Health and Care Bill (Nineteeth sitting)

Philippa Whitford Excerpts

Committee stage
Wednesday 27th October 2021 Public Bill Committees

[Karin Smyth]

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

At the risk of my career, I am again trying to be helpful to the Government. During the debate, we have come round in a circular way about the lack of accountability in the Bill and the quite astonishing levels of power taken directly by the Secretary of State. Those may be two separate things, but, in terms of the culture that we want to embed in the health system, they are really quite worrying.

The Bill puts into law the organisational changes of the last few years—based on what the NHS, I agree, has been asking for—on a population basis, not on competition or autonomy. Most of us genuinely welcome that: we want to see better population health, people working together, and services rooted in the community; we want to empower local people and guarantee service levels locally. We want to ensure transparency on funding to see if one area is funded more favourably than another. Historically, there have been problems with that and we want to understand that. We want to know why certain services operate in one area and not another.

Opposition Members often talk about a postcode lottery. I do not always agree with that terminology because if the population shows that it needs different levels of services in different parts of the country, then the local NHS needs to reflect that. My own city, Bristol, is a very young city; we have a very small population of over-85s. Further to the south-west, in nearby Torquay and Torbay, that situation is reversed. I would expect to see different population levels of healthcare in Bristol and Torbay.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

When we talk about a postcode lottery—something I have worked against my entire career—it does not really refer to the area of the postcode, but the access of individuals. At the end of the day, 85-year-olds in Bristol should get the same service as 85-year-olds in Torbay, even if there are fewer of them. Everyone should get the mandate of the service both health and social care deliver, even if it is delivered in a different way because of geography or demographics.

[Karin Smyth]

I thank the hon. Lady for her intervention, and I do not disagree. The terms are bandied around and people often do not know what we mean by them, which is why, without going back into the past too much, I was a strong supporter when we were in Government of the national service frameworks and certainly of guaranteeing a level of care and access, as she says.

However, it is the case that different health systems will have different demands on them, and therefore should respond differently. On that basis, my point is that that local difference should be reflected: it should make the system accountable to and understandable by local people, and should involve them in the decisions made on their behalf. That seems self-evident.

We often hear in this Committee about the Minister’s, the shadow Minister’s and my other colleagues’ experiences in local government, but I think people would agree that the experiences of people involved in local government and people involved in the health service are so far apart as to be completely unrecognisable, in terms of the national accountability that the health service seems to have and the local accountability that local government has.

These bodies are deeply troubling. I have called them local cartels, in their form as integrated care boards. They have no accountability to the local people they serve, or nationally through Parliament. We have heard that the chair and chief executive are to be chosen in London according to criteria we know not, with all power vested in the Secretary of State and some promise of further detail in secondary legislation.

However, the logical conclusion of the Bill, and the way out of the problem for the Government, is a system, as we have tried to suggest, of elected chairs akin to the police and crime commissioners or metro Mayors. Elsewhere in the debate, my hon. Friend the Member for Ellesmere Port and Neston and I have highlighted the vast discrepancy in money and powers that exists between police and crime commissioners, or even my local Mayor, and the health service. Health service spending dwarfs both of them.

I will not press the new clause to a Division, because I would like to see it picked up elsewhere in the debate as the Bill progresses through this place, and I would like to leave it as something helpful for the Government to keep considering. If the Government do not want to go down the election route, and we heard the reasons from the Minister, bringing back some form of the Appointments Commission, which disappeared in the coalition’s bonfire of the quangos, would be very helpful. There, we had clear role descriptions and person specifications for people who sit on those bodies, a transparent recruitment and interview process, and performance oversight and accountability. I was subject to that when I was a member of the primary care trust in Bristol North some time ago.

The other vital change is to try to bring in some genuine openness and transparency and some independent oversight of the process of appointment. The new boards and integrated care systems are a radical departure from the past 30 years. Earlier in the Committee, I made us pause momentarily as we saw off section 75, autonomy and competition. This is a big moment, and the new systems will need very highly skilled and experienced people to develop them to their potential, because, as we have heard, it is not clear how they are to be run.

The Government keep talking about permissiveness. The systems will be run by people on the ground, and the sort of people we want in charge must be imbued from the off with the culture that we want to see. The hon. Member for Central Ayrshire talked the other day about the safety board being strangled at birth, and there is a danger that these bodies, some of which have been operating quite well, will not fulfil their potential and will be strangled at birth, because that culture of feeding up accountability just to NHS England and not to local populations will make them not work in the way they should, and certainly will make them not work well with local government.

This huge culture change is a culture change for clinical leaders as well as managers. There are some great opportunities here for population-based health, but we are asking clinical leaders—clinical leadership is already a real problem in these bodies—not to look to their own departments in the first instance and their own institutions in the second, but to look outwith their institutions, working with clinicians across the primary-secondary interface, and at a population-based approach rather than their own specialty-based approach. Again, that is a massive sea change for them. Having the clinical leaders doing that at the board level and giving them the support they need to do that in their specialities requires people who are highly skilled and who will be respected locally for their experience and skills, and for, I would argue, their independence from not being hand-picked by the Secretary of State.

The Government continue to lurch from one cronyism charge to another. A transparent process would help them get over that problem—again, I kindly offer the Government some help through their difficulties. The NHS should be seen as an exemplar for appointments and recruitment. The NHS has a terrible problem with diversity. Yesterday, I chaired a meeting of the all-party parliamentary group on social mobility on the work the civil service is trying to do around improving recruitment, particularly at the higher levels, of people from lower socio-economic backgrounds and black and minority ethnic backgrounds. The NHS has also failed that test over many years, and I believe that a more representative local selection—I would like it to be elected, but it could be selected through an appointments process— would help.

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[The Minister for Health (Edward Argar)]

It is nice to see you back in the Chair, Mr McCabe. I am grateful to the hon. Member for Bristol South. Although we may not fully agree, again I take the new clause in the spirit in which she tabled it. I will reflect on what she said, but I will also set out why I cannot accept what she is proposing. I will always reflect on what she says and proposes; when she proposes things, they are well thought out. We may come to different conclusions, but the points she made are certainly deserving of reflection. I can give her that assurance up front.

