Excerpts

Wednesday 7th September 2011 Commons Chamber

Brought up, and read the First time.

[The Minister of State, Department of Health (Paul Burstow)]

I beg to move, That the clause be read a Second time.

[Mr Speaker]

With this it will be convenient to discuss the following:

New clause 10—Requirements as to transparency—

‘(1) Regulations may impose requirements on the National Health Service Commissioning Board and clinical commissioning groups for the purpose of ensuring that they are open and transparent in their decisions in commissioning health services for the purpose of the NHS.

(2) Regulations under this section may in particular impose requirements relating to—

(a) the imposition of minimum waiting times for patients,

(b) the imposition of clinical thresholds that a patient must reach before being eligible for treatment.

(3) The regulations may provide for the requirements imposed, or such of them as are prescribed, not to apply in relation to arrangements of a prescribed description.’.

New clause 11—Financial duties on clinical commissioning groups: administrative costs—

‘After section 223K of the National Health Service Act 2006 insert—

“223L Financial duties on clinical commissioning groups: administrative costs

(1) The Board must direct clinical commissioning groups to ensure that their expenditure on administrative costs does not exceed a prescribed percentage of their resource.

(2) The Board must ensure that the total national limit on clinical commissioning groups expenditure on administrative costs in any year from April 2014 does not exceed 55 per cent. of the total spent on administrative costs by primary care trusts in the financial year 2009-10.”’.

New clause 12—Secretary of State’s duty as to education and training—

‘After section 1F of the National Health Service Act 2006 insert—

“1G Secretary of State’s duty as to education and training

For the purposes of improving the quality of patient care, the Secretary of State has a duty to maintain a comprehensive, multi-professional education and training system for health professionals and to ensure the continued professional development of all staff delivering NHS services.”’.

New clause 13—Providers’ duty as to education and training—

‘For the purposes of improving the quality of patient care, all providers of services for the purposes of the health service have a duty to contribute towards the maintenance of a comprehensive, multi-professional education and training system for health professionals and to ensure the continued professional development of all their staff delivering health services.’.

New clause 14—Duties of clinical commissioning groups as to persons for whom they are responsible—

‘After section 3B of the National Health Service Act 2006 insert—

“3C Duties of clinical commissioning groups as to persons for whom they are responsible

(1) A clinical commissioning group has responsibility for persons who usually reside in the clinical commissioning group’s area.

(2) Regulations may provide that for the purposes of this section a clinical commissioning group also has responsibility (whether generally or in relation to a prescribed service or facility) for persons who—

(a) were provided with primary medical services by a person who is or was a member of the clinical commissioning group,

(b) have a prescribed connection with the clinical commissioning group’s area, or

(c) are provided with primary medical services by a member of the clinical commissioning group.

(3) The power conferred by section 3(1B)(b) must be exercised so as to provide that, in relation to the provision of services or facilities for emergency care, a clinical commissioning group has responsibility for every person present in its area.

(4) Regulations may provide that section 3(1A) does not apply—

(a) in relation to persons of a prescribed description (which may include a description framed by reference to the primary medical services with which the persons are provided);

(b) in prescribed circumstances.

(5) The duty in subsection (1) does not apply in relation to a service or facility if the Board has a duty to arrange for its provision.”.’.

New clause 16—Distribution of health service functions—

‘(1) The Secretary of State may direct the NHS Commissioning Board, or a clinical commissioning group, to exercise any of his functions relating to the health service which are specified in the directions.

(2) The functions which may be specified in directions include functions under enactments relating to mental health and care homes.’.

New clause 17—Secretary of State’s directions to health service bodies—

‘(1) The Secretary of State may give directions to any of the bodies mentioned in subsection (2) about its exercise of any functions.

(2) The bodies are—

(a) the NHS Commissioning Board; and

(b) clinical commissioning groups.

(3) Nothing in provisions made by or under this or any other Act affects the generality of subsection (1).’.

New clause 18—Care Quality Commission: duty as regards stability of existing NHS services—

‘The Care Quality Commission, in exercising its functions, must have regard to the need to avoid existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research or case-load, becoming viable or unstable due to an unplanned reduction in income or caseload.’.

New clause 20—Clinical commissioning group commissioning work: public function—

‘The Secretary of State must issue directions to clinical commissioning groups which will ensure that commissioning work is predominantly retained as a function by staff directly employed by the clinical commissioning group.’.

New clause 23—Chief environmental health officer for England—

‘(1) The Secretary of State shall appoint a Chief Environmental Health Officer for England.

(2) The Chief Environmental Health Officer for England shall give advice to and report to the Chief Medical Officer for England on all such aspects of environmental and public health as are relevant to the public health functions referred to in section 2A of the National Health Service 2006 Act and the duties referred to in section 2B of that Act.

(3) The Secretary of State shall report to Parliament annually on the work of the Chief Environmental Health Officer for England.’.

Amendment 1222, in clause 1, page 2, line 2, leave out ‘promote’ and insert ‘provide or secure a’.

Amendment 1223, page 2, line 3, leave out from ‘must’ to ‘improvement’ in line 4 and insert ‘provide or secure a comprehensive Health Service designed to promote’.

Amendment 1239, page 2, line 4, after ‘improvement’, insert ‘and to ensure improvement’.

Amendment 1176, page 2, line 7, leave out subsection (2) and insert—

‘(2) The Secretary of State must for that purpose provide or secure the provision of services in accordance with this Act.’.

Amendment 1224, page 2, line 8, leave out ‘secure that services are provided’ and insert ‘provide or secure, either directly or indirectly, services’.

Amendment 48, page 2, Leave out lines 10 to 12 and insert—

‘(3) The services so provided must be free of charge.’.

Amendment 1174, page 2, line 10, after ‘services’, insert ‘so’.

Amendment 1175, page 2, line 10, leave out ‘as part of the health service in England’.

Amendment 1177, page 2, line 12, at end insert—

‘(4) For the purposes of this Act “the health service in England” is defined as those services provided under section 3 of this Act.’.

Amendment 1240, in clause 2, page 2, line 17, leave out ‘with a view to securing’ and insert ‘so as to ensure’.

Amendment 1241, page 2, line 23, leave out ‘with a view to securing’ and insert ‘so as to ensure’.

Amendment 1212, page 2, line 33, at end insert—

‘(5) In discharging the duty under subsection (1) the Secretary of State retains the power to create a new NHS trust or provider organisation.’.

Amendment 1169, in clause 3, page 2, line 38, leave out from ‘State’ to end of line 40 and insert ‘, so far as is consistent with the interests of the health service, must exercise the functions conferred by this Act so as to secure—

(a) that inequalities between the people of England with respect to the benefits that they can obtain from the Health service are reduced, and

(b) a continuous reduction of inequalities between the people of England with respect to the outcomes achieved for them.

‘(2) The Secretary of State must publish and lay before Parliament an annual report detailing the progress which has been achieved in discharging this duty, and the means by which the Secretary of State intends to fulfil this function in the following year.’.

Amendment 1183, page 2, line 38, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to reducing’.

Amendment 1197, page 3, line 1, leave out Clause 4.

Amendment 1194, in clause 5, page 3, line 16, leave out ‘have regard to the need to’.

Amendment 1242, in clause 9, page 5, line 32, at end insert—

‘(h) promoting co-operation between each of the authority’s relevant partners.’.

Amendment 1243, page 5, line 35, at end insert—

‘(4A) For the purposes of this section each of the following is a relevant partner of a local authority—

(a) where the authority is a county council for an area for which there is also a district council, the district council;

(b) the police authority and the chief officer of police for a police area any part of which falls within the area of the local authority;

(c) a local probation board for an area any part of which falls within the area of the local authority;

(d) a youth offending team for an area any part of which falls within the area of the local authority;

(e) a clinical commissioning group for an area any part of which falls within the area of the local authority.

(4B) The relevant partners of a local authority must co-operate with the local authority in the making of arrangements under this section.’.

Amendment 5, page 5, line 43, leave out Clause 10.

Amendment 1178, in clause 11, page 7, line 15, leave out from ‘Subsections’ to ‘apply’ and insert ‘(1), (3) and (4) of section 3C’.

Government amendment 49.

Amendment 1172,  in clause 14, page 9, line 35, after ‘blood’, insert ‘, haematopoietic stem cells’.

Amendment 1173, page 9, line 37, after ‘tissue’, insert ‘, haematopoietic stem cell’.

Government amendments 50, 51 and 54.

Amendment 42, in clause 20, page 16, line 34, at end insert—

13DA Duty of the Board as to commissioning of services

In carrying out its duties in respect of the commissioning of services the Board must in the exercise of its functions have regard to the interdependency of services and the impact that the arrangements for the provision for one service may have on the financial and clinical sustainability of other services.’.

Amendment 1198, page 17, leave out lines 12 to 19.

Amendment 1184, page 17, line 21, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to’.

Amendment 1185, page 17, line 23, leave out ‘reduce’ and insert ‘reducing’.

Amendment 1186, page 17, line 25, leave out ‘reduce’ and insert ‘reducing’.

Amendment 1187, page 17, line 36, leave out ‘act with a view to enabling’ and insert ‘have regard to the need to enable’.

Amendment 1188, page 18, line 4, after ‘functions’, insert ‘have regard to the need to’.

Amendment 1195, page 18, line 17, leave out ‘have regard to the need to’.

Government amendment 60.

Amendment 1203, page 19, line 28, at end insert—

13OA Duty as regards stability of existing NHS services

The Board must not exercise its functions, in particular in respect of section 13I (Duty as to patient choice) or 13K (Duty to promote innovation) in a way which could lead to existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research, becoming unviable or unstable due to an unplanned reduction in income or case-load.’.

Amendment 46, page 22, line 12, at end insert—

‘(1A) The Secretary of State must publish guidance to the Board, to which the Board must have regard, about the exercise of its powers under subsection (1).’.

Amendment 1167, page 24, line 16, at end insert—

‘Duty to reduce bureaucracy

132ZA Duty to reduce bureaucracy

‘(1) The Board must exercise its powers so as to reduce administrative costs in the NHS.

(2) For that purpose the Board must exercise its duties under 14A and 14C to ensure that at no time there exist more clinical commissioning groups than there were primary care trusts on 1 April 2011.’.

Government amendments 67 and 68.

Amendment 1206, page 26, line 41, at end insert—

223E1 Financial duties of the Board: needs-based allotments

(1) The Board must make allotments to clinical commissioning groups based solely on the need of the population served by each commissioning group.

(2) The Secretary of State may give directions as to how the needs set within subsection (1) are determined.’.

Amendment 1218, in clause 22, page 27, line 17, at end insert ‘provided that the members of a clinical commissioning group cannot consist entirely or mainly of persons who are providers of primary medical services under section 83(2).’.

Amendment 1211, page 27, line 22, at end insert—

‘(c) shall be co-terminus with the social services local authority, unless it is notified by the relevant health and wellbeing board, and the local authority, that they approve an area which is not co-terminus.’.

Government amendments 70 and 71.

Amendment 43, in clause 23, page 34, line 20, at end insert—

14PA Duty of clinical commissioning groups as to commissioning of services

In carrying out its duties in respect of the commissioning of services each clinical commissioning group must in the exercise of its functions have regard to the interdependency of services and the impact that the arrangements for the provision for one service may have on the financial and clinical sustainability of other services.’.

Amendment 1189, page 35, line 2, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to’.

Amendment 1190, page 35, line 3, leave out ‘reduce’ and insert ‘reducing’.

