Health and Social Care Bill

Simon Hughes Excerpts

Tuesday 20th March 2012 Commons Chamber

[Paul Burstow]

The hon. Lady says it is a strange set-up and refers to her endeavours to get an answer to the question. I have not seen details of her exchange with the Secretary of State, but I will look at that and write to her with an answer to the question.

[Simon Hughes (Bermondsey and Old Southwark) (LD)]

My hon. Friend is dealing with matters of great concern outside this place, and I am clear that all these amendments are a move in the right direction. Will he put it on the record that as a result of the Bill, first, it will not be possible in future for any hospital to move, as Hinchingbrooke did, from the public sector to the private sector, and, secondly, that the proportion of private sector business cannot be increased up to the 49% that has been mentioned and will be increased only if the hospital decides, according to the amendments, to increase it by the small percentage that the amendments now allow?

[Paul Burstow]

I am grateful to my right hon. Friend for his questions. Let me start with the issue of Hinchingbrooke, which is an important one. It is worth remembering that the vast majority of the process that led to that franchise arrangement was completed under the Labour Government, not by the current Administration, and was part of the arrangements put in place by the Labour Health Act 2006 and Health and Social Care Act 2008. The Bill makes sure that in future there can be no scope for sweetheart deals to incentivise new entrants into the NHS, it ensures that there cannot be price competition of the sort that was allowed under the 2006 Act, and it ensures a protection for commissioners to decide when and if it is appropriate to use competition. That is not a protection that they enjoy under the 2006 or the 2008 Acts.

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[Andy Burnham]

It is important to begin by setting out the background to many of the amendments in this group. Despite the pause that the Government ordered for the Bill, they failed to allay fears about the creation of a market based on a 1980s utility privatisation, with Monitor acting as an economic regulator—a parallel drawn last November not by me, but by the King’s Fund in a report it published. That, more than anything else, has been behind the huge professional disquiet about the Bill that we have seen over recent weeks and months, with respected professional organisations coming out one after another to express their concern about the damage that will be done to the health service if hospital is pitted against hospital, doctor against doctor. That is where we start.

The Minister began his remarks by talking about the myths relating to part 3 of the Bill and objecting to some of the interpretation that I have just given. I do not know who he had in mind when talking about those myths, but it might have been the noble Baroness Williams. I will quote from an article she wrote in The Guardian on Monday 13 February. It is important because it explains the genesis of one of the amendments that the House is considering tonight. She acknowledged that there were:

“fears among the public and within the medical profession that clinical commissioning groups might become dependent on advice from powerful private health companies, and that the imposition of UK and European competition laws, addressed to markets and not to social goals, might destroy the public service principles of the NHS. In plain terms, this is often described as a fear of privatisation. These are issues that must be addressed.”

When the Minister talked disparagingly about myths, did he have the noble Baroness in mind? I think that he must have done, because in the same article she went on to suggest that the answer to the concerns and fears that she had correctly identified was to drop the whole of part 3. She wrote:

“What that would mean for the bill would be dropping the chapter on competition, and retaining Monitor as the regulator of prices and of the foundation trusts.”

I am not privy to the internal machinations of the Liberal Democrats, but I think that there must have been some wrangling and soul searching in the two weeks following the publication of that article, because by 27 February a letter had emerged that was co-signed by the noble Baroness and no less a figure than her party leader, the Deputy Prime Minister. The call to drop part 3 of the Bill, which had been made so eloquently in The Guardian two weeks earlier, had in fact turned into something very different. The letter stated that they needed to go further to amend the Bill in order

“to rule out beyond doubt any threat of a US-style market”.

If what the Minister has said at the Dispatch Box this evening is true and all these fears are myths, why did his party leader and the noble Baroness send that letter? Indeed, why were there even concerns about the threat of a US-style market, which his party leader acknowledged on 27 February? They do not sound like myths to me; it sounds like they were very real threats indeed.