As in our oral evidence sessions, I join the hon. Lady and the shadow Minister in paying tribute to those in our amazing NHS and care workforce. It is also important that we recognise, as I think she said during questioning of witnesses, that the complexity of the organisations we are talking about—the complexity of an acute trust, for example—means that strong and effective leadership, both financial and administrative, are hugely important to the overall success of the enterprise of our NHS. I therefore join her in paying tribute to those staff who often find themselves, particularly in media commentary and similar shorthand critiques, on the receiving end of criticism. People may ask, “What are they there for?”. They are hugely valuable—just as much as frontline clinicians, nursing staff and those who work in the canteens or clean the wards. It is a team.

[Dr Whitford]

rose—

[Edward Argar]

I will give way to the hon. Lady, as I am sure she will amplify this point. She has worked in clinical settings and will know that a whole team is needed to make things work.

[Dr Whitford]

I cannot resist the opportunity to amplify that point. Having spent over three decades working in hospitals as a surgeon, I know that it is a team sport that depends on everyone. Sometimes when cuts are made we hear the definition of “frontline” or “back-room” services. If I am in a clinic on my own without the patient records, the patient or the laboratory results, I am a complete waste of space. It is critical to recognise that. To get all the moving parts working well, really good managers are worth their weight in gold. They are part of the team and should be valued as such.

We heard with reference to fit and proper persons that the Kark review did not go far enough and should have suggested suggest registration or licensing of senior managers. Sometimes when the system does not work, we see the same people move out of one place and into another in this kind of revolving door manner.

[Edward Argar]

Although I do not always agree with the hon. Lady, I find myself in complete agreement with her. She made a couple of points that referred back to those made by the hon. Member for Bristol South. The hon. Lady is absolutely right that the system needs high-calibre, high-quality people with the right skills, particularly given what we are seeking to do with integrated care systems. We must foster an environment in which those high skills are valued, continually reinforced and refreshed.

On the point about the Kark review, the hon. Member for Central Ayrshire is right. How should I phrase this delicately? People may move on, or be moved on, from posts because it was not a success for whatever reason; I will phrase it like that. We need to look at the challenge posed by those people suddenly reappearing in another equivalent senior post in a different part of the country. There may be a reason why someone has not been a success that is not due to particular circumstances or something beyond their control, and we need to look at the recycling of those people who have not been found to have hit the mark. We need to look at that carefully.

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[Dr Whitford]

I spent a few years in cancer research while doing my doctorate. Does the Minister recognise that when there is that hand-to-mouth need to get a publication so as to get another grant, researchers are taken away from what we might call blue-sky or imaginative research that may not work out? People end up researching something they virtually already know the answer to, because that way they will get a publication and then get another grant. It is not just about their personal insecurity—it skews the type of research that gets done.

[Chris Skidmore]

Absolutely. I thank the hon. Member for making that point. When I was Science Minister, we recognised the need to look again at some of the processes that underpin research applications for UK Research and Innovation, for instance. We have the bureaucracy review that is currently being chaired by Adam Tickell, current vice-chancellor of the University of Sussex who is moving on to the University of Birmingham. We need to end this cyclical process of time—which is ultimately the greatest commodity that anyone has to offer—being taken away from researchers whose expertise is far better spent focusing on their research in the laboratory or performing clinical trials, and ensure that they can get on with what they do best rather than having to worry about the administrative burden of applying and form-filling every year.

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[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume with you in the Chair, Mr McCabe. I commend the right hon. Member for Kingswood for his new clause and for the persuasive case that he made for it. I will cover much of what he said in my contribution, but I highlight his point about long-term certainty, because I was not going to cover that. Those points were very well made. If we want to embed a culture of research in this country and to be world-leading, as surely we do, we must give our researchers that long-term certainty.

I am going to start with the National Institute for Health Research, which was, of course, established by the previous Labour Government in 2006. We are very proud of that, and since then, in partnership with NICE and other organisations, it has delivered on its mission to improve on the health and wealth of the nation through research. I refer any colleagues who have not had a chance to look at it to the 2016 RAND report, which identifies 100 examples of positive change resulting from the institute’s research. You may be pleased, Mr McCabe, to hear me say that I do not intend to read out all 100, but I do want to highlight the role that it has played since in fighting covid-19 by funding, enabling and delivering lifesaving research throughout the pandemic and now in this current phase. I will not list all the ways in which that has been done, but I will highlight the recovery trial that discovered dexamethasone. That was the first drug to reduce covid-19 mortality in hospitalised patients, cutting deaths by one third, and it was funded and supported by the NIHR. It is a great organisation, which we should be backing and should be very proud of.

On research more generally, there is a shared vision and a shared ambition across this place: the UK should be at the very forefront in science more generally, and particularly in research on health and care. We have all the assets to do that, if we link everything up and invest in it, and to make the UK the destination of choice for clinical research. The new clause offers the Government the chance to put that on a statutory footing, and to make good that commitment, ringfencing funding and mandating the Secretary of State’s support and interest in leadership. As the right hon. Member for Kingswood said, we would expect the Secretary of State to make many things a personal priority. We would argue that this is one of those things.

As in many of our proceedings, we are tidying up on the Health and Social Care Act 2012, and this is a good opportunity to do so again. The Minister smiles; I am always here to offer those opportunities. My hon. Friend and I have been ever so accommodating in that regard. The 2012 Act only included the duty for clinical commissioning groups to promote research. I would direct colleagues to the cross-sector written evidence headed up by the Academy of Medical Sciences, which said that the NHS’s lack of ability

“to prioritise the resourcing and delivery of research has been a major impediment to improving the UK’s clinical research environment over the last decade.”

According to that submission, that has subsequently been a contributing factor to wide-ranging disparities in opportunities for patients to engage in research. When it talks about that, we should listen. As with so many things, we have chance to right that wrong in the 2012 Act and to show in the Bill that we want an active research culture in the NHS, building on the last 18 months.