Amendment 1191, page 35, line 5, leave out ‘reduce’ and insert ‘reducing’.

Amendment 1192, page 35, line 22, leave out ‘act with a view to enabling’ and insert ‘have regard to the need to enable’.

Amendment 1193, page 35, line 36, after ‘functions’, insert ‘have regard to the need to’.

Amendment 1196, in clause 20, page 36, line 3, leave out ‘have regard to the need to’.

Amendment 1230, in clause 23, page 36, line 7, leave out from ‘consortium’ to ‘that’ in line 8 and insert ‘has a duty to secure’.

Amendment 1231, page 36, line 16, leave out from ‘consortium’ to ‘that’ in line 17 and insert ‘has a duty to secure’.

Amendment 37, page 36, line 36, at end insert—

14YA Duty as to conflicts of interest

(1) Each clinical commissioning group must exercise its functions so as to ensure that any conflicts of interest, and personal and prejudicial interests are dealt with.

(2) The Secretary of State must issue guidance on how conflicts of interest and personal and prejudicial interests should be dealt with by clinical commissioning groups as part of their decision making.’.

Amendment 1204, page 36, line 36, at end insert—

14YA Duty as regards stability of existing NHS services

Each clinical commissioning group must not exercise its functions, in respect of section 14U (Duty as to patient choice) or 14W (Duty to promote innovation) in a way which could lead to existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research, becoming unviable or unstable due to an unplanned reduction in income or case-load.’.

Amendment 41, page 36, line 43, leave out from second ‘are’ to end of line 44 and insert ‘fully consulted—’.

Amendment 45, page 38, line 22, at end insert—

‘(1A) The Secretary of State must publish guidance to commissioning consortia about its exercise of powers under subsection (1), to which each commissioning consortia must have regard.’.

Amendment 1181, page 38, line 26, at end insert—

‘(3) For the avoidance of doubt it is hereby declared that nothing in this section authorises a clinical commissioning group—

(a) to disregard any enactment or rule of law, including but not limited to section 1(3), or to override any person’s contractual or proprietary rights; or

(b) to charge for anything the group does in the exercise of its powers under this section which relates to any accommodation, service or facility of a type to which section 3(1) applies; or

(c) to charge for anything in relation to the exercise of its functions under section 3 or 3A.

(4) A clinical commissioning group shall exercise the powers specified in section 7(2)(f) only after consulting (to the extent that it appears to it to be practical) any person who appears to it to have an interest through its own previous research in the ideas or intellectual property in question as to whether it should exercise them and, if so, as to any financial arrangements.

(5) A clinical commissioning group shall demonstrate in its annual report under section 14Z3 how the exercise of its power conferred by subsection (1) has not interfered to a significant extent with the performance by the group of its functions.

(6) Income raised by a clinical commissioning group as a result of the exercise of powers under this section shall be specified in its annual accounts, referred to in its annual report under section 14Z13, and paid annually to the Secretary of State.’.

Amendment 1250, page 41, line 38, at end insert—

‘(6A) If the opinion of a Health and Wellbeing Board given to the clinical commissioning group under subsection (5) is that the Health and Wellbeing Board does not consider that the draft takes proper account of each joint health and wellbeing strategy referred to in that subsection, and if the clinical commissioning group does not so consider it, the group shall inform the Health and Wellbeing Board, whereupon it may report to the Secretary of State that it does not consider that such a plan takes proper account of any such strategy and the Secretary of State may require the clinical commissioning group to carry out such further consultation with the Health and Wellbeing Board as he considers appropriate, or may make a final decision on the plan and require the Commissioning Board or the clinical commissioning group to take such action, or desist from taking such action, as he may direct.’.

Amendment 1171, page 42, line 23, at end insert—

‘(3) If in the Board’s opinion, having considered any opinion submitted to it by a Health and Wellbeing Board under 14Z12(1)(a), the plan published by the clinical commissioning group does not take proper account of each joint health and wellbeing strategy published by the Health and Wellbeing Board which relates to the period (or any part of the period) to which the plan relates, the Board must instruct the clinical commissioning group to revise its plans under 14Z10(1).’.

Amendment 1202, page 42, line 23, at end insert—

14Z12A Power of Referral of Commissioning plans to the Secretary of State

(1) If the Health and Well-being Board is of the opinion under section 14Z12(1) that a plan published by the CCG under section 14Z9(6) or 14Z10(2) and which is submitted to it in accordance with section 14Z9(6) and 14Z10(3) or 14Z11(4) or (8), does not take proper account of any relevant joint health and wellbeing strategy it may refer the matter to the Secretary of State for a decision.

(2) Regulations under this section may provide for the mechanism by which such referrals are made.’.

Amendment 38, page 43, line 9, at end insert—

‘(ab) section 14YA’.

Amendment 1199, in clause 24, page 49, line 35, leave out from beginning to end of line 37 on page 50.

Amendment 1213, page 50, line 27, at end insert ‘and must consult with local Health and Wellbeing Boards prior to any decision on this matter with a view to securing their agreement.’.

Amendment 1255, in clause 27, page 53, line 5, leave out ‘the Secretary of State’ and insert ‘Public Health England’.

Amendment 1256, page 53, line 6, leave out ‘an’ and insert ‘a suitably qualified’.

Amendment 1257, page 53, line 20, after ‘authority’, insert ‘, reporting to the Chief Executive of that authority,’.

Amendment 1253, page 53, line 21, at end insert ‘, and will be accountable to—

(a) the local authority, and

(b) the Secretary of State for Health.’.

Amendment 1258, page 53, line 21, at end insert—

‘(2A) The individual so appointed is to be employed by Public Health England, which shall have responsibility for their professional qualification and development.’.

Amendment 1259, page 53, line 30, after ‘authority’, insert ‘or Public Health England’.

Amendment 1254, page 53, line 42, leave out ‘consult’ and insert ‘obtain the agreement of’.

Amendment 1260, page 53, line 42, leave out ‘the Secretary of State’ and insert ‘Public Health England’.

Amendment 7, in clause 29, page 54, line 30, at end insert—

‘(3) This section comes into force on a date to be specified by order by the Secretary of State.

(4) The time specified in subsection (3) must be after such time as the Secretary of State is satisfied that the workforce education and training functions of strategic health authorities are being fulfilled by another body.’.

Amendment 1237, page 256, line 31, leave out Clause 299.

Amendment 1238, page 257, line 29, leave out Clause 300.

Amendment 47, in clause 304, page 261, line 19, at end insert—

‘(1A) Section 29 comes into force in accordance with sections 29(3) and (4).’.

Amendment 1245, in schedule 2, page 269, line 21, leave out from ‘consortium’ to end of line 24.

Amendment 1244, page 269, leave out lines 25 to 29 and insert—

‘(3) The arrangement must include provision for the functions of the clinical commissioning group to be exercised by, and only by, its employees on its behalf.’.

Amendment 1249, page 269, leave out line 29.

Amendment 1234, page 269, line 29, at end insert—

‘(4) Nothing in paragraph (3) shall authorise the inclusion of any provision for any of such functions to be exercised by—

(a) any of the clinical commissioning group’s members who hold or benefit from contracts to provide primary medical services under section 83(2); or

(b) individuals who have been employees of such members; or

(c) by a governing body, committee or sub-committee which consists entirely or mainly of such members.’.

Government amendments 292 to 299.

Amendment 1170, in schedule 4, page 278, leave out lines 35 and 36 and insert—

‘(a) omit “Strategic Health Authorities” and insert after “(a)”— “the National Health Service Commissioning Board”, and

(b) omit “Primary Care Trusts” and insert after “(b)” — “Clinical Commissioning Groups”.’.

Amendment 1247, page 281, line 10, at end insert—

‘(2A) Regulations made under this section must specify that—

(a) direct payments can not be made in respect of the whole or part of a course of private health care or in respect of insurance premiums which have the purpose of providing healthcare, and

(b) direct payments can only be made in respect of services which NICE has specified are services that can be provided by the health service, having particular regard to safety, efficacy and cost-effectiveness.’.

Amendment 1248, page 281, line 23, at end insert—

11A In section 12C (Direct payments pilot schemes) omit subsection (8).’.

Amendment 31, in schedule 23, page 417, leave out lines 18 to 21.

Amendment 32, page 418, line 34, leave out lines 5 to 8.

[Paul Burstow]

I rise to support the Government’s amendments and to explain the Government’s thinking on the amendments tabled by Opposition Members and other Members in the House. This large group of amendments covers a range of key clauses that enable us to deliver on a number of key tenets of the Bill: first, an NHS led by clinicians; secondly, an NHS with quality at its heart; thirdly, an NHS that is open and collaborative; and, fourthly, an NHS with clear, stronger political accountability. It is on the last point that I would like to start my remarks today.

The role of the Secretary of State has been the subject of great debate, especially in recent weeks. It is right that we should have this debate and it is a very important issue, especially given its particular complexity, but let us ensure that the debate is based on the facts. Too often, opinions have been offered and accusations made without full knowledge of what the Bill does and does not do.

Let me start by clearly setting out what the Bill does not do. First, it is absolutely not the Government’s intention in this Bill to allow the Secretary of State to wash his hands of the NHS. The Government believe in a comprehensive, tax-funded NHS that is free at the point of use, based on need and not ability to pay. Nothing in this Bill will change that. Secondly, I want to reassure hon. Members that there is no question but that the vast bulk of NHS-funded health care will continue to be delivered by NHS bodies that are bound by law and their constitutions to remain as public sector bodies and to fulfil a primary duty of providing services to the NHS. Indeed, the Bill contains a new provision—for the first time—specifically to prevent any future Secretary of State or NHS bodies from acting to promote the private sector over the public sector.

Let me turn to what the Bill does. It ensures not only that the Secretary of State will remain politically and legally accountable for a comprehensive health service but that he will retain the capacity to intervene where necessary to ensure that a service is provided.

Let me start with the accountability of the Secretary of State. Not only does the Secretary of State retain a raft of specific duties that mean he cannot wash his hands of the NHS but the Bill retains the legal requirements that services should be free of charge except where already specified. It now includes requirements, too, on securing continuous improvement in the quality of services, on promoting research and the use of evidence learned from research and, for the first time ever, on the need to have regard to the need to reduce health inequalities.

[Helen Jones (Warrington North) (Lab)]

Will the Minister explain to the House why, rather than providing a duty to act to reduce health inequalities, the Bill requires bodies only to have regard to health inequalities? It is quite possible to have regard to them and to do nothing to reduce them.

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[Paul Burstow]

There is a clear duty on the boards to act, too, and I ask the hon. Lady why the Labour Government, in 13 years, chose not to do anything about that matter. There was never a legal duty of any sort in the past and we now have clear duties on all the bodies and on the Secretary of State. Of course, I shall come on to talk about the mandate, which has a role to play, too.

[Andrew George (St Ives) (LD)]

I merely wish to seek clarity from my hon. Friend on some of the briefings that his Department has been putting out about the duty to provide, to which he has referred already. Those briefings indicate that there was somehow no provision in the National Health Service Act 1946 for a duty on the Secretary of State to provide. I wanted my hon. Friend to acknowledge that section 1(1) states

“and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act.”

Equally, the National Health Service Act 1977 contains the same reference to the

“purpose to provide or secure”.

The requirement to provide or secure is repeated throughout all the Health Acts.

[Paul Burstow]

I am grateful to my hon. Friend for that intervention. If he listens carefully to what I am saying, he will hear that I am developing an argument that will go towards answering that question. Rather than trying to answer it in a very small way now, I would rather answer it in a comprehensive way through reference to what I had planned to say to the House.