What I want to address this evening is the fact that when the package of amendments that were meant to put the Clegg-Williams package into the Bill finally emerged, they fell considerably short of what was promised in the letter. Indeed, we are dealing with some of those tonight. I will focus on Lords amendment 148 in particular, which deals with the private patient income cap. When the Minister spoke a moment ago, I did not find him reassuring at all. When he spoke about foundation trusts in the future he said that they would of course remain the principal providers of NHS services, but I do not find that at all reassuring. The exchange he had with the right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was very revealing. The right hon. Gentleman made a mistake that the noble Baroness made when she took on Polly Toynbee on the same issue. The right hon. Gentleman, like the noble Baroness, does not seem to understand the effect of the amendments he is agreeing to. He began by asking, “Wasn’t it the case that the 49% figure was now completely ruled out and wasn’t relevant?” No is the answer to that. All that the Minister has offered him is that if the increase is more than 5%, it then has to be passed by a vote. I find it incredible that a Member of his years and standing in this House has just revealed that he does not understand the amendments that have been signed up to in order to deliver the package set out in the Clegg-Williams letter. That is a terrifying state of affairs; I do not know what the Members in his party who voted against that might make of it.

[Simon Hughes]

I absolutely understand the amendment, as I am sure does the right hon. Gentleman. Given that 1%, 2% or 3% of most hospitals’ activity is private at the moment, as he well knows, it seems to me that it is a much better guarantee that we have a rule that says that no hospital can increase that by more than 5% of what it is now unless there is a decision made locally. That gives much more security than anything else previously in the Bill, and that is why it seems to me to be a very worthwhile amendment.

[Andy Burnham]

Let me answer that directly. The Financial Times has analysed the latest data on actual NHS income earned through the treatment of private patients and demonstrated that in the last year not a single hospital trust would have been caught by this so-called safeguarding amendment. It used the example of Great Ormond Street, which increased its income from private patients by 19% from 2009-10 to 2010-11, to £25 million. In percentage points, that increase was less than 1%. Given the small numbers in the cap which the right hon. Gentleman has just mentioned, he is agreeing to trusts being able to increase their income from private patients by multiples of hundreds of percentage points without any reference to their boards of trustees. Frankly, he has not addressed the point that he has failed to understand that the Bill still gives trusts the permission to increase it to 49%. They could go to the trustees and increase it to 49%. He might be reassured by that, but I most certainly am not.

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[Andy Burnham]

The amendment gives us no protection at all, and it gives us no protection from the NHS cross-subsidising private care. There is nothing in the Bill which says, “The whole costs of the provision of that care have to be reimbursed to the national health service”, as the Financial Times has again demonstrated, and that is why we object to what is happening. We are going back to the old days of the NHS, whereby patients are told, “You can go private or you can go to the back of the queue and wait longer.” That is the choice which we removed from the NHS during our 13 years in government, and we will not accept any return of it.

[Simon Hughes]

I do not think that I have any more support or encouragement for the private sector in the NHS than the right hon. Gentleman does. May I therefore get him to accept that what Lords amendment 148 does is to limit in relation to each hospital an increase to—

[Grahame M. Morris]

49%

[Simon Hughes]

No, to 5% of its current figure—not 5% in total, but a 5% proportion. That is what the amendment says, and that gives Guy’s hospital, St Thomas’s hospital and King’s College hospital and patients the reassurance that I think they need. The right hon. Gentleman should read the amendment.

[Andy Burnham]

I am not going to debate that now. The right hon. Gentleman is going to have to defend himself on whether he has his facts right. I do not think that he has.

We need to put firmly on the record that there are real flaws in the Liberal Democrats’ proposal. They say that it is a safeguard to state, “The governors will decide and it is better done at a local level,” but the governors are going to be under pressure from the management of the hospital because of the pressure on the hospital’s finances. If they make a decision that is in the interests of that hospital, it does not mean that it is in the interests of everybody and of NHS patients.

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[Alex Cunningham]

I rise to support the amendment and to speak against anything that will allow 49% of the capacity of our local hospitals to be used for private patients.

Along with other measures in the Bill, the Government have accepted various amendments that will result in lengthening waiting lists for NHS patients. The Government’s relaxation of NHS waiting times targets means that hospitals are free to devote more theatre time to private patients, and they will have a clear incentive to do so in order to maximise income, given the move towards full financial independence and a “no bail-outs” culture whereby hospitals in financial trouble are allowed to go bust with no help from the Government.

The Health and Social Care (Community Health and Standards) Act 2003 placed a cap on the level of income that a foundation trust could earn from private patients. It was based on the level of a foundation trust’s private income in 2003—the year when foundation trusts first came into being—which was typically about 2%. The Bill in effect sets trusts free to deploy as much as 49% of that capacity to generate income from private patients who can afford the fees to jump the queues, which ordinary hard-working people, and the most vulnerable in our society, cannot do. This is not what patients want, not what the professionals want, and not what the NHS needs.