Evidence shows that a strengthened research mandate would bring many benefits. First, patients treated in research-active NHS organisations have improved outcomes. They have lower mortality rates and higher confidence in the care they receive, which really is a big prize. Secondly, at a time when the NHS is dealing with many work force issues, this increases job satisfaction, with most doctors surveyed by the Royal College of Physicians wanting to be more involved in research and two thirds more likely to apply for a role with dedicated research time. We know it is what our excellent clinicians want too. Thirdly, it brings economic investment into this country; £2.7 billion was generated by NIHR clinical research network-supported activity in 2018-19, making the NHS around £350 million from life science companies. So we win here both coming and going; it is better for our patients, better for clinicians and better for our economy.

There really is a lot in this very good new clause with regard to both the NIHR itself and research more generally. I hope that the Minister will look favourably on the new clause. If he does not, I hope that he will give the Committee comfort on how this will be not just a broad priority for the entire system, where it is not quite clear who is responsible, but something that he as a Minister, and the Secretary of State, will be driving personally and taking as a personal responsibility. As I say, the prizes are very great indeed.

[Dr Whitford]

Although this would obviously apply in England and not Scotland, and the NIHR does not generally fund a lot of clinical research that comes from Scotland, I absolutely support the principle. When I was lead clinician in the west of Scotland, we put trial support staff into all 13 breast cancer units around the west of Scotland. That drove up participation in trials, which, as the hon. Gentleman just said, is what generates confidence among patients and results in better outcomes. Most trials come with a lot of bureaucracy, and people working in very busy clinical jobs in district generals often do not engage because of that. Putting trial staff out in district generals can actually mean that, instead of research being within academic units, it is suddenly available to all patients. That is really important.

Having a questioning mind should be part of being any doctor. All junior doctors are encouraged to develop auditing and clinical ideas as an approach. The hon. Gentleman—I have forgotten the constituency, I am afraid.

[Alex Norris]

Nottingham North.

[Dr Whitford]

I was going to guess some other city and get it wrong, but it is somewhere north. The hon. Member said that having access to research time as a clinician, which the right hon. Member for Kingswood mentioned is a way of retaining staff, is quite important. My local health board now employs younger, as opposed to older, doctors as clinical fellows, and they have a day a week as part of their contract. It is not just one or two doctors; the board are doing it as a standard approach. It has become really popular and has certainly helped with our workforce issues in Ayrshire and on Arran. It is important to see laboratory and trials research and frontline outcome audit and clinical ideas research from all young clinicians, and we should encourage that. The money is great, but we then have to work out how the money feeds into the health service to generate the biggest impact.

[Edward Argar]

I am grateful to my right hon. Friend the Member for Kingswood for bringing this discussion before the Committee today. It behoves me to pay tribute to his work as Science Minister in the past. He is correct to have mentioned that he is the only person to have held that post and my current role one after the other. In fact, I think he sandwiched my current post between two stints as Science Minister, so he knows a lot about the subject and has done a lot of work on it. I pay tribute to him for that.

The amendment seeks to legislate for an additional duty for the Secretary of State with respect to research and to ringfence funding for the National Institute for Health Research—the NIHR. The NIHR is the delivery mechanism through which the Department of Health and Social Care funds high-quality, timely research that benefits the NHS, public health, and social care. I understand and appreciate the intention behind new clause 9. When discussing previous amendments, I alluded to the fact that I can recognise what my right hon. Friend is seeking to achieve. The benefits of research funded through the NIHR have proved invaluable to us during the pandemic, and the great work of the NIHR is addressing much-needed research into better ways to tackle a host of other health and care challenges that we face.

However, referring to the NIHR in primary legislation and proposing ringfencing of the research budget would not be appropriate, as the NIHR is not a legal entity separate from the Department and funding for the NIHR needs to be considered in the round alongside other elements of the Department’s funding—of which it is a component part—all of which are aimed, ultimately, at improving health and wellbeing.

New clause 9 seeks to broaden the wording of the Secretary of State’s duty to promote research, so that it includes the care system in addition to the health service. I recognise that the intention of my right hon. Friend is to ensure that social care is considered a priority area and does not get neglected in the face of demands from health. However, the NIHR already funds both health and social care research. Adult social care is a strategic priority for the NIHR and its research for patient benefit programme has an annual competition specifically for social care proposals.

The amendment seeks to modify the existing duty of the Secretary of State to “promote research”, and to become a duty to

“support the conduct of research”.

It imposes a requirement for the Secretary of State to

“promote the use in the health and care systems of evidence obtained from research”.

We consider that the existing statutory duty has ensured that research has been championed, and that evidence obtained from research has been well and correctly used. The Secretary of State already supports health and care research through funding to the NIHR, and NIHR research evidence is widely used to underpin improvements across the health and care system. Many examples of NIHR impact have been documented in published NIHR annual reports.

For those reasons, I gently encourage my right hon. Friend not to press the new clause to a Division, but I am happy to reflect on the matter further and I suspect that their lordships may well return to this theme in the other place as well.

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[Edward Argar]

I can certainly tell the hon. Gentleman that I think there is a consensus across the Committee, and indeed across both Houses, condemning the reprehensible behaviours and practices that he has highlighted. As he says, the challenge is the mechanism, particularly given the concept of extraterritoriality that applies here, so I will talk about that a little bit. I fear we may have to return to this; I suspect, given the complexities, that it may well be their lordships’ House that grapples with it a little further. Although it is not normally the done thing to recognise those in the Public Gallery, as they are not in the Chamber, were there to be a distinguished Peer in the Public Gallery, I would also pay tribute to their work on this. I hope that just about keeps me in order, Mr McCabe.

New clause 14 seeks to extend the provisions in section 32 of the Human Tissue Act 2004, which prohibit commercial dealings in human material for transplantation. The amendment would make it an offence for someone to travel outside the UK to receive such material without free, informed, and specific consent or in exchange for a financial gain or comparable advantage.

