Healthcare (International Arrangements) Bill
Stephen Hammond ExcerptsMonday 21st January 2019
(5 years, 3 months ago)
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The Minister for Health (Stephen Hammond)
It is a great pleasure to bring the Bill to its Report stage tonight. Before I address new clause 1 and amendment 1, it might help the House if I set out with clarity what the Bill actually does. It provides the powers to fund and arrange payments for healthcare for UK residents, or indeed former residents, outside the UK as well as to share the necessary data to facilitate this. In a deal scenario, the Bill’s powers would support the Government’s attempts and motivation to implement a future relationship with the EU from 2021 and bilateral arrangements with individual member states, should the EU agreement fall short. In a no-deal scenario, the powers would ensure that the UK was prepared for any outcome. This could include implementing any negotiated reciprocal healthcare arrangements, which might differ from the current EU arrangements, or making unilateral arrangements for UK nationals in order to assist with accessing healthcare abroad in exceptional circumstances.
I am grateful to the hon. Member for Ellesmere Port and Neston (Justin Madders) for tabling new clause 1, because it gives me the opportunity to reiterate what I said in Committee about the important issue of financial reporting and facilitating parliamentary scrutiny. I note that, in Committee, the hon. Member for Burnley (Julie Cooper) tabled exactly the same provision as new clause 1, and that it was defeated. I said at the time that I recognised the new clause as a device that Oppositions always used. That does not make it any less relevant, but I explained that the Government were committed to openness when it came to the managing of public money. Expenditure by the Department of Health and Social Care relating to EU reciprocal healthcare arrangements is currently published in this place in the form of annual resource accounts, and will continue to be so. However, given that we do not know the provisions and administrative processes of future reciprocal agreements, the Government are once again unable to accept the proposal. As now, the Department’s future expenditure on reciprocal healthcare would be subject to the existing Government reporting requirements.
However, the hon. Gentleman’s new clause asks the Government to place a statutory duty on future Administrations to collect and report on data, which we have not yet agreed to exchange with other countries. This cannot be appropriate. The frequency and detailed content of a financial report should and could be determined only when reciprocal healthcare agreements have been reached. Currently, the UK and other EU member states are able to collect data and report both nationally and at EU level, as provided for in the relevant EU regulations. Spending on EU healthcare is reported as part of the Department of Health and Social Care annual report and accounts laid before this place.
My Department is currently working to ensure that UK nationals can continue to access healthcare in the EU in exactly the same way as they do now, either through an agreement at EU level or through agreements with the relevant member states. In either case, we will have to agree how eligibility is evidenced, the way in which and frequency with which that information is exchanged and, of course, the reimbursement mechanisms that will govern the new agreements.
Lady Hermon (North Down) (Ind)
I have listened closely to what the Minister has said. It would be helpful if he could offer some reassurance to Irish citizens living in Northern Ireland who, under the terms of the Good Friday/Belfast agreement, are entitled to regard themselves as Irish citizens, British citizens or indeed both. I presume that their rights will continue unchanged in Northern Ireland after Brexit. Am I right?
Stephen Hammond
The hon. Lady is completely correct. We explored that in Committee, and discussed the purposes of the common travel area. Indeed, there was an explicit debate in Committee on the arrangements for Northern Ireland. I am happy to confirm that to her.
Each of the agreements that we are seeking to strike could differ from country to country. Such agreements will have to take into account the operational possibilities and limitations of each contracting party, to ensure the smooth operation of reciprocal healthcare arrangements. This should include how NHS trusts in the UK can evidence eligibility for the treatment of non-UK citizens in the most efficient and least burdensome manner. Only when these technical details are known will the Government be able to speak confidently to the specific measures that we can report on for each country. Regardless of the specifics of any arrangements entered into, and as with all departmental expenditure, reciprocal healthcare costs are and will continue to be authorised by the Treasury supply process and to be included in the Department’s annual estimates, as well as being included in the annual resource accounts, which are audited by the Comptroller and Auditor General. I said in Committee that I hoped that the hon. Member for Ellesmere Port and Neston would be satisfied by that commitment to transparency, and I give that commitment again tonight. With that, I hope that he will feel able to withdraw new clause 1.
Turning to amendment 1, the hon. Member for Ellesmere Port and Neston again raised the important issue of appropriate levels of parliamentary scrutiny. The Government clearly recognise the importance of such scrutiny for this Bill and for secondary legislation made under it. The hallmarks of an effective and responsible parliamentary system are the processes by which we draft, consider and test legislation, and the appropriate parliamentary procedure for the scrutiny of regulations made under this Bill is the negative resolution procedure. The exception to that is where provision within regulations is needed to make consequential changes to amend, repeal or revoke primary legislation. Consequently, the Government are once again resisting that amendment.
As I have said previously, the powers in this Bill provide the Government with both the flexibility and the capacity to implement detailed and complex arrangements concerning healthcare access abroad. The remit of our regulation-making powers is tightly focused. They can be used only to give effect to healthcare agreements or arrange, provide for or fund healthcare abroad. Therefore, the subject matter to which the regulations relate is narrow. I say again that when regulations amend, repeal or revoke primary legislation, they will of course be subject to the affirmative resolution procedure, which is the appropriate level of scrutiny for such powers. However, where statutory instruments do not make changes to primary legislation, and deal with procedural, administrative or technical provisions, they should be subject to the negative resolution procedure, and that is reflected in our approach to this Bill.
We have been clear about our intentions for reciprocal healthcare in the context of exiting the EU. In the short term, our policy is to maintain the current system of reciprocal healthcare with the EU on a transitional basis until the end of 2020. That would happen automatically if there is an implementation period, and it is something that we are seeking to agree individually with member states in the event of no deal.
Kevin Foster (Torbay) (Con)
I welcome the Minister’s confirmation of the Government’s intentions behind this Bill. Will he confirm that the nonsense we heard from the shadow Minister about funding hip operations in Arizona is absolute tosh? While the shadow Minister may be enthusiastic about the healthcare system in the United States, will the Minister confirm that we are not?
Stephen Hammond
My hon. Friend is right. I said continually in Committee and I say it again now that this Bill is tightly focused in terms of the regulations that can be made under it. We want long-term reciprocal healthcare arrangements with the EU or relevant member states, and that is the Bill’s focus.
When the UK negotiates an international healthcare agreement in the future, the most important elements setting out the terms of that agreement would, as Members should expect, be included in the agreement itself. Such agreements are likely to contain all the detail of which Parliament should have due consideration, such as who is covered under the terms of that agreement. In contrast, the regulations implementing the agreement would not include anything fundamentally new. They would contain the procedural, administrative and technical details, such as the types of documents or forms to be used. It is therefore right that regulations issued under this Bill be subject to the negative procedure. That is an appropriate use of parliamentary time. Were we to accept amendment 1, it is likely that this Parliament would find itself debating whether the forms required to process reciprocal healthcare arrangements should be changed. That would clearly be a misuse of Parliamentary time.
I once again reassure the House that Parliament will have the opportunity to undertake appropriate scrutiny of future binding healthcare arrangements. Where we strike a comprehensive healthcare agreement with the EU or with individual member states, that agreement would be subject to the appropriate parliamentary scrutiny. Part 2 of the Constitutional Reform and Governance Act 2010 sets out the process under which Parliament can review what are intended to be legally binding healthcare agreements. That provides an opportunity for parliamentary scrutiny in respect of the substance of healthcare agreements. Implementation of such an agreement, if that is by way of regulations under the Bill, will then be subject to its own scrutiny before ratification of the healthcare agreement.
Everyone in this House wants reciprocal healthcare arrangements. Overwhelming support for reciprocal healthcare has been shown throughout the passage of this Bill, including in Committee during the evidence sessions with the expert witnesses. We heard directly from several Members and evidence was presented, and there is a clear desire for current arrangements to continue.
Stephen Hammond
I beg to move, That the Bill be now read the Third time.
We have had a productive debate on the Bill, and I am grateful to all Members, including those who recently contributed, who have engaged so constructively with the passage of the Bill and demonstrated a shared commitment to protecting the healthcare-access options of UK nationals in the EU. The support shown to the Bill throughout its passage shows the value of reciprocal healthcare. I wish to put on record my appreciation for the consensual approach shown by all parties in the House, and particularly to note the contributions from the hon. Members for Burnley (Julie Cooper) and for Ellesmere Port and Neston (Justin Madders). Not only in Committee but on Report, they raised objections but were very helpful in respect of the passage of the Bill.
Although the Bill is short, it is nevertheless important. The powers it contains will ensure that we are prepared, whatever the outcomes of exiting the EU are, and also that we are able better to implement complex reciprocal healthcare agreements with members and non-member states. Powers under the Bill will enable the UK to fund and give effect to our future relationship with the EU on reciprocal healthcare. The Bill allows us to look to the future. The powers it contains will allow us to implement strengthened reciprocal healthcare arrangements, or new ones with countries outside the EU. It is necessary to provide the Government with the powers to ensure a smooth transition from our current relationship with the EU to the future one.