As I was saying, hon. Members should ask themselves how the Secretary of State would be able to wash their hands of the NHS while simultaneously being legally required to deliver on all the duties I have just outlined. Crucially, the Secretary of State also retains the duty to promote a comprehensive health service, which dates from the Act that founded the NHS in 1946 and has been unchanged by this Bill. The Secretary of State will also have the duty to secure that services are provided for that comprehensive health service and will have failed in that duty if they are not.

The Secretary of State also has the ability—the obligation, in fact—to set goals and priorities for the NHS through the mandate. That will set out what the Secretary of State wants the NHS to deliver, which will be updated every year. It will be widely consulted on and Parliament will scrutinise it, for the first time ever giving Parliament a detailed say in what the NHS is tasked to deliver.

The Secretary of State has further powers in addition to the mandate to impose standing rules by which the NHS commissioning board and the clinical commissioning groups must operate, which will be subject to scrutiny and control by Parliament—a power Parliament does not currently have. What is changing, however, is the Secretary of State’s relationship with the NHS in terms of the role of Ministers in the commissioning and provision of services to the NHS. The Government believe that it should not be the job of Ministers to provide directly or commission NHS services, either. It should be the role of front-line professionals, who should have the freedom to focus on driving up quality of care, free from interference by Ministers in operational decisions—something that all parties in this House have said that they want to see.

We understand that all Government legislation has a responsibility to foresee the unforeseeable, to ask questions about the worst-case scenario and to ensure that the answers stand up to scrutiny. That is why this Bill contains a number of back-stop provisions to make it absolutely certain that any future Secretary of State will not be able to turn a blind eye to failings of service provision, so we have ensured that the Secretary of State has the power to step in if the board, or Monitor, is failing to deliver on its duties, including any duties imposed on the board through the mandate.

Finally, in the event of a significant emergency such as a pandemic, the Secretary of State will have powers to direct any commissioner or provider of NHS services.

[Owen Smith (Pontypridd) (Lab)]

In the event where there is not an emergency, will the Minister confirm that under the new provisions the Secretary of State will not have the power, as he has, to direct a commissioning group to do what he thinks is appropriate for the people in that area?

[Paul Burstow]

No, he will not have powers of direction. Of course, powers of direction are not subject to any form of parliamentary scrutiny and can be issued by a Secretary of State by fiat. In future, this House, through regulations, will be able to look at and agree—or not—standing rules that in most effects will have the ability to direct clinical commissioning groups and the NHS commissioning board on a wide range of matters. I direct the hon. Gentleman to clause 17, which sets those out at great length.

[Simon Hughes]

I am listening very carefully and, as my hon. Friend knows, we have had conversations and a wider debate about this issue. I understand what he is saying about the specific power of the Secretary of State both to act and to direct if things are failing, but does he accept that some of us would still like to be persuaded that the best way of enunciating the fundamental duty at the beginning of the legislation is not to say that the principal job is to secure the provision of the services of the NHS but to write in that it is to provide them? The back-stop encompassing statement, as it were, would mean that we could be sure that the duty rested with the office holder of the role of Secretary of State in England at any one time.

[Paul Burstow]

I am grateful to my right hon. Friend for having given me the opportunity to talk about this at some length, and I want to give him some reassurance. However, it is hardly a back-stop to have in clause 1 something that is not what the Secretary of State on a day-to-day basis actually does. It is a back-stop to say that when things fail, the Secretary of State should be able to exercise those functions to make sure that things are put right. I would like to say a bit more about that now.

I want it to be clear that we do not envisage the Secretary of State having to intervene other than in exceptional circumstances. Nevertheless, the measures are the legislative back-stops in the Bill and it is right that they are there to protect the comprehensive nature of our NHS and to provide reassurance. To answer my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) directly, there are a number of ways in which the Secretary of State could secure the provision of services. In particular, he could impose requirements on the NHS commissioning board and clinical commissioning groups using both the mandate and the standing rules. He could establish, and has the powers to do so, a special health authority, and could direct it to carry out any NHS function. That power has been used in the past to establish NHS Direct—a service-providing organisation. Also, he could intervene, including by replacing the management and directing them in the event of a significant failure. Those measures are the belt and braces in the Bill to make absolutely sure that the NHS and the public are protected from all eventualities. We have ensured that the Secretary of State’s powers are sufficient to ensure that a comprehensive NHS is provided, including through the public sector, rather than simply relying on existing providers and the market.

The position is clear: we are giving the NHS more freedoms and autonomy—something that many of us in the House have for many years argued should take place—and we are increasing its accountability. We are making watertight the obligations to provide a comprehensive health service that is free to all, based on need and not ability to pay.

[John Pugh (Southport) (LD)]

Will the Minister confirm that the Secretary of State will retain his powers to create new hospital trusts and that the Bill does not change that power ?

[Paul Burstow]

The power to establish NHS trusts is contained in previous legislation. The Bill provides for, in due course, the repeal of the provision to establish NHS trusts. As we indicated in our response to the NHS Future Forum, that will not take place for several years to come. Regardless of that, however, the Secretary of State will retain the power to establish special health authorities that can exercise a provider function.

[Rosie Cooper (West Lancashire) (Lab)]

The Minister just said that the Secretary of State will have the power directly to remove the management of hospitals or provider organisations. Will that apply both to NHS and private providers? Will the Secretary of State’s reach go that far?

[Paul Burstow]

We discussed yesterday at some length the role of Monitor and its powers through the licensing regime, which will apply not just to NHS public sector providers but to private and voluntary sector providers. The powers there are extensive and I recommend that the hon. Lady should look at the debate we had yesterday.

Another issue that comes up is the duty of autonomy. Amendment 1197, which was tabled by my hon. Friend the Member for St Ives—not all of Cornwall—(Andrew George), seeks to remove clause 4, entitled “The Secretary of State’s duty as to promoting autonomy”. This clause was highlighted by the legal team advising 38 Degrees about the changes to the role and functions of the Secretary of State. The specific purpose of the autonomy duty is to free front-line professionals to focus on improving outcomes for patients rather than looking up to Whitehall. It does not undermine the overarching duty to promote a comprehensive health service, nor enable Ministers to abdicate responsibility for the NHS.

It is our view that the legal opinion published by 38 Degrees overstates the effect of clause 4. The opinion suggests that the court will expect the Secretary of State to demonstrate that any steps he took that interfered with the autonomy were “really needed”, or “essential”, and that no other course of action could be followed. This is not the Government’s intention and we do not believe that that is the effect of the clause. It would be sufficient for the Secretary of State to demonstrate that he had reasonable grounds for concluding that a course of action was the most effective way to act in the interests of the health service and fulfil a duty imposed on him by, for example, clause 1 or a new section 1A in the Bill.

--- Later in debate ---

[Simon Hughes]

rose—

[Paul Burstow]

I will give way to my right hon. Friend the Member for Bermondsey and Old Southwark and then I shall make some progress because this is a very big group of amendments.

[Andrew George]

It is my amendment.

[Simon Hughes]

I am very grateful and I will not keep the Minister long. I have listened very carefully, as colleagues will have done, to my hon. Friend’s extremely reassuring comments. If he and the Secretary of State are committed to working on some wording that will alleviate concerns at the beginning of the Bill, I know that my colleagues and I will be very happy to work with him.

[Paul Burstow]

I am grateful to my right hon. Friend. I can say no more than I have said and I think I have said what is necessary to make the Government’s intentions clear. Of course, I will now give way to my hon. Friend the Member for St Ives, who has been so diligent in tabling so many amendments.

--- Later in debate ---

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. We must have shorter interventions, as we have a lot to get through. Hon. Members should not take advantage of the Minister’s generosity in giving way.

[Paul Burstow]

I am grateful for your protection, Mr Deputy Speaker. I will take that as advice in relation to further interventions.

I have heard my hon. Friend’s comments and I think he needs to look again at what I have said. I have been very clear that we are listening and that, if necessary, we will offer clarifications or further amendments, and I am very happy, as is the Secretary of State, to carry on those discussions.

There are a number of amendments regarding other duties on the Secretary of State that I believe would not improve the drafting of the Bill. Amendments 1240, 1241, 1169 and 1183 seek to revise the duties of quality and inequality. I know that the amendments are well meant, but they would make the duties undeliverable. The Secretary of State cannot improve quality and reduce inequalities in isolation, and the duties have to reflect that. Amendment 1194 is unnecessary as the Bill already recognises the need to promote research and the use of research evidence, and creates, for the first time, responsibilities for taking a whole-system approach to achieving this. Amendments 1184 to 1193, 1195, 1196 and 1198 seek to change the extent of similar duties on the board and the clinical commissioning groups. Each of the board’s and clinical groups’ duties has been drafted to ensure that the duty is suitably strong, realistic and appropriate.

Let me address the role of the Secretary of State in relation to another issue that has been misunderstood—charging. I want to be very clear that nothing in the Bill enables the board or clinical commissioning groups to charge for services provided as part of the comprehensive health service. Services will remain free at the point of need, except where legislation specifically allows for charges to be made—for example, prescription charges and charges for dentistry. The Government have also committed not to introduce any new charges.

Amendment 48, tabled by the hon. Member for Brighton, Pavilion (Caroline Lucas), who is not in her place at the moment, would prevent charges from being imposed for any service provided by the NHS. It has always been possible for Ministers to provide for charges for certain health services. There are limited provisions for charging even in the original NHS legislation introduced by Nye Bevan and the Labour Government of 1946. Under the current system, there are extensive exemptions: about 60% of the English population do not pay prescription charges, but—it is an important but—NHS charging raises over £1 billion a year of revenue that is ploughed back into services for patients, and it does make an important contribution to the overall affordability of the NHS. Therefore, I cannot accept the amendment.

The hon. Member for Brighton, Pavilion also tabled several amendments on direct payments. The amendments are unnecessary and too restrictive. Amendment 1247 would restrict direct payments to being spent on services approved by the National Institute for Health and Clinical Excellence. The great opportunity of personal budgets is that they allow people in areas where less medicalised services are provided to have much greater control over aspects of their care—those community-based services that are so important in maintaining the quality of life for many people with long-term conditions.

Finally, amendment 1248 would remove the power to extend direct payments nationally following the pilots, which are continuing. The Health Act 2009 provided that direct payments could be extended with the active agreement of Parliament using the affirmative procedure, and that seems a perfectly reasonable way of having a parliamentary check over the outcomes of the pilots that will be reported to the House next year. Amendment 1247 would prevent direct payments from being used for private health care or health insurance. The amendment is unnecessary. NHS funds could never be used to pay people’s private health insurance premiums.

I shall now turn to education and training. We have already committed to introduce at a later stage in the Bill’s proceedings an explicit duty for the Secretary of State to maintain a system for professional education and training. Work is ongoing and an amendment will be tabled in the House of Lords. That will be more effective and more precise than the long-term measure of simply blocking the abolition of strategic health authorities, so amendments 7 and 47 will not do.

Our vision of a modern NHS has clinical commissioning at its very heart. We want clinicians, GPs, nurses and other health care professionals to have the autonomy to commission innovative new services, and to have the true responsibility that the previous Government denied them. That involves striking the right balance between freedoms for clinical commissioning groups and their essential responsibilities to other parts of the health care service.

We made many changes in response to the recommendations of the NHS Future Forum report. We always wanted clinical commissioning groups to have a robust set of governance arrangements, to involve a wide range of other professionals and to be transparent in how they conducted their business, and we have now further strengthened those parts of the Bill so that they are very much improved.