We believe that much, albeit not all, of what the clause seeks to achieve is already covered by different aspects of existing legislation. I will talk first about those travelling from the UK, forcibly or otherwise, and the protections available for them from having their organs harvested, and then I will turn to those travelling from the UK to receive organs.

Provisions in the Modern Slavery Act 2015 make it an offence to arrange or facilitate another person’s travel, including travel outside the UK, for the purposes of their exploitation in any part of the world. Travelling covers the arrival or departure from any country, or within any country, and exploitation includes the supply of organs for reward. The Modern Slavery Act applies to the activities of UK nationals regardless of where the travel or the arrangements for it take place.

A person found guilty of that offence could be liable for life imprisonment, and those guilty of aiding, abetting, counselling or procuring it are liable for up to 10 years’ imprisonment. This means that existing extraterritorial legislation already makes it an offence for a UK citizen to purchase an organ for transplant overseas, provided that the purchase involves arranging or facilitating a person’s travel for the purpose of the removal of their organ for sale.

Furthermore, section 32 of the Human Tissue Act already prohibits the giving of a reward for the supply, or for an offer to supply, any controlled material. If a substantial part of an illicit transaction takes place in England, Wales or Northern Ireland, it will constitute an offence under this provision. It could, for example, be an offence to arrange a purchase and pay for an organ from a UK bank account and, likewise, it could be deemed against the law if somebody were to take steps in the UK to find someone who would sell them an organ overseas.

By adding an explicitly extraterritorial offence, as this amendment seeks to do, the interpretation of the existing provisions could be restricted, thereby potentially weakening our existing tools under those two pieces of legislation. As this amendment would prohibit travel outside the UK to receive an organ without the specific consent of the donor or next of kin, there is a chance that it could also inadvertently make it an offence for someone from the UK to receive an organ in a country with deemed rather than explicit consent provisions. This is at odds with our domestic position, where deemed consent is accepted as an appropriate form of consent for organ donation.

There is also the possibility of an unintended consequence of criminalising the recipient, as opposed to the supplier and buyer, of a trafficked organ. It is not difficult to imagine a case of a vulnerable person receiving a transplant abroad, perhaps through arrangements made by relatives, and having been misled as to the provenance of their organ. Under these circumstances, we believe that those who made the arrangements to purchase and supply the organ should be prosecuted and deemed liable, as they already can be under the Human Tissue Act and the Modern Slavery Act.

[Dr Whitford]

There is a problem with the shortage of organs for transplant generally within the UK. While making it an opt-out system will hopefully help with that, is there not a need to have legislation here so that the market is discouraged or prohibited, and therefore we do not have customers for those organs overseas? If there are customers, the business will exist.

[Edward Argar]

I take the hon. Lady’s point. I will turn to new clause 15 in a moment, but we are as one in our concern to ensure that the current legislation is as effective as possible and that it does what we want it to do. I will make some further remarks on my future thinking when I conclude.

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[Justin Madders]

Many of these procedures are becoming increasingly popular. There is a well-articulated concern that non-medically and medically trained practitioners are performing treatments without being able to evidence appropriate training, or the required standards of oversight and supervision. One need only look on Facebook, for example, to see the proliferation of adverts for all types of treatments. These are usually done by unlicensed individuals who call themselves doctors. We have talked recently about the lack of proper regulation of social media. Although such a debate is not for today and falls outside the scope of the new clause, it is a matter that also needs to be addressed.

Cosmetic treatments can cause serious harm if not carried out correctly, in a safe environment and by competent, trained practitioners. Anything that punctures the skin carries the risk of the transmission of blood-borne viruses. There are countless tragic stories of people who have had life-changing injuries and conditions as a result of poor treatments. The amendment seeks to put the protection of the public at the forefront by giving the Secretary of State power to bring into force a national licensing scheme for cosmetic procedures. It would be a departure from the wild west we face at the moment. We recognise that significant research and engagement with all stakeholders would be needed to develop a scheme that will work well for all cosmetic treatments, as well as providing a practical and efficient system that will be understood and adhered to by members of the public, regulators and practitioners.

Any new scheme would have to have some flexibility in order to capture new cosmetic treatments coming on to the market in future. It would need to be able to set standards for training, qualifications and competency requirements of practitioners, including, we think, periodic checks of premises. Importantly, it would provide for continuous professional development of the practitioner. There would be a requirement for indemnity insurance and access to redress schemes for members of the public to be provided, should complications arise as a result of any aesthetic procedure. There are a number of sad stories about supposedly reputable companies doing damage to their customers, going into liquidation and their insurers then refusing to pay out. I do not think any Member wants to see that happening anymore if we can do something about it.

We would hope that any licensing scheme would have the characteristics that I have set out, and there would be accompanying sanctions for those who contravene it. At present, there is no provision to ensure that prescription-only medicines, such as Botox and anaesthetic creams, adrenaline and hyaluronidase, which are prescribed by regulated prescribers, are actually prescribed in accordance with safe practice. For example, beauty therapists are reliant on registered prescribers prescribing injectables, such as Botox, which they are unable to obtain without a prescription.

Although doctors are required to have a face-to-face individual assessment of each service user prior to prescribing to third parties, such as beauty therapists, a significant body of evidence exists to confirm that individual assessments are not actually taking place in many cases and that telephone prescriptions are being provided remotely. The proposed licensing scheme would provide a requirement for all prescribers to be officially named and to operate in accordance with required practice standards.

Of equal importance is the need for a licensing scheme to close the loophole that currently exists relating to the import of unlicensed injectable products from Korea, such as Botulax. There is a registration scheme in England for certain specialist treatments, such as electrolysis, tattooing, piecing, semi-permanent make-up and acupuncture. However, some of the riskier and newer types of cosmetic treatment cannot be included within the scope of the current regulatory regime. The system also does not allow regulators to specify conditions, qualifications or competency requirements, or to remove anyone from the practitioner register.