Let me take this opportunity to thank those Members who served on the Public Bill Committee, in particular my hon. Friend the Member for South West Devon (Sir Gary Streeter) and the hon. Member for Blackley and Broughton (Graham Stringer), who ably chaired the Committee. I reiterate my thanks to those who gave oral evidence to the Committee and to those who provided written evidence, including Mr Alastair Henderson, Mr Raj Jethwa, Ms Alisa Dolgova and Ms Fiona Loud. Their expertise and perspectives were vital in understanding the importance and impact of reciprocal healthcare arrangements to medical professionals, insurers and, most importantly, the patients. I also put on record my thanks to my officials, who have guided me through this process.
As a responsible Government, it is important that we plan not only for every eventuality currently before us but for the future. The Bill is intended to provide reassurance to UK nationals living in the EU or those planning to travel to the EU. Again, I thank Members for their support. I commend the Bill to the House.
Oral Answers to Questions
Stephen Hammond Excerpts(5 years, 3 months ago)
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Jim McMahon (Oldham West and Royton) (Lab/Co-op)
The Minister for Health (Stephen Hammond)
Good morning, Mr Speaker. The NHS employs more staff now than at any time in its 70-year history, with a significant growth in newly qualified staff since 2012. We have increased the number of available training places for doctors, nurses and midwives, and taken further actions to boost the supply of nurses, including offering new routes into the profession and encouraging those who have left nursing to return. The long-term plan, which was announced last week, sets out the framework to ensure that the NHS has the staff it needs.
Neil Coyle
Guy’s and St Thomas’s, which is based in my constituency, offers globally renowned, first-class healthcare, but the trust has seen a massive drop in applications from other EU member states, including of almost 90% in midwives alone. All vacant posts across the NHS present the risk of longer waiting times and risk patient safety, so why did the Government not publish the workforce strategy in the so-called long-term plan? When will it appear? Will the Government reinstate nursing bursaries to address the shocking staff shortfall across the NHS?
Stephen Hammond
As I said a moment ago, the long-term plan sets out a framework to ensure that, over the next 10 years, the NHS will have the staff it needs. To ensure that we have the detailed plan the hon. Gentleman wants, my right hon. Friend the Secretary of State has commissioned Baroness Harding to lead a rapid and inclusive programme of work to set out a detailed workforce implementation plan, which will be published in the spring.
Helen Jones
Fifty per cent. of the staff the NHS will need in 15 years’ time are working there now, yet one in 10 nurses is leaving, 80% of junior doctors report excessive stress and six out of 10 consultants want to retire at 60 or before. Does the Minister not accept that this Government have presided over a disastrous decline in morale in the NHS, and will he say what the workforce plan will do to address it?
Stephen Hammond
Nurses are at the absolute heart of our NHS. There are 13,400 more nurses since May 2010. We have announced the biggest expansion of nurse training places, with 5,000 more available from 2018. Alongside that, we are opening up new routes. As the hon. Lady will know, the workforce is at the heart of the long-term plan and, as I have just said, a detailed workforce implementation plan will be published in the spring.
Stella Creasy
Last week, a 14-year-old boy lost his life in my local community, yet in September, when the Department wrote to my local community asking for ideas about mental health provision, I wrote back to Ministers asking for an urgent meeting to talk about how we could get mental health workers into our schools to work with young people who might be at risk of being involved in gang violence and youth violence. With the shortage of mental health workers at a rate of one in 10, can I finally have that meeting with Ministers so that we can talk urgently about how to support such young people and save not only money, but lives?
Stephen Hammond
The answer to that question is yes. The Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Thurrock (Jackie Doyle-Price), will be delighted to meet the hon. Lady.
Jim McMahon
The most recent Care Quality Commission inspection of the Royal Oldham Hospital said that it failed to meet safe staffing numbers in maternity and it only had 85% of the required staffing contingent in surgery. There is a human cost to that. We see list after list where people have died, including children, because of unsafe staffing numbers in that hospital. Where is the urgency that is required to address that? Will the Minister meet me about this particular hospital to see what more can be done?
Stephen Hammond
The hon. Gentleman is right. I recognise that the overall CQC rating was that the hospital requires improvement. I understand that the funding that has gone into it has been more than adequate and that it is improving. However, I recognise the concerns he raises and I would be delighted to meet him to discuss them.
David Tredinnick (Bosworth) (Con)
Will my hon. Friend congratulate Conservative-controlled Hinckley and Bosworth Borough Council’s health and wellbeing board, and its approach to NHS workforce shortages? It has, for several years, been working on collaboration between GPs and community services, which is in line with the 10-year plan. Will he look at the registers of the Professional Standards Authority, which are not mentioned in the long-term plan, and see if he can make better use of the 80,000 properly regulated practitioners on those registers?
Stephen Hammond
My hon. Friend is right to recognise that community provision lies at the heart of the long-term plan, and that a number of health service professionals make up that community provision. If he wishes to write to me about registers, I will be delighted to respond.
Victoria Prentis (Banbury) (Con)
The Minister knows about our difficulties in recruiting obstetricians, which has led to what we very much hope is the temporary closure of the full obstetrics service at Horton General Hospital in Banbury. We are doing everything we can locally to rectify that situation. What more can the Minister do to help us nationally?
Stephen Hammond
I pay tribute to my hon. Friend’s campaign and her tireless work on behalf of her constituents. Figures from the Royal College of Midwives show that there are over 2,000 more midwives on our wards since 2010. The NHS plans to train 3,000 more midwives over the next four years, and as of last September there are over 5,000 more doctors in obstetrics and gynaecology than there were in May 2010. The NHS is hoping to fulfil what my hon. Friend wants to see.
Mr Philip Hollobone (Kettering) (Con)
Will the Minister confirm that since the Brexit referendum in June 2016 there has been an increase of 4,000 EU nationals working in our NHS?
Stephen Hammond
My hon. Friend and I do not always agree on everything about the EU, but numbers and statistics show that he is correct on that matter.
Bob Blackman (Harrow East) (Con)
Clearly, it is important as we move forward with the NHS to train more doctors and nurses. What is the Minister doing to encourage young people to start training to become nurses, doctors, and for other positions in the health service?
Stephen Hammond
My hon. Friend is right, and we are ensuring more routes into the nursing profession, such as nursing apprenticeships and nursing associates. We are training more GPs, and we are determined to get 5,000 extra GPs into general practice. A record 3,400 doctors have been recruited into GP training and, as part of the long-term plan, newly qualified doctors and nurses entering general practice will be offered a two-year fellowship to support them to stay there.
Justin Madders (Ellesmere Port and Neston) (Lab)
The long-term plan admits that staffing shortfalls are “unsustainable”, yet incredibly there is no mention anywhere in the document of the damage done by the abolition of the nursing bursary. The plan contains an ambition to double the number of volunteers within three years, and although we should rightly celebrate the fantastic contribution made by volunteers, is it not damning that, with a record 100,000 vacancies in the NHS, the main plank of the Government’s strategy to tackle the workforce crisis is to rely on volunteers?
Stephen Hammond
The hon. Gentleman is right to say that volunteers in the NHS provide an invaluable service, but he is completely wrong to suggest that any part of the long-term plan relies on volunteers. There is an expansion in numbers of nursing associates to deal with those vacancies and, as I have said to other hon. Members, we have seen an increase in the number of doctors in GP training. Obviously, he will welcome the £20.5 billion a year that is going into the national health service. That will inevitably mean more doctors and nurses, which is why we are making more training places available.
Wes Streeting (Ilford North) (Lab)
Karen Lee (Lincoln) (Lab)
The Minister for Health (Stephen Hammond)
Our policies have allowed the NHS to recruit over 13,400 more nurses into all wards since 2010. Additionally, we have increased the number of available nurse training places, offering new routes into the profession and encouraging those who have left nursing to return to practice, alongside retaining more of the staff that we have now.
With your permission, Mr Speaker, I was so enthusiastic about the number of extra staff in the national health service, I might have inadvertently misled my hon. Friend the Member for Banbury (Victoria Prentis): it is 500 obs and gynae doctors since 2010.
Mr Speaker
In calling the hon. Member for Lincoln, I congratulate her on her birthday.
Karen Lee
You are very kind, Mr Speaker. The latest Care Quality Commission report on Lincoln County Hospital found sufficient nursing staff on only four of the 28 days reviewed and a heavy reliance on agency staff. As people know, I was a cardiac nurse for 12 years, and I can tell the House that agency nurses are expensive and create extra work—often they cannot do IVs and they are not familiar with paperwork, so the regular nurses end up doing half their jobs for them. Will the Secretary of State explain to the House why the NHS long-term plan has no policy on effectively tackling understaffing and no mention of reinstating the nursing bursary, which enabled nurses like me to train?
Stephen Hammond
The hon. Lady is right: we want to see more nurses in the NHS. That is why we have provided funding to increase nurse training places by 25% and why the long-term plan will have a detailed workforce implementation plan. She talked about the bursary, but since that was replaced nurses on current training schemes are typically 25% better off. Alongside that, additional funds support learning.