As I said at the start of my remarks, I should like to speak briefly to a number of amendments, as I am conscious that many other hon. Members wish to speak. First, I will address some amendments that are very similar, if not identical, to those that we had the opportunity to debate at least once, and possibly twice, during the first stage of the Committee and in the re-committed Committee.

Amendment 1181, which is like amendments 45 and 46, seeks to restrict clinical commissioning groups’ powers to raise additional income. As was explained in Committee, those amendments are unnecessary. The Secretary of State has already published guidance, which can be easily updated, specifically on the powers to generate income, which applies to current NHS bodies, including primary care trusts.

Amendments 37 and 38 are on conflicts of interest. We have listened to the concerns that were expressed in the listening exercise and made changes, so the Bill already requires clinical commissioning groups to make provision for dealing with conflicts of interest.

Amendments 31 and 32 would prevent any property currently held by PCTs or strategic health authorities from being transferred to any provider that is not a public authority. As we said in Committee, we have no intention of giving away NHS property to private companies. That will not be the case and, given the safeguards that are in place, it cannot happen.

Several amendments have sought to probe accountability within clinical commissioning groups. I repeat what we said in Committee. A clinical commissioning group is not able to delegate its statutory responsibilities for carrying out its functions. It cannot palm them off or pass them on to others. Amendment 1245 would limit representation on CCG committees and sub-committees, preventing those clinical commissioning groups from inviting other professionals and experts to participate—something that we were told during the listening exercise was widely welcomed and wanted.

Amendment 1249 restricts the use of sub-committees—an essential part of any organisation with a wide range of functions. Similarly, amendment 1234 would prevent GPs or their employees from working on behalf of a clinical commissioning group, which would be a severe constraint on those groups’ ability to function. Amendment 1244 would prevent a clinical commissioning group from delegating its functions to anyone other than its employees. That would make it very difficult for those groups to carry out their statutory functions effectively.

New clause 20, tabled by my hon. Friend the Member for St Ives, similarly would restrict the support that clinical commissioning groups can draw on. We want to allow those groups to access the best support and advice available—to be able to work with local authorities, third sector organisations and charities, research organisations and the independent sector. I mentioned in Committee several times, and it is worth repeating, that the support organisation established by the Neurological Alliance is proving of invaluable assistance to commissioners, and amendments such as new clause 20 would prevent it from doing the work it does for the clinical commissioning groups. I can follow the intention behind the amendments, but I hope my reassurances about the final responsibility—the statutory responsibility—for decision making in clinical commissioning groups resting with their members and the governing body are clear.

There is a raft of amendments dealing with the relationship between local authorities and commissioning groups. We want that to be a dynamic relationship, with constant dialogue and collaboration, which is precisely why the Bill proposes the establishment of health and wellbeing boards. Amendments 1202, 1171 and 1250 would introduce a new, centrally imposed procedural requirement on health and wellbeing boards and clinical commissioning groups. Clinical commissioning groups will have a duty to have regard to the relevant joint health and well-being strategy.

Where commissioning plans vary significantly from the joint strategy, the group will need to justify or consider amending its plans. Health and wellbeing boards also have the power to refer their views and concerns to the NHS commissioning board when they feel that the plans have not had proper regard to the joint health and well-being strategy. That indicates to the NHS commissioning board that the health and wellbeing board believes the CCG is actively failing to fulfil its duties. Anything further would undermine the important balance that needs to be struck in what is fundamentally a partnership relationship between two organisations that have separate sets of sovereignties and responsibilities.

The importance of that partnership approach highlights why it would be impossible to create an obligation on clinical commissioning groups to act alone to secure integration of services. How can one body decide to integrate with another against the wishes of the other? A duty cannot be imposed on one side unless the relationships exist that will allow that to take place. That can be achieved only by both parties working together, and for that reason amendments 1230 and 1231 do not contribute to that relationship’s working well.

Amendment 1211 seeks to make the clinical commissioning groups coterminous with local authorities. We have accepted the NHS Future Forum’s recommendation that the boundaries of local clinical commissioning groups should not normally cross those of local authorities, with any departure needing to be clearly justified as part of the establishment process set out in the Bill.

Amendment 1213 would prevent a clinical commissioning group that had received a reward under the quality premium from using that money without first securing the agreement of the local health and wellbeing boards. That would severely limit the CCG’s freedom to spend its quality payment as it saw fit. Health and wellbeing boards will shape commissioning priorities through the joint health and well-being strategy, by being consulted by the CCG on their commissioning plans. Under the duties set out in proposed new section 14Z14 of the National Health Service Act 2006, the NHS commissioning board must also consult each relevant health and wellbeing board in making its annual performance assessment of those CCGs.

[Rosie Cooper]

Great play keeps being made about consultation. I do not hear any play being made about the right to be heard or a right of veto, or whatever. CCGs can ask the health and wellbeing boards what they think; health and wellbeing boards might make a recommendation, but there is no obligation for anyone to listen.

[Paul Burstow]

The hon. Lady is completely wrong when she says that there is no obligation. There are clear duties in the Bill for health and wellbeing boards’ views, and their preparation of joint strategies on health and well-being and joint strategic needs assessments, to be legally binding documents, in the sense that CCGs must have regard to them. They are not pieces of paper that can be just tossed aside and dismissed. They are very important documents in the emerging system.

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

A number of us are trying to understand what will trigger some kind of higher-level arbitration if it becomes abundantly clear to a significant group of people in a local community that the health and wellbeing board’s view is not being properly considered by the CCG. At that point, when there is a clear conflict, how will that conflict be exposed so that the Secretary of State or someone else clearly arbitrates so that there is fairness, not lip service? A lot of people are anxious about that.

[Paul Burstow]

That anxiety was expressed in Committee by some Opposition Members. As a result of the NHS Future Forum’s recommendations, we have put in place further checks to ensure that those concerns are allayed. Not least of those—as well as our view that the health and wellbeing boards should have on them a majority of elected councillors—is that they will have clear rights of membership from the local healthwatch, which will be listening to the wider community and will represent those wider concerns. They will have the views and expertise of the director of public health, the director of adult social services and the director of children’s services. If they feel that the strategy that they have all agreed is not being honoured in the commissioning strategy, they can ultimately refer that matter to the NHS commissioning board, and that can lead to changes being made.

[Helen Jones]

Many of us are concerned that we will not know properly what is going on in CCGs, because there is no requirement for them to be subject to the Public Bodies (Admission to Meetings) Act 1960 and to meet in public. They can decide whether to meet in public. How on earth is accountability to be maintained if those bodies can decide in private—[Hon. Members: “No, they can’t.] Yes, they can. They can decide in private how they will consider input from the health and wellbeing boards, and what they will do about it. Where is the line of public accountability?

[Paul Burstow]

I fear that, unfortunately, the hon. Lady might well have dusted down an old copy of the Bill, before the Future Forum made its recommendations and we made amendments to make it absolutely clear that a CCG’s governing board must meet in public. That is the decision-making body. Moreover, we also require those boards to set out in detail and publish all their decision-making arrangements—unlike PCTs, whose decisions could be made in private and no one would know.

Let me move on to health and wellbeing boards influencing commissioning decisions. Other people have questioned why we should have a quality premium at all. Indeed, amendment 1199 would remove the NHS commissioning board’s ability to reward CCGs financially for the quality of services—I emphasise that—and the outcomes that they secure, or reductions in health inequalities, which is something that all hon. Members across the House want to be promoted. That is the basis on which we want things to move forward, and high-quality services should be recognised and rewarded.

With amendments made in the second Bill Committee, we made it absolutely clear that such payments will provide an incentive to CCGs to focus on improving quality and outcomes. We will work with patients and professional groups to draft the regulations to reinforce that clear undertaking, which was made as a result of listening.

[Steve McCabe]

Will the Minister give way?

[Paul Burstow]

I am conscious of the time, and the fact that other hon. Members want to move and speak to other amendments. If the hon. Gentleman will forgive me, I will make a bit more progress.

[Andrew George]

Will the Minister give way?

[Paul Burstow]

I am talking about my hon. Friend’s amendment, so I will, of course, give way.

[Andrew George]

I am grateful to the Minister for giving way to me, as he is referring to my amendment. I think that I understand what the Government are trying to achieve here, but in order to assess properly what quality and outcomes are, that assessment must not be pre-empted. The purpose of my amendment is to ensure that good quality and outcomes are not rewarded too early after treatment, before people can make a proper assessment and know the long-term impact of a new procedure.

[Paul Burstow]

My hon. Friend makes a fair point—one that, I think, we would agree with entirely. That is why the Government published, for the first time ever, an outcomes framework for the NHS that is all about considering how clinical care leads to the sort of longer-term outcomes that he seeks, so I hope that that addresses his comments. That will be built into the way in which we go forward with drafting the regulations to reinforce that approach.

On the stability of services, my hon. Friend has tabled amendments 1203 and 1204 and new clause 18, which link very closely to Opposition amendments 42 and 43 on the interdependency of services. My right hon. Friend the Secretary of State spoke to two similar amendments that my hon. Friend moved yesterday. We agree with hon. Members about the need to secure continued access to services for patients. We have introduced substantial new proposals to improve on our previous plans. However, I repeat what my right hon. Friend said yesterday: this is not about securing access to the same services in perpetuity. That has never been the case, and it should not be the case. Services evolve, and we must allow new providers—whether NHS, social enterprise or private sector—to come in where they can deliver high-quality care for patients.

I shall turn now to excessive prescription and a number of issues that arise from several amendments, which would tilt the balance in a way that would turn the system much more into a command-and-control one than many hon. Members have argued that we should have for many a year. Amendment 1218 would break a fundamental principle at the heart of our proposals: that the membership of CCGs should consist solely of GPs, and that we should encourage, rather than prescribe, how they involve other professionals.

Amendments 1237 and 1238 would remove the Secretary of State’s power to make transfer schemes for property, staff, rights and liabilities, thus making it less flexible to make transfers from, for example, a PCT to a CCG. I am well aware that many people feel that the ability to transfer staff in that way is an essential part of managing a smooth transition. Therefore, to deny the Secretary of State the ability to do that seems very odd. Amendment 1167 is unnecessary for the same reason. CCGs are different entities from PCTs, with different structures, duties and functions. It does not make sense to set a limit on the number of CCGs by comparison with PCTs.

Opposition amendment 5 would delete clause 10, but Opposition new clause 14 would reinstate it, so it is a sort of hokey-cokey set of proposals, whereby a provision would be taken out and then put back in again. As the Bill includes a power to make regulations to take account of people in specific circumstances, new clause 14 and amendment 1178, which is consequential on it, are unnecessary.

New clause 11 would require the NHS commissioning board to limit the administration spend of CCGs individually and collectively by comparison to 2009-10. In other words, it would set an arbitrary starting line and effectively lock the budgets that way. An absurd shackling of the NHS commissioning board or CCGs in that way belies common sense and sound financial governance.

Amendment 1206 runs the inherent risks, as discussed in Committee, of trying to prescribe the setting allocations in legislation. I understand the concern expressed by my hon. Friend the Member for St Ives (Andrew George), and the White Paper made it clear that we want to ensure that access in every part of the country is fair and equitable. We will want to ensure that that is achieved, and I am happy to continue to discuss those issues with my hon. Friends.