The Government amendments must be changed to ensure that any increase in the proportion of patient income has the approval of Monitor. Allowing individual trusts to make the decision alone means that there is no strategic overview, which Monitor would offer, and so in theory it would be possible for all the trusts in a locality to make that increase to 49% if their individual boards approved it. I wonder what that would mean on Teesside. We have two major hospitals, so half the capacity for NHS patients could go. Labour’s amendment would set a tougher cap on private patient income. Without the amendment, the NHS will take a huge step towards privatisation and we will fail to put in safeguards to ensure that the needs of the general public are met. Rather than the NHS being free at the point of delivery, more and more people will be pushed towards insurance schemes, thereby putting money in the pockets of the insurance industry and denying the exceptionally important right to have free, high-quality health care when it is needed.

[Simon Hughes]

I am absolutely clear that I was not sent to this place to force through the privatisation of the NHS, to force people from the public sector into the private sector, or to undermine great hospitals such as Guy’s, St Thomas’s and King’s College or the other hospitals in my constituency and my borough. Like colleagues from all parts of the House, I know what a fantastic service the NHS provides, not as a matter of policy but from personal experience. It saved the life of my younger brother and looked after my mother in her last days in the most fantastic way that anybody could wish for. I am clear about the commitment of the NHS.

I am therefore clear that we have to look at what the Bill says and what it will do. I have had an exchange about that with the shadow Secretary of State for Health. This is a really important issue outside this place. Clause 161 sets out the following principle:

“The principal purpose of an NHS foundation trust is the provision of goods and services for the purposes of the health service in England.”

That was not thought to be enough, so colleagues in the other place said, “Let’s for the first time ever make it clear that private activity can never be more than a minority activity.” That is why the 49% figure appeared.

However, that is not still enough—[Interruption.] Let me deal with this point. That is why Lords amendment 148 is before us. It states that if any foundation trust hospital in England proposes to increase its private income by 5% or more from its current level, which is usually about 2% or 3% of its income, the governors have to agree to the proposal by a majority. There will not be any great vote by the governors of Guy’s and St Thomas’s, King’s College or any other hospital, with the public participation in the debate that there would be, suddenly to increase their private sector activity. That is not the real world, because that is not what the British public want. There are one or two cases—

[Andy Burnham]

Will the right hon. Gentleman give way?

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[Simon Hughes]

In a second. There are one or two cases, such as the Royal Marsden, which have historically had a higher percentage of private sector activity. Those hospitals have justified doing so, because they are specialist hospitals that have got money in from outside. However, I do not want us to leave this debate letting the public believe that there will now be the opportunity for all the hospitals in England suddenly to move, without any control, towards undertaking huge amounts of private sector activity.

[Andy Burnham]

rose—

[Paul Burstow]

rose—

[Simon Hughes]

I will give way to my hon. Friend and then to the shadow Secretary of State.

[Paul Burstow]

I am grateful to my right hon. Friend for setting out these issues again so clearly and for putting to rest the myths that are yet again being fanned by Opposition Members. I confirm that the Bill provides two further safeguards. First, Monitor will continue to have a direct oversight role in this regard. It will be able to intervene and use its licensing powers and other powers to deal with concerns if NHS services are put at risk by the decisions of a foundation trust. Secondly, there are the contractual relationships that commissioners have directly with these organisations.

[Simon Hughes]

I accept that. That is why the amendments tabled by the right hon. Member for Leigh (Andy Burnham) are not necessary. Monitor already has a control that it can exercise to ensure that what he calls strategic control or central control is retained, as well as local decision making.

I will end this point by saying that although, technically, there could be a vote of the governors of any hospital—in the right hon. Gentleman’s constituency or mine—every year to increase private income by more than 5%, that is not the real world. In the real world, the people of this country love their national health service, NHS staff love their national health service, and the governors of the hospitals that I represent love their national health service. Those people are not suddenly going to change their attitude after 60 years of the NHS.

In the post-war Parliament, when the Labour party, supported by the Liberal party, put through the plans drawn up by Beveridge, the Liberal, for the NHS, it accepted from the beginning that there would be some private sector activity. From the beginning, GPs and some dental services were in the private sector, and they have remained there.