Rachel Maclean (Redditch) (Con)
I welcome the fact that my local trust has 94 more nurses than in 2010. What is the Minister doing to ensure greater retention of nurses at my local hospitals, so that they have their own nurses instead of relying so much on agency nurses?
Stephen Hammond
As I said earlier, nurses are absolutely the heart of our NHS, and my hon. Friend is right about the extra number of nurses at her hospitals. She is also right that retention is one of our big issues. That is why the Agenda for Change pay award was put through last year, why we are working with Health Education England to look at other retention methods and why we are increasing the number of training places to ensure that we not only retain nurses but recruit more into the national health service.
Julie Cooper (Burnley) (Lab)
I join you, Mr Speaker, in wishing my colleague a happy birthday. I acknowledge that no one knows better than she does about the crisis in nursing staff levels. At the same time, the shortfall in GPs has risen to 6,000, and a third of all practices have been unable to fill vacancies for over three months. Unsurprisingly, waiting times for GP appointments are at an all-time high. As ever under this Government, it is patients who suffer. The situation is set to get worse, with more practices destined to close this year. Why are the Government not taking urgent action to tackle that? When will we finally see the workforce implementation plan that has been promised?
Stephen Hammond
The hon. Lady asks about GPs. As she would want to acknowledge, a record number of doctors are being recruited into GP training. We are determined to deliver an extra 5,000 doctors into general practice. NHS England and Health Education England have a number of schemes in place to recruit more GPs and to boost retention—the GP retention scheme and the GP retention fund—and she will know, as I have said it twice this morning, that the workforce implementation plan, which is part of the long-term plan, will be published in the spring.
Andrew Selous (South West Bedfordshire) (Con)
Mr Robert Goodwill (Scarborough and Whitby) (Con)
The Minister for Health (Stephen Hammond)
My right hon. Friend is right to welcome the announcement for Scarborough Hospital, and I understand that the full business case for the redevelopment of Whitby Hospital is going through the Hambleton, Richmondshire and Whitby governing body for approval on 24 January. I am assured that the clinical commissioning group remains supportive of the redevelopment of Whitby Hospital and, if it is helpful, I would obviously be delighted to meet him after 24 January.
Barbara Keeley (Worsley and Eccles South) (Lab)
This Government’s cuts to council budgets have meant that 100,000 fewer people received publicly funded social care over the past three years, and 90 people a day died while waiting for social care last year. What does the Secretary of State think it says to their families that the social care Green Paper and the meaningful funding settlement have been delayed again?
Andrew Lewer (Northampton South) (Con)
Stephen Hammond
Departmental officials have worked alongside the council to engage with Shaw Healthcare to identify the causes and explore the solutions to minimise the number of empty beds under the PFI. Through improved contract management and regular meetings with Shaw, significant improvements are being made, and contract changes are under discussion to further improve performance. This aligns with the Department’s best practice centre for PFI contracts, as the Chancellor announced in the Budget—
Mr Speaker
Order. I appreciate the natural courtesy of the Minister in looking in the direction of the person questioning him, but the House wants the benefit of his mellifluous tones, so he should face the House. We are grateful to him.
Helen Goodman (Bishop Auckland) (Lab)
Stephen Hammond
The hon. Lady will know that in the long-term plan we have committed to ensuring that more people are treated and that more money is spent in hospitals. The decision on closure is for local organisations, as she will know, but, as I have said to other hon. Members, my door remains open and I would be delighted to meet her.
Gordon Henderson (Sittingbourne and Sheppey) (Con)
Mohammad Yasin (Bedford) (Lab)
Stephen Hammond
A number of MPs, including the hon. Gentleman, have raised issues about the trust’s performance, and a range of actions have been put in place. He will be pleased to know that I met the performance director in December. I have been discussing several support mechanisms involving both the NHS and the Department, and I continue to receive reports. He will also be pleased to hear that the trust’s performance improved over December.
Maria Caulfield (Lewes) (Con)
Children’s hospices provide vital support for children with life-limiting conditions and their families at the most difficult of times. I welcome the £25 million of extra investment in these services, but what more can be done to support children’s hospices across the UK?
Winter Preparedness
Stephen Hammond Excerpts(5 years, 4 months ago)
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The Minister for Health (Stephen Hammond)
This Government recognise that winter, with demand placed on services with colder weather and seasonal flu, is a challenging time for the NHS as it is for health services around the world. DHSC Ministers meet weekly with our systems leaders in the NHS to ensure that our services are equipped for winter to support those who need them.
We have been busier than ever, but our NHS has been rising to the challenge over the festive period.
The latest data to November shows that compared to last year, we have seen 3.6% more attendances per day at A&E, and that over 1,600 more patients per day were seen within four hours so far this year. Despite that, the published NHS winter operational updates show that in December there have been fewer ambulance handover delays and diverts to other A&Es compared to last year. This means ambulances spend less time at hospitals and more time on the roads reaching patients.
Ahead of winter
We started the run up to the winter period with over 2,200 more doctors and 1,600 more nurses on our wards than just a year ago, bringing the total increase since 2010 to 16,500 more doctors and 13,400 more ward nurses
We also increased NHS funding by £1.6 billion at the start of this year, to support and improve A&E and elective care performance.
On top of this, in advance of winter, more than £420 million has been provided to help the NHS this winter:
£240 million for adult social care—allowing councils to plan to provide care for 40,000 more people.
£145 million capital funding to hospitals for winter improvements—to upgrade wards and redevelop A&Es—the benefits of which the NHS expects will bring the equivalent of an additional 900 beds.
£36.3 million has been invested into the ambulance services for new vehicles and ‘make-ready hubs’. This will pay for more than 250 new ambulances, with 100 delivered by Christmas Eve.
The NHS has continued to work to improve services in advance of winter, to help people avoid a hospital visit or admission, and get them home quickly if they do have to stay. This has included:
Increased access to GP appointments at the evening and weekends. The latest figures (August 2018) show that full extended access was available for 40 million people, which is an increase of over 4 million from March 2018.
Fully embedded clinical streaming in A&Es following our investment ahead of last winter of £100 million, which means patients are directed to the most appropriate service.
Improved NHS 111. Half of calls to NHS111 now receive clinical input and ahead of this winter we have rolled out 111 online across the country so that the public can access care advice and services through digital channels and reduce additional pressures on A&E. 91% of the population have access to NHS Digital’s 111 online service.
Work to standardise services provided by urgent treatment centres and increasing public awareness of this as an alternative to A&E for minor illness and minor injury.
Increased implementation of ‘hear and treat’ and ‘see and treat’ by ambulances—reducing unnecessary conveyance to hospitals.
Joint working between hospitals, councils and other local partners to reduce long lengths of stays in hospital and helping improve transfers to community and social care. The published NHS winter operational updates show that the number of beds occupied by patients staying more than 21 days in hospital on average per day is down by more than 2,000 (12.5%) this winter so far, when compared to the equivalent period last year.
Extending the flu vaccination programme—already the most comprehensive in Europe—even further. Vaccination remains the best line of defence against flu and this year, we have more effective vaccines available than ever before.
This winter we have also encouraged all healthcare workers to be vaccinated, are funding the vaccination again for frontline social care workers, and have extended the offer to staff giving direct care in the voluntary managed hospice sector. Free vaccine eligibility has also been extended to include children up to nine years old (Year 5) so that all two to nine year olds are now offered the vaccine.
Performance over the next few weeks
The NHS continues to make some progress in rising to the seasonal challenges, but we also know that there is no room for complacency at this early stage of winter.
There are clearly a number of hospital trusts where the situation has been challenging. The most recent statistics showed that 75% of all 12-hour trolley waits occurred in just 10 trusts.
In addition, NHS England and NHS Improvement continue to monitor NHS performance daily. They are supporting hospitals nationally and, working with regional teams, will maintain a close grip and oversight during winter of their performance.
The Care Quality Commission will be continuing to monitor hospital services over the winter months with over 30 visits to hospital emergency departments planned. The CQC is able to undertake further visits in response to any emerging risks identified.
And we will go further to support this through our long-term plan to guarantee the future of the health service—backed by an extra £20.5 billion a year in real terms by 2023-24.
[HCWS1232]
NHS Reorganisation
Stephen Hammond Excerpts(5 years, 4 months ago)
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The Minister for Health (Stephen Hammond)
It is a pleasure to serve under your chairmanship, Mr Gapes. It is a pleasure to respond to the hon. Member for Warrington South (Faisal Rashid). I am pleased that he secured this debate, and I agree with him that the NHS is a great credit to our country. I know that the Opposition spokesman will have heard me say yesterday—I will repeat it—that the Government and I, as Minister for Health, greatly value the staff who work in the NHS. It is our absolute intention to ensure that they recognise that and that we continue to show that.