Amendment 1167 is unnecessary for the same reason. CCGs are different entities from PCTs, with different structures, duties and functions, and it would not make sense to set limits in such a way. The additional statutory provisions set out in new clause 10 are also unnecessary. Imposition of a minimum waiting time would not take account of the clinical needs of individual patients, and it is for clinicians to plan care on the basis of the clinical needs of patients and their right to access the best service.

We are considering how best to prevent PCTs from imposing clinically inappropriate blanket minimum waiting times, but there are already sufficient powers in the Bill to address the issue when it comes to CCGs.

Amendment 41 is also about consultation and transparency. We have already changed the Bill to enhance the duty on CCGs to involve and consult the public, but the commissioners must have sufficient flexibility to be proportionate in how they involve patients and service users. CCGs will not be able to use that flexibility to underplay their duty to involve the public.

I want to discuss a section of the Bill that I know concerns some of my hon. Friends and which perhaps was not much discussed in Committee—public health. A number of amendments are relevant here. New clause 23 would create the role of a chief environmental health officer. The chief medical officer, however, is already able to provide the very advice that the new clause would establish a new role to provide. The chief medical officer can provide independent advice on environmental health issues. At a time of financial stringency, the new clause would create a layer of wasteful bureaucracy.

Amendments 1253 to 1260 relate to the role of directors of public health. Our position is that they should be employed by the local authority to support local government in the new role that the Bill confers on local authorities in respect of public health.

[Fiona O'Donnell (East Lothian) (Lab)]

The Minister and the Government are fond of pausing with this Bill. I want to offer him the opportunity to pause as he comes near to the end of this long list of amendments and apologise to the many health organisations and patients organisations across the country for the anxiety and concern that he and his Ministers have caused.

[Paul Burstow]

I am sure that as people read the transcript of the debate they will wonder why that intervention came at this point, other than to make a cheap party point. It is one that many Members of the House will know has set the tone for much of the Labour party’s contribution to debate on the Bill.

I was about to discuss an important issue, which is how we improve the health of our nation through our public health services. Returning to amendments 1253 to 1260 and the role of director of public health, we are having discussions about how best to ensure that the director of public health has an appropriate status within the local authority. There is concern about who directors report to and are accountable to. We intend to return to that matter once the consultations are concluded to make that absolutely clear, and to address those concerns.

[Mr Stephen Dorrell (Charnwood) (Con)]

Will my hon. Friend repeat the statements that were made in a Select Committee hearing about the status of directors of public health? Is it the Government’s view that, at the very least, they should encourage—and preferably make mandatory—the status of a director of public health as a senior officer of the local authority, not reporting through any other senior officer of the authority?

[Paul Burstow]

My right hon. Friend is right to remind the House of the clarifying statement that was made before his Select Committee. That is what we want to encourage. We are listening to the results of the consultation exercise at the moment. Such people should be officers who report to the council and to the chief executive. Those are the issues that we are considering, and we will return to the matter.

Amendment 1254 would require the local authority to obtain the agreement of the Secretary of State before dismissing its director of public health. Our view is that as the local authority is the employer, it is not appropriate for the Secretary of State to intervene directly. The Bill already requires local authorities to consult the Secretary of State before dismissing a director of public health, so there is a safeguard already built into the legislation.

Amendment 1256 would require the director of public health to be suitably qualified. It is important to be clear that, as the Bill sets out, the director of public health must be jointly appointed by the Secretary of State, who can ensure that only appropriately qualified individuals are appointed. The amendment is therefore unnecessary.

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[Paul Burstow]

My hon. Friend the Member for Bradford East (Mr Ward) is right. That is why the outrage was expressed as it was. This part of the Bill and the schedule have the same effect as the Public Bodies (Admissions to Meetings) Act 1960. That Act does not say in a blanket way that every meeting must be held in public. It allows local authorities to exercise judgment about confidentiality. We are applying the same principles in that regard in exactly the same way as to PCTs, with the additional provision that for the first time all these arrangements must be published.

[Owen Smith]

I am grateful to the Minister for that further intervention, just as I assume that he is grateful for the intervention of the civil servants in the Box, who must have passed him a note. Clearly, he was not aware of that earlier. When he said that CCGs must meet in public, he was under the impression that that was the case.

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“The Government will liberate the NHS from excessive…political control”.

[Paul Burstow]

Is it still the Opposition’s policy to seek a division between the role of commissioning or purchasing health services and the provision of those services? Does the hon. Gentleman believe in that split?

[Owen Smith]

Yes. The current situation is clear: the Secretary of State has a legal duty placed upon him in the legislation to secure and provide—not just to promote—a comprehensive health service in this country, and to issue direction to PCTs and SHAs, such that they so do. Those two crucial aspects of the current legislation are being changed in the Bill, and I intend to discuss them in a moment.

In version 1 of the Bill, the Government were less coy, because it actually excised section 1 of the original 1977 Act. After the deluge of criticism, however, they decided that they needed to put it back in, making it explicit, as they put it, that the Secretary of State will be responsible, as now, for promoting a “comprehensive health service”.

Section 1 of the Act was duly reinstated, as was the duty to promote, but there was a critical change, in clause 1(2) of the new Bill, which diluted the traditional duty to provide and secure. Ultimately, it placed a duty on the Secretary of State only to

“exercise the functions conferred by the Act so as to secure that services are provided”.

I shall come on to the reason why that is significant, but equally significant and allied to it was the retention—against the advice of Opposition Members and many others—of clause 10, which amends section 3 of the 2006 Act, thus keeping commissioning bodies, not the Secretary of State, as the parties with a legal duty to provide health care in England.

The net effect of those changes—despite what the Minister said earlier, and despite what the Secretary of State has said on several occasions, including notably on Second Reading—is no change. The Secretary of State is still, as the Minister put it, washing his hands by divesting himself not of the NHS but of a direct duty to provide a comprehensive health service. That is the distinction which the Minister failed to make today. The Secretary of State is palming off that precious duty, which has been placed upon successive Secretaries of State, and handing it on, via the mandate, to a quango and to unelected commissioning bodies.

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[Owen Smith]

With respect, there is not a legal duty on the Secretary of State to provide, as there has been in successive health Bills. When Bevan talked about hearing the bedpan dropped on the ward in Tredegar, he did not mean that he wanted to pick it up. [Interruption.] I do not know whether the Secretary of State wants to listen. Bevan did not mean that it needed to be picked up by the Secretary of State, but he certainly meant that he would like to be able to direct those responsible operationally for picking it up so to do.

The critical difference in this Bill is that the Secretary of State will divest himself of not only the duty to provide that service, but the power to direct the operational parts of the NHS, save for—[Interruption.] The Minister is waving his head, nodding or something; I know what he is going to say. Under the Bill, save for in cases of crisis or emergency, the Secretary of State will not have responsibility for running the day-to-day operations of the NHS.

[Paul Burstow]

The hon. Gentleman is wrong again. Unlike the previous Government, who were happy to have directions that did not have any parliamentary accountability, this Government are putting in place the ability, through regulations, to set the standing rules for the NHS, which, as set out clearly in clause 17, include all the issues that the hon. Gentleman is concerned about and show that the Government are committed to ensuring that there is a comprehensive health service.

[Owen Smith]

As the Minister has just confirmed by omission, there will be no power to direct and therefore no power to deliver absolutely a comprehensive, universal health service as we have come to expect and understand it. Those are the key differences. [Interruption.] The Minister can shake his head, but that is an accurate interpretation of what has happened.

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[Owen Smith]

I am grateful to my hon. Friend for that intervention. As she will know, the Government have no mandate for any of these things—they were not in the manifesto, the election or the coalition agreement. There is a mandate, but not one to effect these sorts of changes. That is another disgrace given how large the changes are.

I am going to move off this issue, but I will conclude by reading back to the Government their own words, which make it absolutely clear what they are doing in getting rid of direction. Paragraph 66 of the explanatory notes states:

“Currently, the Secretary of State is directly responsible for providing or securing the provision of all health services as set out in the NHS Act, a function which is largely delegated to Strategic Health Authorities and Primary Care Trusts…However, the new commissioning structure proposed by the Bill means that this would no longer be the case.”

The explanatory notes also state that

“functions in relation to the health service are conferred directly on the organisations responsible for exercising them”.

Effectively, the Secretary of State will move on and his focus will shift to public health.

[Paul Burstow]

I want to be absolutely clear about this. The hon. Gentleman is happy with an arrangement that allows the Secretary of State to make directions to the NHS that do not require him to come to this House to account for his actions—is that correct?

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It is therefore scandalous that we come to this juncture, many months after we started our debates on the Bill, with SHAs—the repositories of the training and planning function in the NHS—on the verge of being abolished. Their abolition has shifted from seven months to around 14 months, but in legislative terms SHAs are on the verge of being done in by the Government. However, the Government have absolutely no idea what they will replace the education and training facilities with—and the Minister has had the temerity to come to the House today and inform us that a new amendment is to be tabled in the House of Lords to deal with this crucial part of the Bill.

[Paul Burstow]

I have said that before.

[Owen Smith]

The Minister has not said it before in a public realm of which I am aware. He certainly did not say it in the Public Bill Committee, all 40-odd sessions of which I feel I sat through. The Minister knows that the issue is crucial, because the Future Forum that he commissioned said so. Indeed, it said that

“one of the most widely voiced criticisms of the proposed changes was a deeply felt concern at the risks to healthcare education and training in England posed by the fast pace of change.”

The Government responded by saying:

“we will introduce an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service.”

We are still waiting. What will that duty look like? [Interruption.] The Minister says “We have said that we are going to do it”, but here we are, eight months and 1,500 amendments later. How long must we wait? Are we sure that we will see the duty introduced in the House of Lords? Are we positive about that? I must say that I am not certain about it.

[Paul Burstow]

The shadow Minister rarely criticises the Government for telling the House again what they said in the response to the Future Forum, which is that we would introduce that explicit duty. We will introduce it in the House of Lords, as I have told the House today. We are committed to doing so, having listened carefully to the concerns of NHS professionals.

[Owen Smith]

The very simple question to be asked is “Why the delay?” Why could the Minister not have introduced it earlier? We have known about the problem for eight months and more. The Secretary of State, who has been keen on changes such as this for a long time, must have given some thought to what he was going to do about staff training and work force planning in the NHS.

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[Valerie Vaz]

No, I will not.

I again ask the Secretary of State for Health what discussions he has had with the Cabinet Secretary about the change regarding accountability for the public money that will be transferred—£60 billion of it—to those quangos. If he is asked questions about this in the House he will say that it is an operational matter.

I want to show hon. Members what the scenario will be like, because this is already happening in my constituency and this is what it will be like throughout England. The out-of-hours GP and urgent care service provider Waldoc has just lost the contract to provide out-of-hours services after 16 years, without a right of appeal to the strategic health authority and despite a patient satisfaction rate of 95%. When the contract was lost and staff turned up to find out whether they had jobs, they did not even know whether they would have a job the next day. That is how they have been treated. This has been happening in most PCTs, as some Members will know from their constituencies. People have left, vital expertise has gone and no one from the Government side has been able to give us a figure for the redundancy costs. When I asked the Minister how much this whole reorganisation would cost, he said he did not know the figure and that there was no new money. That must mean that money has come out of services.

We have, however, had a figure—£1.4 billion—from Professor Kieran Walshe of Manchester university. No wonder waiting times have gone up. Members of the public need to know that in an increasing number of areas, consortia will be conducting competitive tenders in which, potentially, foundation trusts, the constituent members of consortia and commercial providers will be bidding. Clearly, there will also be a conflict of interest. It has been estimated that a single procurement process can cost from £5,000 to £30,000. That is a waste of public money, and the whole regime of procurement is a waste of costs.