Only a small handful of areas across England have introduced their own licensing schemes in order to protect the public—London, Nottingham and Essex are notable examples. There are currently two Professional Standards Authority-approved voluntary registers of accredited practitioners, and one voluntary register of approved education and training providers that operate in the sector. However, joining is not mandatory, which means there are many unaccredited practitioners providing treatments to members of the public without any checks.

The creation of a national licensing scheme in England for practitioners of cosmetic treatments would ensure that all those who practise are competent and safe for members of the public, and it would also cover some of the newer practices not covered by existing licensing laws. There is a large body of support for such a move, including the Chartered Institute of Environmental Health, the Royal Society for Public Health, the Institute of Licensing, the Joint Council for Cosmetic Practitioners, the UK Public Health Network, the Faculty of Public Health and Save Face, as well as about 90% of the public, accordingly to at least one survey.

The Minister is keen on giving the Secretary of State additional powers, but I know that he is also keen on finding savings wherever possible. Were he to support this new clause, there would undoubtedly be a saving to the wider NHS in the long run—for example, through reduced visits to A&E and GPs to correct mistakes made by poorly trained and unregulated practitioners.

Here are some examples of the impact on the NHS of that lack of regulation: outbreaks of infection at skin-piercing premises, resulting in individuals being hospitalised and, in some cases, disfiguration and partial removal of the ear; second and third-degree burns from lasers and sun beds; allergic reactions due to failure to carry out patch tests or medical assessments, which have led to hospitalisations; and blindness in one eye caused by the incorrect administration of dermal fillers. Those are all tragedies for the individuals involved and mistakes that could be avoided. They are a cost to the NHS and to wider society. I believe that a system of licensing would put a stop to a lot of those tragedies.

[Dr Whitford]

I rise to support the new clause. As a surgeon working in general surgery, I know that, as many of these new techniques emerged, the pressure on the NHS became obvious—for example, as a result of local infections and extensive necrosis. Fillers can also migrate. That might seem a minor side effect, but it can create a lot of psychological and mental health distress for the person who went ahead with the procedure and ended up disfigured because the filler was incorrectly administered. Botox has become ubiquitous, but we should remember that it stands for botulinum toxin, which is one of the most dangerous toxins on the planet. It is used in tiny doses, but it can still cause problems if incorrectly administered.

In addition to these aesthetic techniques, which have become extensive because they appear minor and are often delivered by people without significant training—part of their danger is that they are projected to the public as being very simple techniques—we have the issue of more extensive cosmetic surgery, such as breast surgery, abdominal uplifts, liposuction and so on, which involve anaesthetic—often a general anaesthetic—and major intervention. The public think that plastic surgeons and cosmetic surgeons are the same. Although a plastic surgeon, who is a trained and licensed NHS surgeon, may also carry out cosmetic surgery, there are many clinics providing cosmetic surgery that is not carried out by plastic surgeons. Here the side effects and repercussions for a patient can be quite extensive, and indeed they have previously led to loss of life, which in some cases has been well publicised.

If this issue is taken forward, I would like to see a recognition that both these minor aesthetic interventions and cosmetic surgery should be regulated.

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[Justin Madders]

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

This is a probing new clause, and I will not press it to a vote. I am not sure that this is the best legislation for it, but we are trying to make some points about the importance of patient safety. I hope we can all agree that for good care to be central, there need to be enough staff, not just notionally through some measure of the number of posts, but by ensuring that those people are actually in place at the time of giving care. We can have a debate about what level of staffing is enough. For a long time, the issue was left to the good sense of managing clinicians but, of course, that has always been strongly impacted on by the level of budget that could support staff.

Across the world, much attention has been placed on setting out what levels of staff and skill are needed in various settings to achieve the required levels of safety. The debate is not at any fixed point in time, because pathways, models of care, and staffing skills and mixes develop and evolve, but there will always be a correlation between safe staffing and levels of funding. It is a sad fact that our NHS, which should find planning easy as a single national system, has struggled for some time in almost every of aspect of workforce planning. It has shied away from asking questions about safety that come when the available workforce is not matched to the resources. At the end of the day, it is the patients who lose out when we are in that situation.

Much of the discussion on this topic historically has focused on the nursing workforce, which is by far the biggest of the staff groups. The Royal College of Nursing put out guidance pre-covid and during covid and set out where the legal responsibilities lie. It also pointed out recently:

“These are unprecedented times. Nursing staff in almost all settings are facing challenges beyond what were ever expected. Staffing levels are poor in many places, on most shifts and care is being compromised as a result”—

“care is being compromised” can be read to mean unsafe staffing levels.

New clause 17 calls for a duty to be placed on the Secretary of State to ensure that there are in fact safe staffing levels, even if there is not a specific legislative requirement in England. I say in England because in Wales, Labour has led the way with the Nurse Staffing Levels (Wales) Act 2016. In Scotland, the Health and Care (Staffing) (Scotland) Act 2019 became law, although I understand that covid has meant that there has been some delay in its implementation. I also understand that Scotland included social care staff in that remit.

A decade ago, research showed that low levels of nurse staffing are linked to worse patient outcomes and unsafe conditions. Before 2013, decisions to assess and review staffing levels were made locally, with little national guidance. However, the Francis inquiries in 2010 and 2013 identified nurse staffing as a patient safety factor that contributed to the care failings identified at Mid Staffordshire NHS Foundation Trust. They highlighted that decisions about nurse staffing were made without full consideration of the risks to patient safety. Francis said:

“So much of what goes wrong in our hospitals is likely, and indeed it was, in many regards, the case in Stafford, due to there being inadequate numbers of staff, either in terms of numbers or skills”.

In response to that statement and the Francis inquiries, the Department of Health developed four strands of policy that aimed to create safe nurse staffing levels in the NHS. The National Institute for Health and Care Excellence published guidance for safe staffing in all NHS acute hospitals in 2014. It endorsed the safer nursing care tool to help hospitals to plan their staffing. There was a National Quality Board report outlining the principles that NHS trusts were expected to apply in relation to planning staffing, and trusts were required to monitor the differences between planned and achieved nurse staffing levels and to report them through NHS Choices.