I want to start with a few facts, because having listened to what the hon. Member for Warrington South described, I think there are other things that are worth pointing out. There are 11,000 more nurses in the NHS than there were in 2010. There are 18,200 more doctors than in 2010. Almost nine out of 10 patients are seen within four hours in an emergency department. We are committed to 5,000 training places for doctors in general practice—this year saw 10% more than we aimed to achieve. Of course, this is the highest level of funding that the NHS has had in its 70 years. The hon. Gentleman raised a number of other issues, as did the Opposition spokesman, and I will try to respond to those in my speech.
The hon. Member for Mitcham and Morden (Siobhain McDonagh) made a contribution. I have immense respect for her. Anyone who knows her knows that she always argues her case passionately and stands up for her constituents, and she did that again today. She and I have occasionally shared joint endeavours on St Helier Hospital. I think we both agree that there is a substantial case for keeping the acute services there. I think we would both agree—I say this in a constituency capacity—that the infrastructure needs upgrading, and I think we have had that discussion. She rightly points that we have had another consultation this year. As a Minister, I say that we expect any significant service changes to be subject to exactly the full public consultation she has described, if it is going to happen, and that the proposals must meet the Government’s four reconfiguration tests, which are support from GP commissioners; strengthened engagement with the public; clarity on the clinical evidence; and clarity and consistency with patients’ choice. She says that there have been rounds of consultations, as I certainly saw when I was on the council—I think she was already a Member of Parliament then—under Governments of all colours over the past 20 years.
It is the same with the hon. Member for Strangford (Jim Shannon). I have had the pleasure of taking interventions from him in several debates. He is always a powerful advocate for his constituents. I listened carefully to his point about out-of-hours care, which may have been slightly out of the scope of the debate. Yesterday, I had the chance to visit the North Middlesex University Hospital. Some of its work on the integration of out-of-hours care and triaging in A&E moves along the lines that he discussed. I have seen that several times.
To address the crux of the debate, between 2016 and 2036, the UK population is expected to increase from 65.6 million to 71.8 million, which is a growth rate of about 10% in 20 years. In the same period, the number of people aged 75 and over is expected to grow by 64% from 5.3 million to 9 million. Those figures are clearly something to celebrate, showing that the NHS is doing exactly what we want it to, but they mean that more will need to be done to make sure that those years are quality years.
For the NHS to continue to deliver high-quality care in the next 20 years, as it has done for the last 70 years, we need to look at new models of care that promote more joined-up care across the NHS and social care. In the past few years, the Government have supported a number of pilots at local and national levels to test new models of care that bring together the NHS, local authorities and wider public services to develop new ways of ensuring that services are delivered in a more joined-up way. Those areas have seen some improvements in access to services, patient experience and moderating demand for acute services.
It is time for the NHS to move beyond those pilots and embrace wholesale transformational changes across the whole system in every part of the country. It is therefore developing a 10-year plan for its future, which is underpinned by a five-year funding offer. To support the NHS in delivering for patients across the country, the Government announced a new five-year budget settlement for the NHS, in which funding will grow on average by 3.4% each year to 2023-24. The hon. Member for Strangford, who has just left the Chamber, welcomed the fact that that means the NHS budget will increase by more than £20 billion compared with today, underpinning the 10-year plan to guarantee the future of the NHS.
The hon. Member for Warrington South remarked on sustainability and transformation partnerships, and commented on his own local STP. The Government are fully committed to NHS England’s vision of STPs transforming how care is delivered and putting the system on a sustainable footing for the future. We will back STPs where they are clinically led and locally supported.
The hon. Gentleman questioned some aspects of local democracy. Each partnership has to set out agreed priorities and say how they are going to be delivered, and have a strategic priority to work with partners in local authorities. The Cheshire and Merseyside STP is making some progress in building those relationships, but he is right to acknowledge—I acknowledge it as well—that it is an extremely large and diverse area.
Clearly, the hon. Gentleman and the hon. Member for Ellesmere Port and Neston (Justin Madders) will recognise that there are now nine local footprints, including Warrington Together. The idea is that they will develop some of the integration suggestions and plans, and the consultation with local authorities to which the hon. Member for Warrington South referred. The STP brings local areas together to tackle the challenges, and I think he would acknowledge that it makes sense to do that across a bigger area, so the smaller areas build into the larger area.
Last week, the Government announced that they were supporting the Cheshire and Merseyside STP with £11 million in capital spending for improving emergency department capacity at the St Helens and Knowsley Teaching Hospitals and for a 12-bed, tier-4 child and adolescent mental health services unit at Alder Hey Children’s Hospital. The hon. Member for Ellesmere Port and Neston challenged me on STPs, so I will say that, in their more mature form, they are integrated care systems that promote collaboration between NHS bodies, local government and local communities. The 10-year plan will set out how they will spread the integrated care models that have been developed and tested through the whole vanguard programme.
There was also a challenge about what were formerly known as accountable care organisations and are now called integrated care providers, with several questions about that. At a small number of sites, commissioners are looking at how contractual models can support more integrated care. To support that, NHS England has developed the draft integrated care provider contract which, if introduced, will give the NHS the option of having a single lead provider that is responsible for primary, community and hospital services, with the aim of integrating services across traditional silos.
If NHS England chooses to introduce a contract for the ICPs, Parliament will have a chance to debate the regulations. I recognise that the regulations are subject to the negative procedure, so there is not an automatic debate, but as the hon. Member for Warrington South will have spotted, in those circumstances, if Parliament decides, there will be an opportunity to have that debate. NHS England has recently concluded the public consultation on the draft ICP contract and we expect a response in due course.
I want to touch on the premise that the ICP contract is privatisation. It is completely misleading to suggest that an integrated provider model is a step towards privatising the health service. The NHS will always offer free healthcare at the point of use—that is not just the Government’s view. I am sure that the Library briefing that the hon. Member for Strangford challenged me to read notes the evidence from the Health and Social Care Committee, whose Chair, my hon. Friend the Member for Totnes (Dr Wollaston), said that the evidence received by the inquiry into integrated care—the report was published in July 2018—was that ICPs
“and other efforts to integrate health…and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”
That is quite powerful and I hope that the hon. Members for Ellesmere Port and Neston and for Warrington South take note.
Justin Madders
I know what the Select Committee said; I am interested in what the Government are saying. Is the Minister ruling out any private provision from ICPs?
Stephen Hammond
I am not ruling out private providers from bidding, but it has been made clear, and I say again, that we expect any ICP contract to be won by NHS bodies. As I said, the evidence to the Select Committee inquiry tends to support that that is our view and that is what is likely to happen.
The Government have made it clear that the change is not about reorganising the NHS from the centre or adding more layers to an already complex system. As the Prime Minister reiterated in her speech in June, the Government should learn the lessons of the past and not try to impose change on the NHS. To achieve that, we firmly believe that any changes to the model of care for patients need to be locally led, informed by knowledge of the population and the population need, and supported by clinicians on ground.
That is why we have asked local leaders in STPs and integrated care systems to create five-year plans detailing how they will improve local services for patients and achieve financial sustainability. Of course, this is something that we may want, but it cannot just be wished into being, which is why the Government are supporting the NHS with £20 billion of additional funding.
Local plans will build on the work of the last three years to develop new ways of delivering services and enhance collective efforts to use that additional funding to improve people’s health and wellbeing. It is essential that that process proceeds in a spirit of genuine partnership and that all local partners, including local government, are fully involved from the outset.
For any significant system reconfiguration, we expect all parts of the system to be talking to the public regularly; it is vital that the public shape the future of their local services. That relates directly to the point that the hon. Member for Mitcham and Morden made earlier. To make it absolutely clear, no changes will take place without public consultation and engagement.
After all, the aim of integrating services is not an end in itself; it is to improve the patient experience and quality of care, so it is essential that the views of the public should be at the heart of local plans. Integrated care means a health and care system built around people’s needs, whereby physical, mental and social care needs can be addressed together, and patients should feel as if their care is being provided by one organisation.
Integration also gives us the means to avert ill health, preventing unnecessary hospital visits and supporting patients to have happier, healthier lives into old age, and taking the pressure off NHS staff. For example, in Thanet, the Margate Task Force is an integrated service that brings staff from 16 different agencies together in a single “street-level” team.
In conclusion, integrated care provides the best opportunity to ensure that the NHS continues to deliver the highest level of quality services to people and to meet the demands of the 21st century. The Government have supported the NHS to implement the five-year forward view and to develop new integrated ways of working to meet those demands. It is now time to drive those initiatives and spread them across the whole country. That is why we are committed to those plans and it is why we have committed to increase the NHS budget, to support the national move towards integrating care.
NHS Overseas Charging Regulations Review 2017
Stephen Hammond Excerpts(5 years, 4 months ago)
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The Minister for Health (Stephen Hammond)
On 16 November 2017, the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Winchester (Steve Brine) announced to the House that my Department would be conducting a review into the impact of amendments made to the NHS charging regulations in 2017, with particular regard to any impact on vulnerable groups and those with protected characteristics.