[Paul Burstow]

rose—

[Valerie Vaz]

What is so extraordinary is that the Secretary of State does not want to be the Secretary of State; he wants to let the Future Forum consult and listen to people, but that is not how decisions are made in government. In government people hear the evidence from all sides—[Interruption.] I have made it pretty clear: the Minister has had his time, but I am a Back Bencher and I do not get much time to speak.

People in government hear the evidence from all sides and weigh things up. Then they make a decision reasonably and give their reasons. The Secretary of State is hiding not only behind the Future Forum but behind the NHS commissioning board. He is like Macavity the mystery cat:

“At whatever time the deed took place—MACAVITY WASN’T THERE!”

I would like to draw hon. Members’ attention to a paper dated 29 August 2011 by Dr Lucy Reynolds, Dr John Lister, Dr Alex Scott-Samuel and Professor Martin McKee, “Liberating the NHS: source and destination of the Lansley reform”, which I will place in the Library. It draws a link between a paper written in 1988 by the right hon. Member for Wokingham (Mr Redwood) and the Minister of State, Cabinet Office, the right hon. Member for West Dorset (Mr Letwin). It is therefore no surprise that when the Minister of State, Cabinet Office was called in to look at the proposals he endorsed them, because they were his. Paragraph 3 of the paper is entitled “Implementation of the Redwood/Letwin Plan in the Lansley reform”. The paper was sent to me by a young academic who said that his life had been saved twice by the NHS but would not have been saved under an American-style privatised health system.

The most recent satisfaction survey by Ipsos MORI last March showed 72% public satisfaction with the NHS, but it was not published by the Department of Health even though the Department had asked for it to be done. Members will have seen a report from Colin Pritchard and Mark Wallace which said:

“In cost-effective terms, i.e. economic input versus clinical output”,

the UK health service was “the most cost-effective” in reducing mortality rates, compared with the US health care system.

Finally, I say to hon. Members—including the hon. Member for Hexham—as they think about what has been said, “Stand up for democracy, stand up for the trust between elected representatives and their constituents, and stand up for the NHS: vote against this Bill.”

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[Joan Walley]

My hon. Friend is right. Constituents go to Members of Parliament as a last resort to try to ensure fairness in how the system deals with everything. I have just had a high-profile case in my constituency relating to the postcode lottery, which my hon. Friend the Member for Pontypridd (Owen Smith) referred to.

[Paul Burstow]

The hon. Lady is making some important points and is trying to respond to that raised by the hon. Member for West Ham (Lyn Brown). Interestingly, the hon. Member for Leicester West (Liz Kendall) earlier recounted all her concerns about the PCT and how it has dealt with GP services in her area. The anxiety seemed to be that the PCTs were not accountable, but the hon. Member for Stoke-on-Trent North (Joan Walley) now seems to be saying that they are.

[Joan Walley]

We have just had an awfully long debate about precisely that issue. Many of us would say that the PCTs were not operating accountably, but Members of Parliament could have influence and bring pressure to bear. The last resort is through the Secretary of State, and it is important that that should be retained in the Bill.

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[Andrew George]

It is a great pleasure to follow the hon. Member for Stoke-on-Trent North (Joan Walley), who addressed the issue of political accountability in a considered way. I shall return to that and relate it to a number of amendments in my name and those of some of my hon. Friends. I shall refer to a number of amendments that the Minister of State, my hon. Friend the Member for Sutton and Cheam (Paul Burstow) covered in his opening remarks and dealt with in a fair and balanced manner, although not entirely to my satisfaction in every case. I shall also raise further questions.

I have enormous respect for all that my hon. Friend has done. His contribution to the debate on social care is second to none. That expertise is especially beneficial to the Government at present and some important advances have been made, for which we are all grateful. I acknowledge that he approaches all aspects of his work with the best of intentions, and I do not question those. The amendments that I have tabled indicate that I believe we may need to reconsider some of these issues. I should also mention at this stage that I may seek to push one or two of them to a vote.

On Second Reading, I made a speech that was critical of the Bill and refused to support the Government by abstaining at that stage, and of course the Bill has gone through a number of significant changes since then and concessions have been made. I have been criticised by some for making that speech and refusing to support the Government, but I feel vindicated as a result of the pause and the listening exercise. I might be criticised and accused of disloyalty, but that is how Back Benchers exercise our role of holding the Government to account. It is reasonable for us to use our powers to bring forward amendments and, in so doing, probe the Government and ask them to be accountable for the policies that they are bringing forward. I hope that in the weeks and months ahead, I will be vindicated for having done so, but I do not necessarily expect that acknowledgment to be provided now.

I was relatively content with the original coalition agreement. I am no great defender of primary care trusts, but I think that using the existing institutional infrastructure, grafting in accountability to the patients and communities that the commissioning bodies will serve and ensuring clinician involvement in those commissioning decisions, would strike entirely the right balance. That would provide a way of going forward without scuppering, dismantling or exploding the whole system in the way the Bill is doing.

There was no mention in the coalition agreement of changing the duties of the Secretary of State, and I have read a number of legal opinions on that issue. I also believe, as I have indicated in several interventions so far, that some of us have been misled on that point. Some of the legal advice that I have been given by colleagues suggests that the Secretary of State in fact never had a duty to provide in the 1946 Act. That is fundamentally wrong. Perhaps I will discuss this with the Minister after the debate and show him the documents that I have been given and some of the comments that have been made. As some of my colleagues who were there at the time and heard the advice will know—[Interruption.] I hasten to add that they were not there in 1946—I know that I have aged in my time in Parliament, but I cannot recollect that time. My colleagues know that we have been briefed that there was never any duty to provide in the 1946 Act, but there is evidence—I do not need to give the quote a third time—that there was clearly a requirement in the 1946 Act to provide and secure effective provision. That requirement has always been there in successive health Acts in this country. I want to relate that to a point the hon. Member for Pontypridd (Owen Smith) made in a more tribal manner.

[Paul Burstow]

May I just make it clear that I do not think that I or any other Minister at any point, either at the Dispatch Box or in other discussions, ever suggested that the 1946 Act or any subsequent Act did not have the duty to provide? What we have said is that the duty to provide has progressively, particularly over the past 20 to 30 years, become a duty that is not exercised. It has been delegated and is increasingly exercised instead by separate bodies, such as NHS trusts and foundation trusts, using their own independent power to provide services.

[Andrew George]

Yes, and my new clause 16 proposes to address that issue through an opportunity for the Secretary of State to intervene as necessary.

The Secretary of State in his intervention on the hon. Member for Pontypridd made it clear that in any case Secretaries of State tend not to micro-manage by intervening or by providing on every whip and flip, and there is no suggestion of that, but as a backstop we require the guarantee that, if all else fails and the whole system does not provide what we believe needs to be put in place to provide for a comprehensive health service, the Secretary of State will be there. There would be no harm in putting that word back in the Bill in one form or another. I do not understand the obstinacy, and in my view there is no legal impediment to the Government doing so.

--- Later in debate ---

Rather than just asserting the opposite, will the Minister publish the legal advice that appears to contradict the advice that has been obtained? That states that the “hands off” clause is a real barrier to the Secretary of State’s intervention—as, after all, it is designed to be. Members could read the two bits of advice and see which was more convincing. Better still, will the Minister amend the Bill to put the matter beyond doubt?

[Paul Burstow]

I draw my hon. Friend’s attention to the Department of Health’s website. Yesterday we published a detailed response to both 38 Degrees opinions. It obviously draws on the legal advice given to Ministers and provides a full exposition of why we believe the points that I set out in my opening remarks.

[Andrew George]

I am grateful to my hon. Friend for that. During his remarks, he said that he believed that there was a risk that the Secretary of State might be drawn into micro-managing; that was one of his primary arguments. All I can say is that if there were a risk of the Secretary of State micro-managing, the Secretary of State could decide to do or not to do it. Simply removing the power comes back to my point about at least making sure that the Secretary of State has the ability to direct where appropriate. If the Secretary of State had that duty to provide, it would follow that he must have the powers to intervene as I have described.

[Paul Burstow]

My hon. Friend is making some important points, which give me the chance to underscore the important points that I have made. The Bill retains for the Secretary of State the capacity to intervene and exercise the functions of all the bodies established by it, and—in extremis, as a last resort—to make sure that services are provided. It is clear that that capacity has remained, not least in regard to the Secretary of State’s ability to establish special health authorities.

My hon. Friend is asking for back-stops, and back-stops have to be real and have effect. That is why we put them into the Bill as we have, so that the Secretary of State does have, in extremis—in the circumstances that concern my hon. Friend and others—the ability to take the steps necessary to secure and ensure that services are provided to ensure a comprehensive health service.

[Madam Deputy Speaker (Dawn Primarolo)]

Order. May I gently remind the Minister of two things? First, he has to address the whole House. Secondly, it is not a private conversation between him and his hon. Friend, and his interventions are supposed to be brief. A lot of people are waiting to speak.

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[Martin Horwood]

I am extremely grateful to you for calling me, Madam Deputy Speaker, as you have a tough job this afternoon. I have to declare an interest. I rarely speak in the House on NHS organisation, particularly public health, because my wife is employed as a director of public health. Obviously, the Bill and the public health section of clause 27 will affect her significantly, and by extension those of us in her family, but I make it clear to the House that although my knowledge of her role and profession has informed amendments 1255 to 1260, which stand in my name, she had no knowledge of them or their contents before I tabled them. However, I am grateful to the Faculty of Public Health and others who have given me advice.

Public health is pretty poorly understood, not least in this Chamber at times. There is a constant tendency to confuse it with the traditional, established local authority function of environmental health, and although I have great respect for the hon. Member for Stoke-on-Trent North (Joan Walley) in many respects, I think the risk of her new clause 23 is that it extends that confusion between environmental health and public health. There are many key functions to public health, not just the vital five-a-day style health promotion and health improvement work, but a critical role in health protection, including the management of outbreaks of communicable diseases—serious diseases such as meningitis and influenza—and a key role in influencing, at the moment, NHS commissioning at local level, using population-wide data and medical analysis. That, at the moment, happens very simply and straightforwardly within the primary care trust. Under the Bill at the moment, there is no role for the director of public health within the new clinical commissioning groups, and they have to exercise that kind of influence at several removes. That point was well made by the hon. Member for Plymouth, Moor View (Alison Seabeck).

It was suggested to me at one stage by some civil servants working on the Bill that in order to make up for the gap left by the director of public health in the new clinical commissioning groups—then called consortia—they might actually want to employ someone with public health expertise to make up for the reorganisation. That does not seem to me a very good use of public money.

Some of the things that Ministers have announced are to be welcomed. I will have to skip over them briefly, but principal among them is the very good decision to make Public Health England a separate Executive agency and not part of the Department of Health. That was a key request of the faculty, and I think it is very important that it retain that status and objectivity.

I pay tribute to the Minister of State, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), for taking a great deal of time and care over the concerns that I had in this whole area, but questions remain to be addressed and my six amendments are an attempt to address three main areas.

The first area is, as the hon. Member for Plymouth, Moor View pointed out, that under this scheme directors of public health will be removed from the NHS, as will their staff. One of my amendments suggests, therefore, that they should continue to be employed by Public Health England and retain that integration within a wider public health profession. At the moment directors of public health sit within primary care trusts and it is reasonably straightforward, but within the spaghetti-like structures created by the Bill, public health responsibilities and leadership are now to be split among Public Health England, the Secretary of State, the local authorities, the national commissioning board, the health and wellbeing boards and clinical commissioning groups. The threat is not just confusion and the unclear fragmentation of public health functions, but the fragmentation of the profession itself and of the career paths, whereby people might move from one bit to another and have to leave and rejoin the NHS, and so on. That is one of the issues addressed.