A lot of emphasis was placed on the providers of care, and rightly so. They should use their staff effectively and efficiently to keep patients safe. However, there is also a wider responsibility on commissioners—that is where I think we have fallen down—to ensure that providers do what is required, and on system managers and others who allocate the resources, to ensure that they do it in a way that permits safe levels of staffing. Community, maternity and learning disabilities are all nursing specialities where shortages are most acute. Our new clause makes it clear that all settings would have to adhere to the same standards, with no distinctions, because we believe that good and safe care should be for everyone.

In 2013, the National Quality Board set out 10 expectations and a framework within which organisations and staff should make decisions about staffing that put patients first. The document, entitled “Putting people first”, made it clear that safe staffing was both a collective and individual responsibility and central to the delivery of high-quality care that is safe, effective, caring and responsive. In England we have a website full of guidance, and NHS boards are required to take that guidance into account or have regard to it, but there does not appear to be anything similar for social care. Of course, the point I am trying to make, rather unsubtly, is that that is just guidance.

Looking more broadly, the NHS entered its new planning mode from 2015, and we had the emergence of sustainability and transformation partnerships. There was a requirement for them to design local plans to develop, recruit and sustain levels of staff with the right skills, values and behaviour in sufficient numbers, and in the right locations, to ensure the safety of patients. The plans were developed in great haste, but they did not actually go anywhere. Now we are to have more structured ICBs and new plans, but we still do not have a national workforce plan, which means that ICBs cannot plan properly either.

It would be good to know not just the levels of vacancies, but the gap between the staffing needed to maintain safe levels of working and what is actually in place. We touched on this aspect earlier, and we hope the Government respond positively even if they do not accept the new clause. I am sure the Minister will agree that safe staffing levels are better than unsafe levels. We should all agree that it is possible and desirable to enshrine in law guidance from experts on what constitutes safe levels of staffing in various settings and scenarios. We should absolutely be allowed to know when unsafe levels of staffing occur, especially when it becomes an endemic issue due to staff or funding shortages.

As we have mentioned before, we do not want to overburden the Secretary of State, because he already has a number of new powers under the Bill that will keep him busy. We have tried to remove the attempts to give him more work through the power grab, but it would not be for the Secretary of State to do the rotas or phone round for additional staff in the mornings. He just has to ensure that the duty to have staff levels of staffing is fulfilled by those delivering the service. Any wisdom that the Minister can provide on issues around defining, establishing and enforcing safe staffing, and on who carries the systemic responsibilities, will be greatly appreciated.

[Dr Whitford]

There is no question but that the workforce in both health and social care is one of the biggest challenges across all four nations of the UK. As the shadow Minister highlighted, both Scotland and Wales have passed legislation and aspire to having in law what level should be aimed at, which is quite important. Although covid has impacted in terms of staff leaving the service and the demand on the service, Brexit has also had a huge impact, in that there was an almost 90% drop in European nurses coming to the UK within just months of the referendum. The situation has not recovered, and that impacts right across the system and indeed in social care, where European citizens represented a significant part of the workforce.

When I first came to this place, the former Health Secretary, the right hon. Member for South West Surrey (Jeremy Hunt), talked very much about patient safety but claimed that, in essence, doctors were not really available in the NHS outwith nine to five, and that this was causing what were called “weekend deaths”. Having worked long hours for over three decades, I was a bit afraid that my husband would think I was having serial affairs if I was working only nine to five in the hospital, so I refuted that utterly. However, the evidence available at the time was that the only staff ratio that had any provable impact on patient outcome was that of fully trained, registered nurses—not trainees, not associates and not assistants—to patients. Obviously, that ratio changes, based on the dependency of the ward—whether it is an ordinary ward, a high-dependency ward or an intensive care ward. That is what leads to the basic formula in safe staffing legislation, and England does not have it.

Although covid, Brexit and other things have impacted on the ability of Scotland and Wales to achieve what they aspire to, the guidance has been there for years and it has not been achieved, as the shadow Minister said. Having safe staffing ratios in hospitals is critical, but what action should be taken if that safe level of staffing is not there? What work should not be done so that patients with emergencies can be cared for properly? Otherwise, there is pressure on management to get things done where they want to see throughput. Sometimes, staff simply end up between a rock and a hard place, and that drives staff out of the service. Ultimately, coming home after an exhausting shift feeling that they have delivered poor care because they were covering too many patients is demoralising. It undermines the retention of staff and adds to the problem.

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[Chris Skidmore]

Thank you for allowing me to speak to these two new clauses together, Mr McCabe. They are essentially interrelated and were the product of a roundtable that I put together and hosted with Universities UK and the deans of medical colleges in my role as co-chair of the all-party university group. These were the two asks that the universities and medical colleges had for the Bill. I offer these new clauses as part of that consultative approach, so I will not be pushing them to a vote.

Basically, we are at a crux. I raised this question on clause 33 of the Bill, but when it comes to workforce planning and training, we take a siloed approach, focusing on what the Department of Health and Social Care, NHS England and Health Education England set out as their vision, and the funding flows from that. Not included in that vision, although clearly there are consultative opportunities, is a recognised role and responsibility in legislation for healthcare education providers, the universities and the deans of the colleges in providing the clinicians, doctors and nurses of tomorrow. Nor is there recognition that the workforce is changing. While we have the Government’s commitment to the retention of nurses and doctors, that retention can take place only if there is continuous professional development.

When I was a Health Minister, I was very concerned to ensure an uplift in the budget of Health Education England to 3.4% to match that of NHS England. It had always been thought of as the poorer relation; the money would always flow later, and it took a great deal of lobbying from the relevant organisations to make the point that we needed to put that workforce training money aside, particularly for continuous professional development.

New clause 27, in summary, reflects the fact that if we are to have an integrated care system, and if the new White Paper is to look at how to integrate social care with healthcare, we will need to provide huge retraining opportunities for both NHS and social care staff to enable them to work across whatever that new landscape may be. I do not think it is practical to send everyone back to university, or even always to have physical in-work training opportunities, important though those may be. We will clearly need to have digital opportunities, online courses and a whole technological revolution in how we deliver those retraining opportunities.