The review is now complete, and the evidence received demonstrated that there is no significant evidence that the 2017 amendment regulations have led to overseas visitors being deterred from treatment or that the changes have had an impact on public health.
I am pleased that the review has shown that the 2017 amendment regulations are largely working in the way they were intended. These changes were, amongst other things, made to enshrine in law that overseas visitors not eligible for free care must pay for any non-urgent treatment upfront, to help reduce the need to chase up charges, and to remove the anomaly whereby the healthcare setting or provider type could determine whether services would be charged for or not.
Some case studies presented did reveal that there is more to do to ensure some groups of vulnerable overseas visitors understand their entitlements and treatment options, and that providers of NHS care consider fully when a patient can be reasonably expected to leave the UK before deciding if treatment should be safely withheld if payment is not provided.
We will continue to work to ensure that these issues are addressed, so that the charging regulations are implemented in as fair a way as possible. We will improve information and support for NHS staff and patients and work with stakeholders and interest groups to ensure that key messages and safeguards are understood by all.
To ensure clinicians, NHS and community care staff fully understand our guidance and how it should be implemented in practice, we will revise and relaunch our focused e-learning training programme, and work with NHS Improvement’s support teams to promote it. This will ensure that all relevant aspects of overseas visitors’ personal circumstances are taken into consideration when clinicians decide whether treatment is immediately necessary.
To combat any misconceptions around how the cost recovery regulations affect access to care, the Department and NHS Improvement will continue the close partnership with community groups and stakeholders representing vulnerable individuals to develop user-friendly, culturally-appropriate guidance, and ensure this reaches those who may be impacted by this policy.
Finally, we will continue to work closely with NHS Improvement and frontline staff to keep the impact of the regulations and these further actions under very close review, and to provide additional support and guidance to organisations implementing the regulations in different settings in the best interests of patients.
[HCWS1174]
NHS: Staffing Levels
Stephen Hammond Excerpts(5 years, 4 months ago)
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The Minister for Health (Stephen Hammond)
It is a pleasure to serve under your chairmanship, Mr Hollobone. I thank the hon. Member for Batley and Spen (Tracy Brabin) for securing this debate. As she and hon. Members who have contributed to other such debates will know, the issues she raises are very similar to those that we discussed on 21 November in the debate that the hon. Member for Ellesmere Port and Neston (Justin Madders) has just referred to. However, it is welcome to have the opportunity to discuss them again, because such debates reflect the importance that we all place on the NHS workforce. The one thing that the hon. Gentleman and I agree on is that it is right to begin by reiterating our thanks to the NHS professional staff for their work treating patients day in, day out.
I also thank other hon. Members for their contributions. I note in particular the comment rightly made by my hon. Friend the Member for Lewes (Maria Caulfield) that we need to upscale nurse degree apprenticeship routes. I will speak about that in more detail if I have time. My hon. Friend the Member for Redditch (Rachel Maclean) spoke about the capital announcement made last week, which I was pleased to see come through. My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) made some points about mental health—may I offer him a meeting at the Department to discuss those matters directly, because today I want to concentrate on other matters? The hon. Member for York Central (Rachael Maskell) made a contribution based on her valuable experience.
I should say right at the outset, as I did in our debate two weeks ago, that the Government greatly value the staff who contribute to and support the NHS. We understand its importance and are committed to ensuring that it is supported and funded appropriately, which is clearly reflected in the extra £20.5 billion a year that the NHS will get by 2023-24.
As the hon. Member for Ellesmere Port and Neston quoted me saying in our last debate, we expect NHS England to set out clearly its commitment to the workforce in the long-term plan. The plan will address how to open up the profession to more people from all backgrounds and ensure that they get the right support throughout their training. To answer his question: yes, when the long-term plan is published, he will see the workforce embedded in it and in our strategy. We also expect NHS England to deliver a clear implementation plan to guarantee the future of the workforce. The NHS employs a record number of staff—more than 1.2 million in 2018, which is more than at any other time in its 70-year history—with significant growth in newly qualified staff since 2010.
Let me repeat what I said two weeks ago:
“the Government, and I as the new Minister for Health, should never be complacent”.—[Official Report, 21 November 2018; Vol. 649, c. 372WH.]
We are not. We are absolutely committed to ensuring that nursing remains an attractive career so that the NHS can build on the record numbers of nurses on our wards. Actions already taken to boost the supply of nurses range from training more nurses and offering new routes into the profession to enhancing rewards and pay packages, and there are now 11,000 more nurses on our wards than in May 2010.
NHS England, NHS Improvement and Health Education England are working with trusts on a range of recruitment, retention and return to practice programmes to ensure that the required workforce is in place to deliver safe and effective services. We should note that NHS Improvement has had some real success with its retention programme. Retention seems to me one of the key issues for the Government to focus on, and that will be reflected in the long-term plan. NHS Improvement’s programme continues its direct work with trusts to support improvements in retention, with a focus on the nursing workforce and the mental health clinical workforce. So far, 35 trusts have been involved and the initial evidence is positive and encouraging, with more flexible working programmes and greater support for older workers. It is therefore right that that programme be expanded further to all remaining NHS trusts in England.
Maria Caulfield
Revalidation is a new system for nurses to retain their registration, but it is a very difficult and stressful process for nurses who may be part-time or part of a hospital bank. I was lucky because my NHS trust, the Royal Marsden, is extremely supportive to its bank workers, but will the Minister ensure that bank nurses are supported through the revalidation process to keep them registered?
Stephen Hammond
I am listening carefully to my hon. Friend, and I will ensure that that work is undertaken.
As I have said today and on previous occasions, the priority is to get more nurses on our wards. There are currently 52,000 nurses in training, and we have announced a policy change that will result in additional clinical placement funding to make 5,000 more training places available each year. My hon. Friend made the point that nursing bursaries were not always the panacea that everyone suggests; students on the loans system are at least 25% better off than under the previous system. However, we recognise that students incur additional costs as a result of attending clinical placements, so we have introduced a learning support fund with a child dependants allowance, reimbursement of travel costs and an exceptional hardship fund. When I spoke to nurses at Barts last week, I listened carefully to the points they made about the need for help with travel in particular, and I am looking carefully at that issue.
The hon. Member for Batley and Spen raised the RCN proposal. Yesterday, as I had promised I would, I responded to the RCN in a formal letter to Dame Donna, and I look forward to meeting her to discuss her proposals in the near future—hopefully the very near future.
We are increasing the number of midwifery training places by more than 3,000 over the next four years. There continues to be strong demand for nursing places, with more applicants than places, but I am under no illusions, nor am I complacent. We need more people applying and we need to increase that route. A number of routes are open. HEE’s programme covers all fields of nursing; its RePAIR—reducing pre-registration attrition and improving retention—programme explores effective interventions to ensure that people are supported through their whole student journey from pre-enrolment to post-qualification.
The hon. Member for Batley and Spen was right to mention the number of new routes into nursing. In particular, she will have noted the report published last week by the Select Committee on Education on the nurse degree apprenticeship. We are working with the Department for Education to carefully consider the Committee’s recommendations and I will respond in due course.
I want to turn to the story of doctors. In the NHS today, it is true that there are 18,200 more doctors in trusts and CCGs than there were in 2010. My hon. Friend the Member for Central Suffolk and North Ipswich raised the matter of the additional 5,000 doctors. This year, we have recruited 3,473 GP trainees, against the target of 3,250. That is an increase on last year, but we are determined to meet the commitment of 5,000. To ensure that that is possible, we have rolled out an extra 1,500 medical school places. By 2020, as he knows, five new medical schools will be open to deliver that expansion.
In the whole of this discussion, it is only right that I recognise that the Government value the professionals. It is key that we ensure that NHS staff are well remunerated. It is absolutely right that we have given NHS staff a well-deserved pay rise. All staff will receive a 3% pay rise by the end of 2018-19.
There is a lot more I might have said. The hon. Member for Batley and Spen raised a number of local issues, including ambulatory care. If she cares to write to me or to catch me, I would be happy to have a longer discussion with her. I thank her and all hon. Members for the points they have made in the debate. I also stress, as I have done today to staff at North Middlesex, and last week, that making sure that we have an NHS long-term plan that sets out a strategy for the NHS and ensures a sustainable supply of clinical workforce—doctors, workers and others—is key, and it is key to delivering our ambitions for the NHS. I thank the staff for all that they do.
Tracy Brabin
I thank colleagues from both sides of the House for their contributions, particularly those with frontline experience, and I thank the Minister for his measured response.
I have a couple of points. First, I am sure the Minister can feel the sense of urgency in this debate. Although I appreciate that long-term discussions are needed, we still do not have a date for when the long-term plan will be published or for the consultation on the Royal College of Nursing proposals. The Minister said it would be soon, but when will we have that?
Stephen Hammond
There is a commitment from the Government to produce the long-term plan before the end of the year, as the hon. Lady knows, and I have written to Dame Donna to request a meeting to discuss the RCN’s proposals.
Tracy Brabin
That is very reassuring.