I am clear that the Bill does not mean that there will suddenly be a market, a route or a tramway for privatisation. Others say I am wrong—I know that there is a lot of concern—so I am clear that when the Bill becomes an Act, we need to sit down with the health professionals who still have concerns—[Hon. Members: “Too late.”] No, it is not too late if people understand what is really in the Bill, rather than what some people say is in the Bill. It is not too late if people look at the wording of the legislation, and do not just listen to the arguments about it.

I say to the right hon. Member for Leigh, whom I respect in many ways, that he has often distorted what has happened in the past and what will happen now. He has ignored the facts that Labour forced privatisation on the health service in many parts of England and that Labour paid more to the private sector to carry out activities for the NHS. I am here to support these provisions in the Bill because I want to end the incentives for the private sector and to end the enforced privatisation of the health service. I will ensure that there is no chance of any hospital in my part of the world voting significantly to increase private sector activity, because the NHS wants to remain in the public sector and deserves to be supported by us to do so.

I refuse to be misrepresented by Labour colleagues who accuse us of doing something that we are not doing. We have a public national health service, paid for through our taxes. Everybody has an entitlement to the best care in the country. I will not do anything that undermines that. I hope that the right hon. Member for Leigh will not and that Ministers will not. I agree that we have some work to do to reassure people outside this place. I hope that, from today, the right hon. Gentleman will join me in telling the truth about the Bill and not tell untruths.

Lords amendment 63 agreed to.

Lords amendments 64 to 147 agreed to, with Commons financial privileges waived in respect of Lords amendments 132 to 141.

Clause 161

Goods and Services

Amendment (b) proposed to Lords amendment 148.—(Andy Burnham.)

Question put, That the amendment be made.

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[Simon Hughes]

One thing that has got lost in all the noise about the Bill is the fact that there will be more opportunity for local authorities and local people in England to be engaged. Will my hon. Friend put on record how an ordinary constituent of his in Sutton, mine in Southwark or anywhere else—not a professional such as a GP or a nurse—will be able to get involved? I think there will be a much better system in future than there has been.

[Paul Burstow]

My right hon. Friend is absolutely right. Hard-wired throughout the Bill are requirements on patient and public involvement in clinical commissioning groups and health and wellbeing boards. Local healthwatch will provide a vehicle for delivering much wider engagement. One criticism that has often been levelled at past attempts at public and patient engagement has been the absence of hard-to-reach groups, which are seldom heard from in our health system. As a result, their voices have not helped to shape commissioning decisions. We need to ensure that they do, so that CCGs commission effectively for their whole population. That is a key part of what the Bill provides for.

As the Bill makes its way on to the statute book, Members of all parties will need to look closely at the opportunities for far wider public involvement that will result from how it has been improved. We have listened closely to groups such as the Richmond group, which has been a powerful advocate on behalf of a wide range of patients’ groups. It has talked about the importance of involving patients far more in co-production and commissioning decisions. That is an essential component of how we intend the Bill to be given effect in the months to come.

In tabling our amendments in the House of Lords, we wanted to ensure that local authorities had greater flexibility in the organisational form that local healthwatch takes. Local authorities are best placed to make decisions about the right way to commission a local healthwatch service for their area, but they cannot decide not to have a local healthwatch organisation, and we would not allow them to do that. It is essential that the voice of patients and carers is heard loud and clear in the decision-making processes of our NHS and social care services.

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[Simon Hughes]

rose—

[Paul Burstow]

I see that my right hon. Friend wants to intervene.

[Simon Hughes]

One last time—I am grateful to the Minister. Will he put on the record what constituents all over England can do if, for example, they hear that their hospital might want to close a ward for the mentally ill, or close accident and emergency services, or if it realises that there is no day care for people with mental illness? What power do they have to stop or start something?

[Hon. Members]

None!

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[Liz Kendall]

I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords, which set out how we could have a separate independent, body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.

National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK, Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.

Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.

The risk register says that there is a high risk that

“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities

“will not invest in establishing effective relationships with existing LINks and other community organisations”

because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch

“doesn’t work effectively with providers and commissioners. HW is not fully representative.”

It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:

“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”

The cause is identified:

“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”

Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.

Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[Interruption.] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified

“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”

The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.