Those opportunities are out there. If we look at the universities and the role of EdTech, it is important that the health service grips that opportunity with both hands while it has the chance to do so, because it will be coming down the tracks. If we want to implement reform via the integration of services, it will only be as good as the people working in those services, as we all know, and those people will be as good as they can be only if they are given the appropriate opportunities to train and retrain during their career.

The need for new clause 28 has become more pressing as a result of recent developments. It sets out a duty for education placement capacity; I will not go into the detail of the new clause, but effectively it is about place planning and ensuring that the universities and royal colleges are involved with that at the very outset. In the debate on clause 33, I talked about the paradox of our having a cap on places, which is causing a bottleneck in post-18 education—those pupils who are desperate to become doctors or nurses, but who find a cap on their aspiration.

That cap is there, as we know, because medical places are expensive; they cost not £9,250 a year, but more like £70,000 over the course of a medical student’s training lifetime. At the same time, however, we have a cap on places for those 18-year-olds entering the system and then—surprise, surprise—we find we do not have enough doctors and nurses in the system, and we have to start retraining from abroad.

[Dr Whitford]

Obviously, there has been a drive to expand medical student places in universities right across the UK, but one part of the system that is controlled centrally is foundation places, which a medical graduate has to spend their first two years in. This year, for the first time, there was a shortfall of about 400 places. Hopefully all those graduates have now got a foundation doctor place, but they cannot practise outwith a foundation place, which lasts two years, so they simply cannot work as doctors, nor can they work as doctors until they complete that two-year foundation role. There is no point in expanding medical school places if those at the end of the production line get turfed out to be unemployed or go and work as something else. It is not just about university places; there is also the issue of placements as foundation doctors for the first two years of their career.

[Chris Skidmore]

The hon. Member is absolutely right. When it comes to the foundation year, I was interested in looking at what future reform might come in the workforce. We would need to work with the royal colleges and vested interests on a replacement, or at least on what could make the foundation process more flexible so as to allow in-work training on that foundation year pathway. That is a huge opportunity, and, if I was still a Minister, I would be pressing for a White Paper to look at how we could deliver workforce innovation, because I do not think we can continue to sustain our trajectory using infrastructure and systems designed in the early to mid-20th century. There is a balance to strike, in that we need to ensure that the safety of patients is accounted for, but technology and training has moved on to a different space. We do not see this constriction in other countries, which can offer fast-track routes through medical training processes, particularly post degree and into the foundation stage.

The issue of placement has become incredibly pressing—it is actually a real-time issue. During the pandemic, because the grade threshold was lowered and teacher assessment was used, an additional 1,900 students were accepted to take up medical places in September 2021. Whatever we think about that, those students were all given a place because they had achieved the right threshold, but to train them, an additional £60 million is needed. However, the Government have capped the training budget at £30 million, so although students have been accepted on to courses, universities are finding that they must make a loss of £2,460 per student in the academic years 2020-21 and 2021-22, and the Government are not opening their books to change that cap on finances.

The cap is therefore returning from this coming year, and as a result 1,000 fewer students will be trained each year. In effect, we will see a reduction in the number of students coming on board to be trained. There is currently this one-off moment that universities are taking forward, but as a result we will go backwards when we know that we need more doctors. The demographic changes that I spoke about in debate on clause 33 are coming down the tracks, but we will end up just recruiting from abroad. It is not that there is necessarily anything wrong with those qualifications; I would just prefer a sustainable and, in effect, sovereign pathway.

The post-Brexit narrative is that global Britain will ensure that we can stand on our own two feet and have a sustainable skilled workforce. That could be recognised if we had a placement strategy for medical students. However, we can do that only if we involve the universities and the education sector. The problem is that the Department for Education controls the purse strings for that budget, and I do not think that it realises the long-term consequences on our healthcare system.

The new clause would close a loophole that is kneecapping the Minister and the Department of Health by placing artificial caps on aspiration and—worryingly —on the future number of doctors entering the healthcare system. I will not press my new clauses to a vote, but the issue is extremely pressing. We will see 1,000 fewer students enter medical places next year than did so this year; and students going through the system have no funding for their places, despite having been given those places. That is a real-time issue that has resulted from the wider policy issue not being resolved. The new clauses would help resolve it, but I will not push them to a vote.

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[Edward Argar]

I am grateful for the opportunity to address new clauses 27 and 28 together. First, new clause 27 seeks to place a specific duty on the Secretary of State to support the transformation of the health and social care workforce for integrated care systems by working with universities and colleges to train the future workforce through investment in technological and inter-professional innovation.

I take on board the broader points made by my right hon. Friend the Member for Kingswood, but we do not believe that the new clause is necessary, as that work is already covered by section 1F of the NHS Act 2006, which the new clause seeks to amend. Section 1F(1) sets out that the Secretary of State has a duty

“to secure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in…the health service”.

Discharge of the duty under section 1F(1) is largely delegated to Health Education England through section 97 of the Care Act 2014. To meet its statutory duties and to ensure that an effective education and training system is in place, HEE undertakes a variety of work, including with further and higher education providers and regulators. Part of that work includes the curriculums for the healthcare professions. Those curriculums are set by approved education providers at an institutional level. HEE can influence the content by representing the employer voice to ensure that the training that individuals receive is relevant and remains up to date.

As part of that work, HEE is particularly keen to ensure that technological and medical advances are included in teaching, alongside new ways of working. Those measures would support newly qualified professionals to be suitably prepared to launch their careers in the NHS. To support that work and engagement with universities, HEE commissioned the Topol review, published in February 2019—probably in association with my right hon. Friend in one of his previous ministerial roles—on how to prepare the healthcare workforce to deliver the digital future.