We hear from across the House that mental health is receiving such little support. People are hanging by a thread. Nurses are saying to their organisations and their MPs, “I am worried for the health and safety of my patients. I’m doing too many shifts. I’m absolutely shattered. I can’t guarantee that I am going to be doing my job properly. They’re bringing in volunteers to support me on the ward.” It is an absolute crisis. While I understand that the wheels of government work very slowly, I hope that the Minister takes from this debate that Brexit has been a universal issue. We are losing staff members. I welcome the commitment to an extra 5,000 doctors and so on, but that is just plugging the gap of the staff who are draining away from our hospitals and frontline services.
Stephen Hammond
I absolutely recognise that Brexit is a pressure on the system, but we should also recognise that there are 4,367 more professionals working in the NHS from the EU than there were at the date of the referendum. It is important to put that on the record.
Clinical Waste: Healthcare Environmental Services
Stephen Hammond Excerpts(5 years, 4 months ago)
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The Minister for Health (Stephen Hammond)
I am today taking the opportunity to update the House about a company which provides clinical waste services to NHS Trusts.
This company—Healthcare Environmental Services (HES)—was subject to previous discussions in Parliament. On 9 October, the then Minister of State for Health, set out concerns that a number of waste storage and treatment sites were well over the permitted levels. This included waste collected from hospitals and other public services. Although the waste was stored securely, the Environment Agency was sufficiently concerned at the activities of this company that they took regulatory action, including launching a criminal investigation.
At the start of October, a number of trusts served by HES’ Normanton site, terminated their contracts, and arranged for Mitie to provide waste collection and incineration services instead.
Until last week, a number of other NHS trusts continued to receive services from HES. Those organisations, supported by NHSI and the Department of Health and Social Care, have been monitoring the situation.
However, HES has now failed to collect waste from 24 further trusts. NHSI has sought assurance from HES that it has not ceased trading and is capable of, and will continue to provide services. Such assurance has not been forthcoming. Contingency arrangements are in place for each of the affected trusts. An optional extension in the Mitie contract has been exercised, which will allow all affected trusts to access a replacement clinical waste collection service. This has been communicated to all Trusts and NHSI is working with affected trusts to mobilise and implement contingency plans.
These robust contingency measures mean there is no gap in service provision and no health risk to the public.
[HCWS1168]
Healthcare (International Arrangements) Bill (Third sitting)
Stephen Hammond ExcerptsThursday 29th November 2018
(5 years, 5 months ago)
Public Bill CommitteesRead Full debate Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 View all Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 29 November 2018 - (29 Nov 2018)
The Minister for Health (Stephen Hammond)
Mr Streeter, it is a pleasure to see you in the Chair this afternoon and to serve under your chairmanship. The hon. Member for Burnley has moved the motion, and in responding, I will take the opportunity to deal with the important issues of financial reporting and facilitating parliamentary scrutiny.
I will say at the outset that there can be no suggestion, nor is it the Government’s intention, that we should have anything other than a commitment to transparency and transparent use of public money. We are also committed to appropriate parliamentary scrutiny: we have taken several significant steps to ensure that central Government data is published in a transparent way, including spending control. However, that needs to be done in an efficient and effective manner, and we need to know what data is available and is not available. I have problems with the hon. Lady’s new clause because such a detailed reporting requirement is premature, and risks the very thing that she seeks to avoid. She seeks to avoid placing an administrative burden on the public bodies, but that is exactly what the new clause might do.
We believe that the frequency and detailed content of a financial report should be determined once the reciprocal healthcare arrangements have been made and the technical and operational details of those agreements are known. At the moment, the collection of administrative data is facilitated by the registration and exchange of e-forms through the processes provided for in the relevant EU regulations. As a result, the UK and other EU member states are able to collect data and report both nationally and at an EU level, based on known processes. Current spending on EEA healthcare is reported as part of the Department of Health and Social Care’s annual report—which the hon. Member for Burnley may wish to look at, or may well already know about—as well as the accounts that are presented to this place. The Department also provides information to the European Commission for its triennial report on cross-border healthcare, as well as providing an annual statement of financial accounts to the Commission.
The Department is currently negotiating with the EU and individual states therein with a view to providing UK citizens with continued access to healthcare in the EEA, either through an agreement or through bilaterals. In that case, we will have to agree how eligibility is evidenced; how, and how often, that information is exchanged; and, of course, the reimbursement mechanisms that will govern the new arrangements. Those agreements will have to take into account the operational possibilities and limitations of each contracting party. That should include how NHS trusts in the UK can evidence eligibility for treatment, and how that can be done in the most efficient and least burdensome manner. I therefore say to the hon. Lady that much of the data she requests is already published. There is no suggestion that the new healthcare reciprocal arrangements will change the administrative burden; in certain cases, it is a simple matter of looking at coding within systems. However, only once the technical details are known will the Government be able to formally commit to any additional reporting, if necessary.
I am bound to say to the hon. Member for Burnley that when I saw that the new clause had been tabled, I remembered that 10 years ago, I was in the place she is in now. It is the traditional role of Oppositions to table these new clauses for almost every Bill; it is also the traditional role of Governments to reject them when they see them, as I remember only too clearly from when I was sat in the hon. Lady’s place. I therefore hope I have gone some way towards making clear to her that we are not trying to avoid any reporting requirement, or to shy away from any parliamentary scrutiny. There are already a number of reporting processes in place, and we want to make sure that any future reporting processes operate in a proportionate and considered manner. I hope that the hon. Lady will accept the spirit of my remarks, and that she will therefore choose not to press the new clause to a Division.
Julie Cooper (Burnley) (Lab)
It is a pleasure to serve under your chairmanship, Mr Streeter, and to respond to the Minister’s points. I appreciate some of his arguments, but we are in unprecedented times. As the Bill will facilitate the arrangement of a diverse range of agreements, it must cover every eventuality. It is therefore perfectly reasonable to expect the technical agreements, once they have been reached, to be reported back to Parliament annually. Parliament cannot be expected to grant a blank cheque. I accept that I do not have the Minister’s experience in this place, but large amounts of money will be spent on as yet unknown agreements, so it seems reasonable to request that, when the negotiations result in an agreement, it is reported back to Parliament once a year. That is the first thing that concerns me.
I should have thought that the Government would want to take the opportunity to report on the improved performance and collection of charges due to the UK in respect of all non-UK citizens seeking to access care in the UK.
Stephen Hammond
Indeed, and of course we are doing so. We have made that clear. As the hon. Lady knows, over the past four years we have quadrupled the amount of income we are recovering.
Julie Cooper
I am grateful to the Minister for that clarification, but my understanding is, as the Public Accounts Committee reported, that the Government have still not met their own targets on improved collection, and there will potentially be greater barriers to protection if several agreements are negotiated. I therefore want Parliament to have the opportunity to scrutinise the Government’s delivery on collection.
I am concerned that the Minister does not think it fitting for Parliament to have sight of an impact assessment of the additional burdens that the collection resulting from the as yet unknown agreements would have on NHS hospital trusts’ general financial wellbeing. I will press this new clause to a Division. I think it is sensible and reasonable, so there can be no cause to object to it.
Question put, That the clause be read a Second time.
Stephen Hammond
The new clause deals with the crucial question of healthcare on the island of Ireland. It focuses on reciprocal access to healthcare between Northern Ireland and Ireland, if there is no UK and EU deal, and would require the Secretary of State to set out plans for an agreement to protect medical access for British and Irish citizens moving between Ireland and Northern Ireland.
We agree that it is absolutely our intention to do two things. First, there should be a deal for reciprocal arrangements between the UK and the EU, and secondly, it is absolutely essential, in the unlikely scenario of no deal, that essential access continues. The UK and Ireland are committed to protecting reciprocal healthcare rights, so that UK and Irish nationals can continue to access healthcare when they live in, work in or visit the other country. We also want to maintain the co-operation between the UK and Ireland on a range of medical issues, including planned treatment, public healthcare and workforce. It is absolutely the intention of the Government that people should be able to live their lives as they do now, and that our healthcare systems support one another.
If there is no deal—in that unlikely scenario—the UK and Ireland will want to set out how we both agree to protect reciprocal healthcare arrangements, but it is also true, and the hon. Gentleman will know, that the UK Government are firmly committed to maintaining the common travel area and to protecting the rights currently enjoyed by UK and Irish nationals when in each other’s states. The hon. Gentleman’s issue about the border is mitigated by the fact that the UK Government are committed to maintaining the common travel arrangements, which allow full protection and maintenance of the status quo for all journeys for individuals between the UK and Ireland. It is currently estimated that there are something like 110 million crossings.
As I said earlier, as with other member states, we would expect to have a healthcare agreement between the two countries in the unlikely situation that there were no deal—an agreement that could be implemented into legislation that would provide the reassurances that the hon. Gentleman seeks. The NHS charging regulations can already exempt individuals that are covered by reciprocal healthcare arrangements. We can also use the powers in the Bill to maintain aspects of our current co-operation, such as reimbursement for healthcare costs and the sharing of data to support entitlements. I therefore say to the hon. Gentleman that I do not think the new clause is necessary, given the clear commitment by both sides. I hope he recognises that commitment and does not feel that he needs to press the new clause to a vote.