The second issue is that people should be suitably qualified. The responsibility for their professional qualification and professional development should lie in the hands of Public Health England, not local authority managers, who might have no medical or professional public health training. It is an important function, so they should be senior officers. Several members of the Health Committee, including its Chair, made the important point that they should report directly to the chief executive. It has been suggested in some parts of the country that the post of director of public health could be combined with or report to other directorates in the principal local authority—for instance, the director of housing.

I wrote to the Deputy Prime Minister on the issues, and he replied:

“given the importance of these new local authority public health functions, the leadership position of the DPH in the local community and the critical health protection functions to be carried out by the DPH on behalf of the local authority, we would expect the DPH to be of chief officer status”.

I do not think that an expectation is strong enough. I have great regard for many directors of housing, but if my child had meningitis, I would not want the director of housing to be on the other end of the phone line at a critical moment.

As it is still possible for the Government to address these issues through the consultation exercise on public health that is being planned, I will not press my amendments to a vote today, but I was rather disappointed with the Minister’s response to them. Should any noble Friends be listening from the Gallery, I hope they might take up the theme of public health in another place. Public health is poorly understood and has not grabbed the headlines in the way that the 38 Degrees campaign has, but over recent years it has been quietly becoming a more and more successful, professional and increasingly medically qualified discipline in the NHS. It saves lives, and we should protect it.

[Paul Burstow]

We have had a full and wide-ranging debate on the many issues covered by this group of amendments. I want to try to pick up a few of the key questions that have been asked. The Bill will increase the Secretary of State’s accountability for a comprehensive health service.

[Mr William Cash (Stone) (Con)]

Will the Minister give way?

[Paul Burstow]

No, not at all.

The Bill will provide all the powers and duties necessary: the duty to keep the health service’s functions under review, a duty to report annually on the health service’s performance and a duty to consult on the board’s mandate and to lay it before Parliament and to lay regulations about how commissioners carry out their functions. All those things are new. They are more than backstops; they are guarantees of a comprehensive health service being secured and the Secretary of State maintaining his accountability to the House and Members of Parliament for that purpose.

I have already made it clear to those who are concerned about clause 4 and the possibility, which we do not accept, that it will lead to a hands-off approach that we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put it beyond doubt that the Secretary of State remains responsible and accountable for a comprehensive health service, which we all want to see.

There has been talk about a postcode lottery. Indeed, the Bill sets out, through the work of the NHS commissioning board, to ensure that the postcode lottery that we inherited from the last Government is something that we can make a thing of the past, as a consequence of the changes that the Bill will introduce.

The hon. Member for Stoke-on-Trent North (Joan Walley) made some important points about environmental health officers and the contribution they make locally and nationally. Although we see the chief medical officer having a key role in providing such advice, I would be happy for us to carry on discussions about how we can further strengthen that role nationally.

As the consultations on the issues raised today by my hon. Friend the Member for Cheltenham (Martin Horwood) carry on, I am certainly happy to discuss with him how we can address those concerns. I can assure him that, because the Secretary of State will be directly involved in the appointment process for directors of public health through Public Health England’s role, they will be able to assure themselves that they are adequately qualified.

[Mr Cash]

Will the Minister give way?

[Paul Burstow]

No.

The Bill has been changed because the Government have been listening carefully. We have acted on the NHS Future Forum’s recommendations.

Our goals are clear in this Bill: they are to place patients at its heart, ensure that the service is clinically led and ensure that it is focused on driving up quality and outcomes.

Question put and agreed to.

New clause 1 accordingly read a Second time, and added to the Bill.

Health and Social Care (Re-committed) Bill

Paul Burstow Excerpts

Tuesday 6th September 2011 Commons Chamber

[The Minister of State, Department of Health (Paul Burstow)]

I beg to move, That the clause be read a Second time.

[Madam Deputy Speaker (Dawn Primarolo)]

With this it will be convenient to discuss the following:

Government new clause 4—Orders under section [Duration of transitional period] that apply to only some trusts.

Government new clause 5—Repeal of sections [Duration of transitional period] and [Orders under section [Duration of transitional period] that apply to only some trusts].

Government amendments 88, 89 and 108 to 112.

Amendment 17, in clause 117, page 122, line 3, leave out subsection (12).

Government amendments 282 and 285.

[Paul Burstow]

These Government amendments will make important changes to extend Monitor’s intervention powers over all foundation trusts until 2016. This would give additional time for foundation trusts’ governors to build the capability that they need to be able to hold their boards to account.

As my right hon. Friend the Secretary of State has described, through part 3 of the Bill, Monitor as the sector regulator would have permanent intervention powers over all providers, including foundation trusts. These will allow it to fulfil its duty to protect and promote the patient’s interest and its functions include supporting commissioners in securing continuity of services. That is why we believe that Opposition amendment 17 is not only ineffective, based as it is on non-existent terms of authorisation, but also redundant.

My right hon. Friend the Secretary of State has already confirmed that we agree that it is essential that Monitor, as health sector regulator, can take action to secure patients’ continued access to NHS services, and our plans ensure this. Monitor would have powers under its licensing regime to require a provider to take specific actions if it gets into difficulties. These will be effective safeguards to protect patients’ and taxpayers’ interests, and will support commissioners in securing continued access to services that patients depend on for their care. I hope, therefore, that the hon. Members who tabled the amendment will not press it.

However, the NHS Future Forum raised concerns about the current readiness of foundation trust governors to take on the strengthened role that the Bill provides for them in holding foundation trusts to account as autonomous NHS providers. In response, the Government have agreed that Monitor’s intervention powers should apply to all foundation trusts until 2016, to allow time for their governance arrangements to become fully effective. The amendments provide for the transitional powers to continue until 2016. They also make corresponding amendments to clause 117 on licence conditions supporting use of the powers, and remove clause 116, about identifying which foundation trusts would be subject to the powers.

The amendments do not change the nature of the transitional intervention powers set out in clause 117. Monitor will continue to have the power to remove or suspend members of the board of directors or members of the council of governors. Monitor would also be able to direct a foundation trust to do or not to do specific things within a specified timetable. These powers are similar to those currently available to Monitor in its role as foundation trust regulator, and would allow Monitor to continue to protect the taxpayers’ interest in foundation trusts.

The powers go beyond those that Monitor would have over all providers, under part 3, as sector regulator. They will help to ensure a smooth transition from the current arrangements for NHS foundation trusts. The amendments would allow the Secretary of State to seek further parliamentary agreement to extend the powers beyond 2016 for all or some foundation trusts for up to two years at a time. That power could be used, for example, if there was a significant remaining concern about the governance of some foundation trusts.

If it were decided to extend the powers for some, but not all, foundation trusts, Monitor would be required to go through a process similar to that originally envisaged in clause 116. It would have to publish the criteria that it would use to decide which foundation trusts would remain subject to its intervention powers. Those criteria would be subject to consultation and would require approval from the Secretary of State. The amendments will ensure that the transitional regime proposed in the Bill provides a more secure safety net while foundation trust governors develop the skills and capabilities necessary to hold their boards to account.

The amendments would enable Monitor to rectify avoidable difficulties at a foundation trust while foundation trust governance arrangements developed, ahead of normal regulatory intervention through the licensing regime. They also provide for the extension of the powers, should that prove necessary. I commend them to the House.

[Owen Smith]

I do not intend to take long, because we must get on to the important next group of new clauses and amendments, which is on the private patient cap; there will be huge interest in that outside this place, and there is far too little time to discuss it. I shall say right at the outset that we will not press amendment 17, because we accept that, as the Minister said, it is effectively made redundant by other amendments that have been tabled.

In some respects, the amendments in the group before us tell the story of the Bill in microcosm. Throughout the progress of the Bill, the Government have responded in two ways. One has been to bolt endless obfuscation and compromise on to the Bill to obscure its true intentions. There was clarity at the outset, in the Bill’s first iteration; it clearly aimed to break up a publicly owned, collaborative NHS and replace it with a competitive, market-driven NHS. The Government have sought to obscure that throughout the Bill’s progress, and have done so relatively effectively. Certainly, more gullible Government Members, perhaps even including the Deputy Prime Minister, have bought into the double-speak about this now being a question of preventing anti-competition, as opposed to promoting competition, but we Labour Members still do not buy that.

Nor do we buy the idea that the other amendments that we have considered today add clarity. In truth, they add to the confusion—the chaos, indeed—that will follow the implementation of the Bill. As the Minister has outlined, the clauses that we are considering effectively extend Monitor’s existing compliance and regulatory roles over foundation trusts to all FTs through to 2016. That is what the Future Forum recommended to Ministers, but they did not do that last time, although they did get rid of the arbitrary 2014 deadline that they had introduced. They are now going a step further and extending Monitor’s compliance functions. That might not be such a bad thing, and perhaps many people will agree with the idea; certainly the Future Forum will. The trouble with it, of course, is that it extends the critical conflict of interest that is at the heart of Monitor’s role.

There is a conflict between what is clearly Monitor’s principal function—as an economic regulator, designed to prevent anti-competitive behaviour and facilitate the exit of providers, such as hospitals, from the marketplace—and its compliance role, which is ostensibly about allowing FTs to flourish, and making sure that they do not fail. How will the Government deal with that apparent contradiction? To use their own words as set out in the original explanatory notes, how will they

“mitigate and manage potential conflicts of interest”

between the transitional functions and Monitor’s new functions? Well, rest easy, because the Government have made a very simple suggestion as to how Monitor should square that circle, which I am sure all Members will find satisfactory, as I do. Clause 62(3), subtly amended by Government amendment 89, explains that Monitor must simply

“ignore the functions it has under section…117 when exercising…its functions”

relating to competition, price-setting, or the licensing of NHS services.

So there we go: in Monitor there are to be Chinese walls, as Ministers colourfully put it in Committee. Monitor retains its role in trying to keep FTs from failing, but it also takes on a role in exiting them from the market and helping other providers—Bupa, perhaps, or Helios, which we know are sniffing around the Department of Health right now—to step into the breach. Chinese walls, competition and confusion: those are the key words for this botched Bill.

Question put and agreed to.

New clause 3 accordingly read a Second time, and added to the Bill.

New Clause 4

Orders under section [Duration of transitional period] that apply to only some trusts

‘(1) Where the Secretary of State proposes to make an order under section [Duration of transitional period] in reliance on subsection (2)(b) of that section (“a section [Duration of transitional period](2)(b) order”), the Secretary of State must notify Monitor.

(2) Monitor, having received a notification under subsection (1), must set the criteria that are to be applied for the purpose of determining to which NHS foundation trusts the order should apply.

(3) Before setting criteria under subsection (2), Monitor must—

(a) consult the Care Quality Commission and such other persons as Monitor considers appropriate, and

(b) obtain the approval of the Secretary of State.

(4) If the Secretary of State approves the proposed criteria, Monitor must—

(a) publish the criteria,

(b) determine, by applying the criteria, to which trusts the order should apply,

(c) notify the Secretary of State of its determination, and

(d) publish a list of the trusts concerned.

(5) If the Secretary of State does not approve the proposed criteria, Monitor must propose revised criteria; and subsections (3)(b) and (4) apply in relation to the proposed revised criteria as they apply in relation to the criteria previously proposed.