That review made recommendations that will enable NHS staff to make the most of innovative technologies such as genomics, digital medicines, artificial intelligence and robotics to improve services. The recommendations support the aims of the NHS long-term plan and the workforce implementation plan, helping to ensure a sustainable NHS. The progress report was published by HEE in 2020 and, as part of the implementation report, HEE has launched a digital readiness programme to continue to lead on developments in preparing the workforce to deliver the digital future.

On inter-professional working, we want a workforce that is less siloed and more flexible and adaptable, and work is ongoing to take that forward in England. For example, at the national level, we are looking at new skill mixes to meet new service models. Those new mixes could include upskilling existing staff, so that more staff are able to do things that have traditionally been limited to a smaller group of professionals—for example, prescribing—or making better use of the wide range of skills and contacts available to reduce duplication.

At ICS level, national guidance on the ICS people function also set out the expectation that the ICB, working with the ICP, will have responsibility for enabling workforce transformation across the health and care system, including through the use of technology and innovation, as well as for work with educational institutions to develop the local future workforce. Nationally, arm’s length bodies will support and enable ICBs to deliver those responsibilities at a local level. I hope that that highlights some of the work being done under the existing statutory duty in section 1F of the 2006 Act.

Secondly, new clause 28 seeks to place three new statutory duties on the Secretary of State. That, in a sense, is at the heart of what my right hon. Friend the Member for Kingswood was getting at. They are: a duty to ensure a sufficient number of clinical placements for the number of students; a duty to ensure innovation—his new clause outlines greater interdisciplinary working, digital technology and simulation as three examples—is supported and funded in the education and training system; and a duty to consult universities and others on clinical placement availability.

We have carefully considered my right hon. Friend’s new clause, but we do not feel that those additional specific statutory duties are necessary, in addition to the existing statutory duty on the Secretary of State in section 1F of the 2006 Act, which my right hon. Friend seeks to amend. Section 1F sets out that the Secretary of State has a duty to ensure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in the health service. Discharging the duty under 1F(1) is largely delegated to HEE through section 97 of the Care Act 2014.

As the hon. Member for Central Ayrshire said, clinical placements are a vital part of healthcare students’ education and training. Good experience during a placement can lead a student to seek employment at their placement provider. As a result, ensuring that there is sufficient placement capacity remains a priority for HEE in order to meet its statutory duties and ensure that an effective education and training system is in place.

[Dr Whitford]

Just to clarify, I was not referring to placements as students, which are absolutely vital; I was referring to the two foundation years that those individuals have to do afterwards. Otherwise, they simply cannot function as doctors.

[Edward Argar]

I am grateful to the hon. Lady for clarification, but she illustrates that placements, both as students and in the context she describes, are vital to enable students to understand and learn the reality and skill of their profession. It is also important that placements are rewarding for students.

HEE has successfully worked with education providers and placement providers to ensure there is sufficient placement capacity for the record number of nursing students that we now have. Such work includes payment of the education and training tariff, which pays a contribution to the costs of providing placements. The Government have also supported HEE through the provision of additional funding, enabling it to launch its clinical placement expansion programme. The programme has seen HEE commit £15 million to fund additional clinical placements across nursing, midwifery, allied health professionals and healthcare science in 2021-22. This funding will increase the number of placements offered to nursing, midwifery and AHP healthcare students from September 2021, which was last month, and it will enable HEE to deliver the future health and care workforce in sufficient numbers, and with the skills that the NHS needs.

Before I turn to innovation, I will address two points that were made by my right hon. Friend the Member for Kingswood and alluded to by the hon. Member for Nottingham North. First, the shadow minister touched on those who come from abroad via normal immigration routes or as refugees, the skills they have and how we need to make it easier for such people to utilise their skills and work in our NHS. He is absolutely right, and we continue to look at how we can make the process easier. We need to balance that with making sure that we can evidence and reference those skills for the safety of patients and those qualifications, but where that can be done and where those skills are commensurate, we need to make it as easy as possible for them to requalify or go through the necessary safety processes to be able to work in our NHS. The only other thing I would say is that we have to be very careful that any recruitment is ethical and that we are not denuding countries of the ability to utilise the skills of clinical professionals in rebuilding their own countries.

The second point made by my right hon. Friend the Member for Kingswood was about the challenges posed for maintaining quality, in terms of people going through relevant courses, and for the operation of the cap. I will not criticise any other Government Department, but he highlights the juxtaposition that often occurs between the Department for Education and the Department of Health and Social Care, or between other Departments where two Departments have an interest in the same policy but different incentives for their policy making. There will always have to be a financial test. There is always a limited budget, and my right hon. Friend highlighted how expensive some of the training courses are. However, it is right to expand the number of medical schools and training places, as we have done—he probably presided over it.

I remember going to the University of Lincoln, when I had just been appointed. Those I met were disappointed that I was not my right hon. Friend, but they were none the less very welcoming to me. The University of Lincoln works very closely with the University of Nottingham, which is in the constituency of the hon. Member for Nottingham North, in setting up a new medical school and drawing on the curriculum and expertise that was already in Nottingham. It is a great example. I very much hope that, when I am not in this Bill Committee, I might be able to go once again to visit the University of Lincoln and perhaps come and see the hon. Gentleman’s local medical school over in Nottingham.

Finally, on innovation, HEE currently works with universities, training providers and regulators on the curricula for the healthcare professions to ensure that they reflect the latest technological innovations. Although curricula are set, as I have said, at institution level, HEE can influence the content by representing the employer voice, to ensure that the training that individuals receive is relevant to what employers need.

In relation to consultation, HEE already works with universities, placement providers and others on the availability of placement providers to assess and ensure that there are the right number and types of placement. As I have mentioned, the number of placements has expanded. That is a direct result of the constructive dialogue and engagement that HEE has with placement providers. At ICS level, national guidance on the ICS people function set out the expectations.

I hope that I have set out that work on the areas highlighted by my right hon. Friend the Member for Kingswood is being taken forward—some of it was started by him a few years ago—under the existing statutory duty under section 1F of the NHS Act 2006. Therefore, at this point, we do not think that further specific duties are necessary, but I suspect that, in the further passage of this legislation, we may well return to the sort of themes that we have discussed today.