Justin Madders
I am minded not to press the new clause to a vote if the Minister assures us that he will endeavour to keep us updated on the contingency plans, if it looks like we are approaching a cliff-edge scenario. That is really what we are trying to achieve.
Stephen Hammond
Let me make the hon. Gentleman the same offer that I made to the hon. Member for Burnley. In that unlikely scenario, I guarantee that I will make my officials available to give a briefing to the hon. Gentleman and any member of the Committee who wishes to understand what our proposals are.
Justin Madders
I beg to move, That the clause be read a Second time.
On Second Reading, I spoke about the importance of dispute resolution, and asked the then Minister for Health, the right hon. Member for North East Cambridgeshire (Stephen Barclay), to set out how he envisaged it operating in both a deal and a no deal scenario. Despite some prompting from me and my hon. Friend the Member for Weaver Vale (Mike Amesbury), the Minister was not able to set out how dispute resolutions will be handled under the terms of any new agreement or even if the European Court of Justice will continue to represent a red line for the Government. The latter point is particularly interesting, given the new role of the right hon. Member for North East Cambridgeshire. It appears that he did not provide detail on that point because, at that stage, the Government were simply not in a position to confirm what was in the draft withdrawal agreement.
The Prime Minister categorically ruled out any jurisdiction of the European Court of Justice very early in the process, but I have yet to hear any serious suggestion about how disputes can be resolved, if we manage to reach a full reciprocal healthcare agreement with the EU27 beyond the transition period, without some reference back to the ECJ. The same concerns would apply if bilateral agreements were necessary in a no deal scenario.
Given the importance that the Prime Minister and members of her Cabinet have placed on the ECJ following our exit from the European Union, it is curious to say the least that we do not have a clear statement of intent from the Government while we debate this Bill. If their position continues to be that we will not have truly left the European Union if we are not in control of our own laws, as the Prime Minister put it in January 2017, it is vital that we have clarity about the arrangement that will be used in place of the ECJ. If a new arrangement is established, what will the cost be? Who will the judges be? Where will it be based? Will it be an open process?
If, on the other hand, we look to the ECJ for dispute resolution after all, even if only in the limited area of reciprocal healthcare, would that not represent a significant political U-turn? This issue is fundamental to the Government’s approach to Brexit. For example, they decided that we could not continue to host the European Medicines Agency, causing it to go to Amsterdam at the cost of 900 jobs in this country, and potentially hundreds of millions of pounds of investment. The Health Secretary’s sole justification for that was that the Government were not prepared to accept the European Court of Justice’s jurisdiction. Our purpose in tabling this new clause is to get clarity from the Minister about whether the European Court of Justice remains a red line for the Government.
Stephen Hammond
The new clause would place a duty on the Secretary of State to lay before Parliament a detailed strategy defining the process for settling disputes concerning healthcare agreements after we leave the European Union. No one in the room would dispute the spirit behind the new clause. As I have stated throughout our examination of the Bill, it is right that there should be transparency regarding the UK’s future relationship with the EU and other countries after exit. It is right that that transparency should apply to the arrangement of future healthcare agreements, and the processes that underpin them, such as dispute resolution, but, although I agree with the spirit of the new clause, I am not entirely sure that it would achieve its intended aim. I will give a number of reasons why.
The new clause would confer a duty on the Secretary of State to lay a strategy on the process for dispute resolution before Parliament. Both in a deal and a no deal scenario, such a strategy would be unlikely to provide information on the process for settling disputes concerning healthcare agreements that is not already available in the public domain. That is not due to a lack of endeavour; it is an issue of timing and consideration of what is already publicly available. In the expected scenario that the UK agrees a deal with the EU, the proposed process for settling disputes has already been confirmed in the White Paper on the future relationship, the draft withdrawal Bill that governs the implementation period and, most recently, the political declaration on the future relationship between the UK and EU. The processes have already been confirmed. They are outlined in those documents and would apply not only to disputes, but clearly therefore to disputes in any reciprocal healthcare agreement.
The hon. Gentleman asks what the dispute mechanism is. I am sure that the Committee will be pleased that I am not going to quote extensively from the withdrawal agreement, but it is worth putting on the record that the mechanism for resolving disputes will be through consultation at the Joint Committee, with the aim of reaching a mutually agreeable resolution. If the parties are not able to resolve the dispute in the Joint Committee, either party can request the establishment of an independent arbitration panel to resolve it. The panel will be made up of five members, with one person being the chairperson. The UK and the EU will nominate two members to sit on the panel and then mutually agree the fifth member, who will be the chairperson. The panel members will act independently and do not represent the party that nominated them. It is binding that the panel members be independent and impartial and they must possess specialised knowledge or experience of EU law and international law.
The hon. Gentleman challenges me on the role of the ECJ. He is right that the ECJ has a role here, but its role is very clear and very limited. The role of the ECJ after the implementation period will be restricted to ensuring the correct interpretation of EU law. There is no suggestion that the ECJ will determine the dispute, or that we would ever agree to the ECJ determining the dispute.
That is the likely scenario and the processes that are already formally set out via the documents that I described earlier. In the unlikely scenario that the UK leaves the European Union without a deal, the United Kingdom will arrange reciprocal healthcare agreements, and in those agreements, there will have to be bilateral dispute resolution. That would clearly have to be determined on a case-by-case basis as part of the negotiations to put those bilateral healthcare agreements in place, and, therefore, there is unlikely to be a single dispute resolution process, which is what the new clause suggests, so while I accept the spirit of it, the wording would restrict the ability for future reciprocal healthcare arrangements.
More importantly, the requirement for such a strategy to be laid before the House one month after the Bill receives Royal Assent does not align with the aim of the Bill to provide future reciprocal healthcare agreements with countries both inside and outside the EU. Clearly, those agreements are likely to be negotiated over a period of time and, as I have just mentioned, the dispute resolution mechanisms within them are likely to be different and may vary. It would therefore be arbitrary and unhelpful to produce a general strategy immediately after Royal Assent.
I understand the intention behind the new clause, but it would place an unnecessary burden and duty on the Secretary of State. In a deal scenario, the procedures are already there. In the unlikely no deal scenario, it would be likely to frustrate the ability to put in place future reciprocal healthcare agreements.
I hope that, having heard that, the hon. Gentleman will accept that, although we understand the spirit of his new clause, its wording would be likely to frustrate the purpose of the Bill. I therefore ask him not to press it to a vote.
Justin Madders
I am grateful to the Minister for setting that out in more detail than we were able to elicit on Second Reading. Given that the withdrawal agreement had not been published at the time, I understand why the then Minister was not able to do that. The present Minister has been very helpful in setting out the process for leaving with a deal. He is right that, if we leave without a deal, we are in uncharted territory. I do not think I heard any confirmation that there are red lines, in terms of the European Court of Justice, in that scenario. That is really what the new clause was meant to establish. I beg to ask leave to withdraw the motion.
Clause, by leave, withdrawn.
New Clause 4
Duty to consult with devolved administrations
Before issuing any regulations under this Act, the Secretary of State must consult the Scottish Government, the Welsh Government and the Northern Ireland Government and have regard for their views on the regulations.—(Justin Madders.)
Brought up, and read the First time.
Justin Madders
I beg to move, that the clause be read a Second time.
I hope this is a straightforward and uncontroversial new clause. We have already spoken about the importance of reciprocal healthcare arrangement to citizens in Northern Ireland, and of course there will also be an impact on patients in Wales and Scotland. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements, and why would they not?
The Delegated Powers and Regulatory Reform Committee was clear in its recommendation that there should be active participation of the devolved Administrations in setting out the UK’s position in future arrangements, but I am not aware that there have been any discussions. I would be grateful if the Minister could set out what conversations have taken place, because we did not get clarity on that on Second Reading.
The new clause repeats some of the issues that we raised this morning, which you did not have the pleasure of hearing, Mr Streeter. It is about the scope and power of the Bill and the wide range of duties given to the Secretary of State, which will be subject to the negative procedure. We think it is important that, as part of the Bill, when those wide powers are given to the Secretary of State, there must be a clear duty to consult with the devolved Administrations before those regulations are enacted.
The Fisheries Bill and the Agriculture Bill have dealt extensively with the need to involve the devolved Administrations. I think this is the bare minimum that we need. It would represent a consistent and equitable approach across the devolved nations, in terms of our future relationship with the EU.
Stephen Hammond
It is a pleasure to respond to this new clause, which addresses the extraordinarily important issue of engaging and working with the devolved Administrations. We completely agree that regulations made under the Bill may relate to devolved matters, by which I mean domestic healthcare. The Government will engage and meaningfully consult with the devolved Administrations in line with our existing arrangements, as found in the 2012 memorandum of understanding between the UK Government and the devolved Administrations, and the principles that underlie relations between us. That reinforces the positive work that the UK Government continue to do with the devolved Administrations daily for the benefit of the whole of the UK on this matter.