[Simon Hughes]

These are important issues, but I hope the hon. Lady recognises that on the public health agenda, which Labour Members regularly say is so important, there is now—I think for the first time—written into legislation an obligation on the Secretary of State, and therefore on the NHS, to secure

“continuous improvement in the quality of services provided to individuals for or in connection with…the protection or improvement of public health.”

That must be reflected all the way down the tree; it will not stay only in the Department of Health office.

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[Liz Kendall]

I have told the Minister that I am not giving way to him.

These amendments are overwhelmingly outweighed by the huge change put forward by the Government in abolishing an effective statutory model for healthwatch bodies locally, which was supposed to give patients and the public a strong and independent voice in the NHS. Labour Members cannot accept the Government’s removal of that statutory body, which they promised and have now betrayed. The amendments make a mockery of the Deputy Prime Minister’s claim in the letter he wrote with Baroness Williams to Liberal Democrat Members that the Bill will ensure “proper accountability” to the public. It makes a mockery, too, of the claims made by the Secretary of State and the Prime Minister that this Bill will put real power into the hands of patients and the public, and that there will be “No decision about me without me.” And, as the national body that represents patients and public involvement in the NHS has said, it is

“a betrayal of public trust”.

This is what has happened throughout the proceedings on a Bill for which the Government—Conservatives and Liberal Democrats—have no mandate, and for which they know they have no mandate. They promised that there would be no top-down reorganisation, but did not present any proposals for an independent regulator on the basis of the system that exists in the privatised utilities because they were worried about what people would say. Above all, on this fundamental issue, which concerns the say that the public and patients have in the NHS, the Government have—as the National Association of LINks Members said—betrayed people’s trust in what they promised, and for that reason we will not support the amendments.

[Simon Hughes]

These amendments—the last group that we shall consider tonight—contain important issues, including that of local community involvement, which was raised by the hon. Member for Leicester West (Liz Kendall). Like other Members, I have an interest in the subject, and have had throughout my time in politics. I happen to know Malcolm Alexander—who was cited by the hon. Lady—very well, because he was once secretary of Southwark community health council.

Let me present my honest opinion of the Bill to my friends on the Government Front Bench. It is not the Bill that I would have presented to Parliament. I think that it has gone much too far in its efforts to introduce top-down reorganisation, which is not what we told the public we would give them; and although there was a fine balance between the arguments in favour of primary care trusts and those in favour of the new structure that we have created, I believe that by changing what we said we would do we have caused more uncertainty, not least among health professionals.

Nevertheless, I am convinced that the process to which the Bill has been subjected has improved it hugely. I am convinced that a year ago my party colleagues performed a public service by setting out an agenda for change, and that we have helped to persuade the Government to amend the Bill in 2,000 different ways. That is not my figure, but one given by the Library in a note with which it provided us before the debate. Since the Bill returned to Committee about a year ago, 2,000 amendments have been tabled, many of them in the House of Commons after the Future Forum had done its work. Today we are considering—technically—374 amendments, all of which are going in the right direction.

It is interesting to observe that only three Labour amendments have been tabled today to the changes proposed by the House of Lords, and that two of them dealt with the same issue. Effectively, that means that the Labour Front Bench has sought to change only three of the many proposals made by the Lords. Of course the 374 amendments are not all substantive—some are consequential, and some are small—but we should not undermine or understate the substantive changes that have been made since the Bill left this place.

Many outside the House believe that there is an opportunity for Members of Parliament to vote on every Bill at the end of all its proceedings, and to deliver a final yes or no decision. There is not, although I think that there should be. I hope to persuade colleagues that we can change our procedure so that all public legislation, whether it starts in the Lords or the Commons, ends up in the Commons for Third Reading. I think that that would make for more democratically accountable decisions. We could then examine the Bill as amended by the Lords, and take a final view. However, we are not there yet; tonight we are considering all these amendments, and with them I thoroughly concur.

I have listened to the debate about accountability, and I accept that there is real disagreement on whether the new system proposed by the Government, at short notice, is an adequate substitute for the statutory HealthWatch. I remember a time—the hon. Member for Leicester West was not in the House then—when, from the Opposition Benches, I ferociously opposed the Labour Government’s proposal to abolish community health councils. I thought that it was a move in the wrong direction, as did my constituents. I still believe that any measure that does not empower my constituents— and the hon. Lady’s in Leicester—and enable them to become involved in decisions, consultations and processes will not be a good thing.