(6) If, having received a notification under subsection (1), Monitor proposes to set criteria the same as those it set on the last occasion it received a notification under that subsection, it need not comply with subsection (3)(a).

(7) A section [Duration of transitional period](2)(b) order—

(a) must apply to all the trusts that are determined under subsection (4)(b) as being the trusts to which the order should apply (and to no others);

(b) may specify the trusts to which it applies by reference to their inclusion in the list published under subsection (4)(d).

(8) Subsection (9) applies where —

(a) a section [Duration of transitional period](2)(b) order is in force at a time when there is in existence an NHS foundation trust authorised after 1 April 2014, and

(b) the initial two-year period in relation to that trust has yet to come to an end.

(9) Monitor must—

(a) determine, by applying the criteria it applied under subsection (4)(b), whether section 117 should continue to have effect in relation to the trust after the end of the initial two-year period,

(b) notify the Secretary of State of its determination, and

(c) publish its determination.

(10) If Monitor determines under subsection (9)(a) that section117 should so continue to have effect, the trust is to be treated as if it had been authorised on or before 1 April 2014 and as if the order referred to in subsection (7)(a) applied to it; and section [Duration of transitional period] (5) is accordingly to apply in relation to the trust.

(11) If Monitor determines under subsection (9)(a) that section 117 should not so continue to have effect, section 117 ceases to have effect in relation to the trust immediately after the end of the initial two-year period.’.—(Paul Burstow.)

Brought up, read the First and Second time, and added to the Bill.

New Clause 5

Repeal of sections [Duration of transitional period] and [Orders under section [Duration of transitional period] that apply to only some trusts]

‘(1) Sections [Duration of transitional period] and [Orders under section [Duration of transitional period] that apply to only some trusts] are repealed immediately after section 117 is repealed; and in consequence of that—

(a) in section 62(2)(a), omit “or under sections 117 and [Orders under section [Duration of transitional period] that apply to only some trusts] of this Act (imposition of licence conditions on NHS foundation trusts during transitional period)”,

(b) omit section62(3),

(c) in section 94(4), after paragraph (a) insert “and”,

(d) in section 94(4), omit paragraph (c) and the preceding “and”, and

(e) omit section 302(5)(e) and (8A).

(2) This section is repealed immediately after sections [Duration of transitional period] and [Orders under section [Duration of transitional period] that apply to only some trusts] are repealed.’.—(Paul Burstow.)

Brought up, read the First and Second time, and added to the Bill.

New Clause 19

NHS Foundations Trusts: phasing out of provision of private health care

‘The Secretary of State must make regulations which provide for NHS Foundation Trusts to be prevented from providing services other than those of the health service in England within three years of Royal Assent of this Act.’.—(Andrew George.)

Brought up, and read the First time.

Care (Older People)

Paul Burstow Excerpts

Tuesday 6th September 2011 Westminster Hall

[The Minister of State, Department of Health (Paul Burstow)]

It is a pleasure to serve under your chairmanship, Mrs Main. I congratulate my hon. Friend the Member for Chatham and Aylesford (Tracey Crouch) on securing the debate. The speeches and interventions have demonstrated why we need Back Benchers such as my hon. Friend to raise such subjects, which Parliament has not debated enough over the past 10 or 15 years. That may be one reason why, as several hon. Members have said, social care has historically been the poor relation of the NHS and inadequately funded relative to the NHS.

We should not delude ourselves that many of the problems and pressures that have been amply and passionately described in our debate have emerged in the last 12 months. Indeed, if one takes a run through Hansard reports of the past 30 or 40 years, one sees that they have been raised previously. I do not say that to excuse the obligation that rests with the present Government to address the issues, but I ask hon. Members to bear in mind the fact that we should come to the debate with humility and recognition that past responsibilities were perhaps not fully met.

Attention was drawn to the fact that by 2033 almost a quarter of the population will be over 65. Indeed, some parts of the country have already reached that proportion—my hon. Friend the Member for Newton Abbot (Anne Marie Morris) referred to the situation in Devon. I agree entirely with the point made by my hon. Friend the Member for Dartford (Gareth Johnson) that all too often in these debates we use the language of time bombs and consternation instead of celebrating not just the successes of our health and social care system in supporting vulnerable and frail people, but the contribution that, in turn, older people make in our society, often to their fellow citizens. We should do more of that and I want to make sure that we do.

It is worth saying that if the NHS and social care are to cope, some systems and processes need to change; I will say more about that shortly, but it is also necessary for older people themselves and their families and carers to call the shots about the decisions that affect their lives, so that the system can provide the care that people want, need and feel comfortable with. The whole agenda of personalising services so that people have the resources to be able to make choices and to be in control of those services is important, and the Government are determined to turn that ambition into reality.

Let me say something about the coalition’s commitment to see health and social care provided in ways that achieve better outcomes and deliver more personalised services. A thread running through the comments from hon. Members during the debate is the role of integration, which is a key element in realising better outcomes and better quality in the system. Integration is about care services working together in the interests of people and the local populations they serve, and about learning from one another’s experience and ending up with care and support that is of higher quality, safer, and more comforting than ever before.

We also need a sea change in the nature of the working relationships at local level, so that closer working relationships between local authorities and the NHS become the norm rather than the exception. That is one reason why we have made extra funding available. We can debate and will continue to debate in the House whether that funding is adequate, and I have no illusions about the challenges facing local authorities, but the Government have done much to ensure that local authorities have the resources to address them.

NHS funding that goes directly to local authorities for measures that support social care and benefit health will rise to £1 billion per year by 2014-2015. It is the first time that any Government have made such a significant transfer of resources. This year, £650 million has been allocated to PCTs and transferred to local authorities to invest in social care services. That will benefit health and have an overall impact on well-being. I am under no illusions about the interdependencies between health and social care services to which many hon. Members have alluded during the debate. One must look at both parts of the system to understand and mitigate the impact.

I look forward, as ever, to the next chapter of the report on social care by the hon. Member for Islington South and Finsbury (Emily Thornberry). From what I see, however, and from discussions I have had, I know that the picture is far from clear; it is mixed and different authorities are adopting different approaches to the challenges they face in meeting the Government’s deficit reduction targets. Some local authorities are being smart in the ways they confront those challenges and are looking at using telecare and telemedicine, investing in relevant services, and redirecting resources into earlier interventions that can make a big difference up stream. Other authorities—the ones we tend to hear about in debates such as this—are adopting more of a slash and burn approach and tightening eligibility without thinking through the consequences of such decisions and the impact on services. We need to challenge such actions not only in the Chamber but in our constituencies as constituency MPs. These pressures on the system are not new and we have seen such features for many years. Indeed, the vast majority of local authorities already used substantial need as a basis for eligibility and access to services before this Government came into office.

The £650 million that is being transferred to local authorities from the NHS is on top of the £530 million from the Department for Communities and Local Government that will go directly to social service departments.

[Emily Thornberry]

rose—

[Paul Burstow]

If the hon. Lady will forgive me, I want to ensure that I answer two or three of the key points raised by my hon. Friend the Member for Chatham and Aylesford. One key issue concerned the role of a Minister for older people. I certainly share my hon. Friend’s view that we must ensure cross-governmental dialogue and gain a much clearer understanding of the interdependencies between different policies and actions across the Government as they affect older people. The Government are not currently minded to appoint a Minister with specific responsibility for older people, but my hon. Friend has made a number of suggestions that could be a way to look at the issue. I undertake to take the point away and discuss with colleagues how we might join up services in a better way. A number of colleagues across Government have various responsibilities and we must find ways to ensure a clear articulation of the Government’s approach to ageing and an ageing society. We must ensure that that happens not only nationally but locally.

It would be remiss of me not to pick up on the comments about Southern Cross. I did not quite catch the second question, so the hon. Member for Islington South and Finsbury may wish to remind me of it so that I can answer. She asked about landlords, and the answer is that work to ensure that the transfers could take place required that measure to be concluded. As I understand, all landlords involved have now been identified, but if I am misinformed I will write to the hon. Lady and give her the details.

The hon. Lady also asked about home closures. In the past, I have said that when Southern Cross first made its proposals for restructuring the organisation, it suggested that the medium-term future—the next three or four years—would involve a limited closure programme. It did not specify a number and has not done so since. In some ways that programme is no longer the programme being followed; Southern Cross is effectively managing its own demise and passing homes on to new operators, which will have to make judgments about the economic efficiency of those businesses and the welfare of the people living in the homes, and decide whether they can carry on. We must have good advice and support to manage any closures that take place, which is why I have said on a number of occasions that I welcome the work done by the Association of Directors of Adult Social Services.

The hon. Member for Dartford raised an important point about tenure to which we must give serious consideration. I do not want to make a policy announcement about that today because the issue is complicated. We do, however, need to look at how we can give people a greater sense of confidence in the place they consider their home, and ensure that in the future they cannot be lightly tipped out to find a new care home. I will write to the hon. Member for Islington South and Finsbury about the second question to ensure that she gets an answer.

I appreciate the warm words of support—broadly speaking—that have come from all parties about the Dilnot inquiry and the appetite to get on with action. I will ensure that that appetite is well understood across Government. We are clear that the report submitted by Dilnot in July makes an excellent contribution to providing a framework or scaffold around which we can take forward a wider reform of social care for the future. We will soon set out a further process of consultation not only about the details of implementing the Dilnot inquiry—he sets out a number of parameters in his report that are up for further discussion, not least the one mentioned earlier in an intervention—but about the wider issues of quality in social care that were referred to by the hon. Members for Wirral South (Alison McGovern) and for Newton Abbot. We will approach all those issues in a combined way that will lead to a White Paper next April—that answers the question raised by the hon. Member for Chatham and Aylesford.

It is above my pay grade to announce what is in the Queen’s Speech; that has to be someone else’s job—probably Her Majesty, when she sets it out in detail, and the Prime Minister and the Cabinet who make those decisions. The Government remain committed to legislating at the earliest opportunity to bring in the Law Commission’s reforms and address the question of funding reform. I hope that answers the points of concern that have been raised.

The hon. Member for Chatham and Aylesford also mentioned housing, and she was right to talk about choice. That underscores the need for a cross-departmental approach to ageing and an ageing society, and I will raise her comments with my right hon. Friend the Minister for Housing and Local Government. Given his responsibilities for supporting people, it is important that I do that.

Prevention underlies many points that have been raised today and there is much we can do both to prevent admissions into hospital appropriately and to manage hospital discharges better. The increased roll-out and use of personal budgets will play a part in that, and will provide people with more control over the packages and nature of the care they receive.

The contribution made by the voluntary sector and charities has rightly been highlighted in this debate, in particular the role that such organisations can and do play in tackling social isolation. They also provide practical, low-level help—for example, helping to change a light bulb, which sometimes seems to take for ever. We must ensure that communities feel confident to give that help and are given support to provide mutual aid. Through our work on the big society we are determined to see that through. Local councils have an important role in improving health and well-being through commissioning those low-level services, and that has been well described in the debate.

The hon. Member for Newton Abbot expressed some concern about the role of the CQC. Like her, I met representatives from the care sector to discuss their views about what will soon be the first full year of operation for the CQC. The CQC was established in 2009 but has been fully operational only since October last year. Not all of what it does and will do has been explained to care providers as clearly as it should have been, but some of those defects are now being remedied. Just last week I had the opportunity to visit the CQC and see the work it is doing to establish a new, much simpler website. That website will provide a lot more information to providers about how issues of compliance with essential standards are being addressed.