Ministers have been asked some perfectly proper questions today, and I am not 100% persuaded that their answers suggest that we will have the best possible system. Let me be absolutely honest: I believe that although, by and large, the amendments contain huge improvements, there is a great deal of unfinished business. Some will be dealt with in regulations, which will enable us to return to these matters, while some will be judged on the basis of experience.

I asked my hon. Friend the Minister of State to put on record the way in which the public can be more involved, because I am clear that there are significant additional opportunities for the public to become involved. That is why, in those areas, it is a good Bill. I am clear that local councils should have more involvement. He may remember that, as my party’s representative when the Bill setting up the Greater London authority was introduced, I argued that the GLA should have the power of the London strategic health authority, so that there would be a democratically accountable strategic health authority. I have always believed in more accountable local health services and in local councillors and councils having more say.

[Liz Kendall]

The right hon. Gentleman says that there is more to do and that that can be done in regulations, but that is not the case on the amendment that we are being asked to agree, which will abolish local healthwatch organisations as statutory bodies. That cannot be changed in regulations. Will he vote against that?

[Simon Hughes]

I understand that. I was not pretending that everything could be dealt with in regulations. I said to the hon. Lady, I hope fairly—I am trying to be fair—that I thought she made a good point that the proposal has come late in the day and does not have the support of the people leading the community involvement at the moment, one of whom she cited and whom I have known for many years. I do not think that the Government have yet given a full explanation of why the new proposals are better than the old ones. I understand why they have suggested that there should not be a one-size-fits-all approach, but I hope that in his winding-up speech the Minister will explain, because I think that Ministers have a case to answer.

[Andrew George]

My right hon. Friend will have heard me intervene on my hon. Friend the Minister of State on that issue, seeking the rationale behind the decision to remove the statutory basis for HealthWatch. As I understand it, his response was that there would be a statutory measure to achieve this—healthwatch organisations would be tied in with local authorities. Does my right hon. Friend agree that there is a potential weakness there? If we are seeking to integrate health and social care, a conflict of interest may arise if a body is tied in with the local authority but is also supposed to be scrutinising the activities of that authority.

[Simon Hughes]

I understand that point and share some of those concerns. I hope that the Minister will explain before the end of the debate why the more variegated model will not carry the risks that were alluded to by the hon. Lady when she read from the document earlier and by my hon. Friend.

I want to flag up two other things in relation to accountability, one of which is to do with the decisions made by the commissioning groups. Like many colleagues, I met a group of my local doctors again the other day. They had two areas of concern. First, they had concerns about the Bill. There is a lot of work to be done by Ministers and by all of us to allay concerns about the Bill when it becomes an Act—that is, on the basis of the facts, not the fiction. There is a huge amount of work to do. I do not think that we should underestimate that. Secondly, they have concerns about the system as it is now, before any measures have become law. I hope that Ministers have heard those concerns, some of which are not of this Government’s making but derive from previous legislation.

There is a concern that there is an excessive interest in some places in looking for private work and private contracts. There is a concern that the middle class and well heeled will speak more loudly and influence the commissioners in their interests, rather than in the interests of the poor and the vulnerable. That is a real issue in a constituency such as mine, where a lot of people are on low incomes and in need of a good public health system.

I want to put on the record that, although I understand the argument about getting rid of tiers of management and giving GPs the power to commission, and that is a good thing, it will not be a good thing if the decisions end up being taken not by GPs and the commissioning groups and the people who are meant to be taking them, but by the people they appoint to do the work for them. They may be private sector companies or somebody else. We have to make sure that it is health service professionals who make the decisions, in an open, accountable and transparent way, not people they employ, who may have a big vested interest in capturing more work for their own commercial gain.

[Paul Burstow]

Just to be absolutely clear, may I say that clinical commissioning groups cannot subcontract decision making about their commissioning functions—that is crucial to the effective delivery of this. On the issue of the local healthwatch organisations, the Bill makes it clear that local healthwatch has to exist in each locality, and that local authorities have to contract for it to exist and to provide the range of services that the Bill provides for it to undertake.

[Simon Hughes]

I absolutely understand both those points. I understand that commissioning groups cannot subcontract their decisions, but the point I am making to my hon. Friend and to other Ministers is that we have to ensure that the groups do not end up in the position where, although they retain the decision, they leave lots of the thinking about it to the people they employ to do the work. The decisions have to be made by the health professionals. In reply to the Labour amendment, the Minister rightly said that it is a safeguard that local authorities will have the decision on the local healthwatch. Where a local authority is concerned that it should remain in a particular format, it will be able to do so.

In conclusion, I am clear, as I have said to Labour’s Front-Bench team, to constituents and to my friends on the ministerial team, that our constituents still have a huge amount of concern about this Bill; I am clear that a lot of it has arisen because of misinformation and misrepresentation; and I am clear that this is not a privatisation Bill and not a “carve up the NHS” Bill. However, everyone, including Government Members, will need to continue to be vigilant and to continue to talk to the health professionals. I hope that the Government and the health professionals will start talking again very soon. We will also all need to make sure that we understand their concerns and pass them on. I know what my constituents want at the end of this debate; they do not actually want lots of conversations about structures of the health service.

[Andy Burnham]

I listened to what the right hon. Gentleman said about misrepresentation and I wonder who he had in mind. Did he have in mind the members of his own party who went to Gateshead and asked for the Lords not to support the Third Reading of the Bill, although they did so yesterday? Did he have in mind those people who raised the most serious concerns about this Bill? I am talking about his own party members, who overturned his party’s leadership. I will not sit here and have him suggest that the concerns exist only among those on this Front Bench, because that is not the case; they exist throughout the country, and he needs to acknowledge that.

[Simon Hughes]

Let me deal with both those points. I acknowledge that absolutely. On past occasions, the right hon. Gentleman has been to our party conference, although I do not think he came to the Gateshead conference. [Interruption.] It appears that one of his colleagues did. There were and are concerns in my party about this. My party wrote the plan for the NHS, which the good Labour post-war Government implemented, so of course we think we are as much the proprietors of the NHS as his party and of course there are concerns. There are many concerns—many colleagues are not happy with the Bill—and I am owning up to that.

I am absolutely clear about that, but do not let the right hon. Gentleman misrepresent what happened at Gateshead. My party is a democratic party. It is more democratic than his, thank God, and much more democratic than the Tory party. Our party voted to commend the Lords for the work they had done, but to suspend judgment on the Bill. My party neither voted to say that the Bill should not go ahead, nor to decide that the Bill should go ahead. That was what the debate, in the end, was about. There was not quite a majority saying, “Stop the Bill”; that was not the view of the conference, although there are many people in our party, as there are in his—this view is also shared by some in the Tory party and elsewhere—who would want the Bill to be stopped.

The Bill is not going to be stopped; it will become law. The Bill contains many good things. My concern now is to reflect what constituents, both health professionals and those who are not health professionals, come to talk to me about. They feel that there is a need to get back to concentrating on the things that really matter, such as making sure the wards are clean; making sure that the staff are of the highest quality; making sure that the waiting times go down; making sure that we can get decent care for the mentally ill; and making sure that our NHS is able to do better on all that it does. That is what the concerns are.

I want to make sure that Ministers understand that once the Bill is on the statute book there should be no cause for rejoicing, because this is not a matter for rejoicing. It is a matter of a challenge for Government to go back in humility to the health professionals and say, “We may not have got it all right—we may have got some of it wrong—but we are willing to listen, to learn and to work with you.” In the end it is collaboration between local authorities, local councillors, local people, Ministers, parliamentarians and those millions of fantastic people who work in the national health service who will make sure that the health service survives. It will survive and prosper in this country as a public health service—thank God—and we must all work together to respond to concerns, alleviate fears and not fan the flames. We must make sure that from now on we work on the basis of facts, not fiction, and that we work with those who have the concern, like we do, that the NHS should survive and prosper.

[John Healey]

I had not intended to speak in this part of the debate but I was so underwhelmed and unimpressed by the Minister that I felt moved to do so. It is interesting to follow the right hon. Member for Bermondsey and Old Southwark (Simon Hughes). I think he was offering his support to the Front-Bench team, but often it was not entirely possible to be certain. One thing he talked about was quite telling—the flaws in the systems we as a Government tried to put in place after we did away with community health councils. The Secretary of State and his colleagues were very critical about those arrangements when they sat on the Opposition Benches. One might have hoped that they would make their criticisms and learn the lessons and not repeat some of the mistakes that we certainly made in the arrangements for a strong patient voice and strong patient representation after the community health councils, but this evening’s debate and what we have been presented with in this final stage of the Bill make it quite clear that that is not the case.

At the heart of the proposal in the White Paper, which was co-signed by the Prime Minister and the Deputy Prime Minister in July 2010, was the proposition to put patients at the very heart of the NHS. That was common ground and was supported by many. It was a promise that really went to the heart of the proposition about the NHS changes. Despite that promise, it is clear that patients are not at the heart of the NHS but at the margins. The slogan for patients that there will be no decision about me without me is simply that—a slogan. I remember that early in the autumn of 2010 patient groups who were trying to come to terms with the plans were saying—quietly at first but more loudly later—that the arrangements in the White Paper and then in the Bill when it was first introduced in the House would lead to less involvement of patients in future, not more. Since that point, the Bill has had more than 1,000 amendments—some 374 amendments were made in the other place and we have four hours to consider those amendments tonight—but looking at the Bill now I can see very little difference from the position as it was first expressed almost 18 months ago, when it first caused concern to those patient groups.

In this area of all areas in which party politics should not be part of provision for a strong patient voice, representation and safeguarding, I want to take the Government at their word. They said that they wanted to set up at the heart of the NHS a strong independent voice for patients. The House needs to consider what that means, and to do that we need to go back to first principles.

It seems to me that there are four principles or characteristics which must serve as yardsticks by which to measure whether an organisation can be a strong, effective voice for patients. The first is independence. In order to function as a strong, fearless voice for patients, any organisation that acts on their behalf must be independent of commissioners, independent of providers and independent of regulators because part of its job on behalf of patients may well be to stand up to and criticise the providers, the commissioners or the regulators at some point in fulfilling its duties. The arrangements that the House is asked to approve tonight fail that first basic test of an effective organisation for patients.

The second principle or yardstick is representation. If the organisation is to be an effective representative voice for patients, clearly it must have some representation system and accountability to the people on whose behalf it acts and speaks. Again, on that test, the arrangements that we are asked to approve tonight fail. The third principle or test of an effective patient organisation is whether it is rooted or grounded in good local information and monitoring. Again, nothing in the arrangements and nothing I heard from the Minister, who has now left the Chamber in the middle of the debate that he opened, gave me any reassurance that that third principle or test is met in the arrangements.

The fourth test or principle for an effective, independent organisation surely must be adequate resources. There are serious questions over the nature, the level and the system for the resources that will allow such an organisation to do the job that we in the House are legislating for it to do on behalf of patients.

At a national level first, I say to the Secretary of State as his junior Minister is not present that setting up HealthWatch England as a sub-committee of the Care Quality Commission just does not cut it. It is implausible that a body can act impartially and fearlessly on behalf of patients if it is a sub-committee of the care regulator. How can it be, and equally important, how can it appear to be independent and authoritative, if it is set up within the administrative, organisational and financial embrace of the CQC? The CQC itself is clearly one of those organisations that HealthWatch England and local healthwatch bodies may need to stand up to and criticise.

There was an amendment in the other place to give the Government an opportunity to change their mind and set up HealthWatch England as an independent statutory body. That Labour-led, Labour-moved amendment was defeated in the other place, I am sad to say, by a combination of Conservative and Liberal Democrat peers.

Secondly, on the local healthwatch organisations, I think I understood what the Minister said earlier—that the Bill introduces a statutory duty on local authorities to set up a local healthwatch organisation. Placing a statutory duty on a local authority to carry out a particular activity is very different from creating a statutory basis for that organisation to operate in its own right. How will that arrangement at local level ensure independence, representativeness, good local links and resources—the four things that I would argue are the essential elements of an effective organisation on behalf of patients? On the fourth point, which is about resources, I may have missed something in today’s debate or in the debate at the other end of the building, but we still have not had clear answers to the following questions. I would be grateful if the Minister answered these questions when he deigns to return to the Chamber to respond to the debate, unless the Secretary of State will be doing that himself.

First, will local healthwatch organisations be funded directly by the Department of Health? Secondly, if funding will go via local authorities, what will the mechanism be for that funding? Thirdly, will funding for local healthwatch organisations be consistent across local areas so that patients, wherever they live, can be confident that they have a strong local representative organisation working on their behalf? Otherwise, this is legislation for a local lottery in patient representation and the strength of local patient voices.