I am forced to reflect that, though the hon. Gentleman’s new clause is not necessary, the sentiment behind it is shared by everyone in Committee, I suspect. The regulation-making powers in the Bill provide us with a legal mechanism to implement international agreements domestically. The Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed with the EU, to the benefit of the residents of England, Wales, Scotland and Northern Ireland. The powers offer flexibility and can be used to implement comprehensive healthcare agreements with third countries in the future for the benefit of all UK nationals.
Healthcare (International Arrangements) Bill (Second sitting)
Stephen Hammond ExcerptsThursday 29th November 2018
(5 years, 5 months ago)
Public Bill CommitteesRead Full debate Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 View all Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 29 November 2018 - (29 Nov 2018)
The Chair
I remind the Committee that electronic devices should be turned to silent or turned off. Tea or coffee is not allowed in the Committee Room during sittings.
We now begin the line-by-line consideration of the Bill. The selection list for today is available in the room and on the Bill website. It shows how the selected amendments have been grouped together for debate. Amendments grouped together are generally on the same or similar issues.
A Member who has put their name to the leading amendment in a group is called first. Other Members are then free to catch my eye to speak on all or any of the amendments within the group, and a Member may speak more than once in a single debate. At the end of a debate on an amendment, I shall call the Member who moved the leading amendment again. Before they sit down, they will need to indicate if they wish to withdraw the amendment or seek a decision. I shall work on the assumption that the Minister wishes the Committee to reach a decision on all Government amendments if they are tabled.
Members should note that decisions on amendments do not take place in the order in which they are debated, but in the order in which they appear on the amendment paper. In other words, debate occurs according to the selection and grouping list, but decisions are taken when we come to the clause that the amendment affects. I shall use my discretion to decide whether to allow a separate stand part debate on individual clauses and schedules following the debates on the relevant amendments.
Clause 1
Power to make healthcare payments
Question proposed, That the clause stand part of the Bill.
The Minister for Health (Stephen Hammond)
It is a pleasure to serve under your chairmanship, Mr Stringer. This is a short, sensible Bill to ensure that we are prepared, whatever the outcome of leaving the European Union. The Bill confers powers on the Secretary of State to make and to arrange for payments to be made in respect of the cost of healthcare provided outside the United Kingdom. It will allow for the funding of reciprocal healthcare arrangements for UK nationals living in the EU, the European Economic Area and Switzerland.
The Bill is part of the Government’s preparation for EU exit and will allow us to take the necessary steps to broadly continue reciprocal healthcare arrangements or to otherwise support UK residents to obtain healthcare when they move to or visit the EU. It is an important and necessary piece of legislation, so that the British public can look forward to the future with the confidence that they will get the healthcare they need when they need it.
Clause 1 introduces a new power for the Secretary of State to make payments and to arrange for those payments to be made to fund healthcare abroad. I will start by setting out for the Committee why it is necessary for the Government to seek that power.
Currently, there are limited domestic powers in relation to the funding of healthcare abroad. The existing reciprocal healthcare arrangements with the EU are based on EU law. Reciprocal arrangements with other third countries at this time do not involve making payments, as they are based on waiver agreements. In line with the Public Accounts Committee concordat, the clause provides statutory authorisation for the expenditure in relation to future funding of healthcare abroad. It enables the funding of any reciprocal healthcare arrangements that the UK may enter into with EU member states, non-EU states and international organisations, such as the EU, as well as unilateral funding of treatment abroad if needed. It is a vital power to ensure a smooth transition post EU exit.
As a number of colleagues set out on Second Reading, including the Chair of the Select Committee on Health and Social Care, it is essential that the Government take appropriate measures to support a reciprocal healthcare arrangement and agreement with the EU. The Bill and the clause are crucial to that endeavour. Our arrangements with the EU are by their nature reciprocal and require a mutual understanding, and continuation of the arrangements are therefore a matter for negotiations between ourselves and the EU. It is incumbent upon any responsible Government to take forward responsible measures, and the Bill will ensure that we can broadly continue reciprocal healthcare arrangements, where agreed, with the EU. It is the Government’s ambition to ensure that we have the powers and the legal basis to implement comprehensive reciprocal healthcare agreements with other countries around the world, where that would be cost-effective and support wider health and foreign policy objectives after the EU exit.
Clause 1 means that we are ready to respond to any scenario concerning future reciprocal healthcare arrangements with the EU on exit day. In a deal scenario, we would use the power to fund a future reciprocal healthcare arrangement with the EU following the implementation period. In the unlikely no deal scenario, our offer to all EU member states would be to maintain reciprocal healthcare arrangements on a bilateral basis for at least a transitional period. We would use the power to fund those arrangements.
On 2016-17 estimates, the United Kingdom spends about £630 million per year on the EU system of reciprocal healthcare. That is an accrued liability where payments are made to individual member states on a monthly basis in arrears. Once we leave the EU, the clause will allow the Government to continue to fund such a system of reciprocal healthcare, subject to any agreement with the EU and/or EU member states.
The payment system for funding reciprocal healthcare arrangements is set out in EU law. In the future, detailed provisions could be given effect domestically by the regulations under clause 2(1), which we will discuss later, and the payments could be made by exercising clause 1.
Of course, the spending of any public money is and should be closely monitored. The money spent under clause 1 would be no exception to that rule—the usual safeguards apply. As with all departmental expenditure, it would need to be authorised by the Treasury supply process and will be included in the Department’s annual estimates, as well as being included in the annual resource accounts that are audited by the Comptroller and Auditor General. The exact arrangements will be provided for under the future reciprocal arrangements, which are obviously a matter for negotiation. It is envisaged that the current arrangements will be used as a basis for future arrangements with the EU.
It may be helpful to the Committee to look briefly at how the current process of payments works. At the moment, if a UK national were to injure themselves on a holiday in France, they would present their European health insurance card, commonly known as EHIC, at the hospital and receive the necessary treatment. The hospital would then raise an invoice for the treatment with its liaison body. In the case of the United Kingdom, that liaison body is the NHS Business Services Authority. The French liaison body would then submit a claim for the cost of the treatment to the NHS Business Services Authority based on receipt of the invoice from the hospital.
Once the NHS Business Services Authority is satisfied that the claim is accurate and valid, the UK would then release the payment to France, alongside any other claims received for that month. Our intention is to provide for those administrative and operational facets through the regulation-making powers in clause 2(1), which I referred to a moment ago and which we will discuss later. Clause 1 will provide for the payment element.
As is clear to all Committee members, the UK Government’s ambition is to have a reciprocal healthcare agreement with the EU, which should include reciprocal healthcare for state pensioners, UK participation in the EHIC scheme, and co-operation on planned treatment. We expect that that will continue to involve our making payments—for example, on the hundreds of thousands of British citizens who require treatment each year during their holidays in Europe. It also reflects current arrangements, whereby we receive money from EU member states when healthcare has been provided in the United Kingdom—for example, when a tourist to the United Kingdom has presented their EHIC.
It is, of course, our ambition to secure a future deal with the EU on the matter. Should that not be possible, we would seek to agree a broad continuation of the current system with EU member states on a bilateral basis for at least a transitional period. The Bill also provides flexibility to fund healthcare even where there is no bilateral agreement, which we might explore using in exceptional circumstances to secure healthcare for certain groups of people.
At the outset of the Committee’s line-by-line scrutiny, I put on the record my thanks to all hon. Members who spoke on Second Reading and who were supportive of the Bill in principle, and I thank hon. Members for their attendance today. I am also grateful, as I am sure everybody is, to the witnesses who attended on Tuesday. I put on the record my thanks to them, not only for giving us their valuable insight but for supporting the Bill.
Hundreds of thousands of people rely on reciprocal arrangements to access healthcare every year. Ensuring that the Government have a clear legal basis on which to fund these arrangements in the future is an essential component of allowing us to meet our shared goals in this area. I therefore recommend that the clause stand part of the Bill.
Question put and agreed to.
Clause 1 accordingly ordered to stand part of the Bill.
Clause 2
Healthcare and healthcare agreements
Question proposed, That the clause stand part of the Bill.
Stephen Hammond
This clause goes to the heart of the purpose of the Bill. It will ensure that the Government have the discretionary powers they need to respond flexibly to all possible outcomes of EU exit; to make regulations in relation to making or arranging payments in respect of healthcare provided abroad; to make regulations to support the provision of healthcare outside the United Kingdom; and to make regulations to give effect to complex international healthcare agreements. The Government can use such regulations to confer or delegate functions. The clause also provides that the Government can issue directions to a person about exercising functions as circumstances require. The powers in the clause are needed to provide the Government with both the flexibility and capability to implement detailed and complex arrangements concerning healthcare abroad. These powers ensure that we are taking the appropriate measures to be able to respond to the multiple EU exit scenarios.
As I remarked earlier regarding the powers in clause 1, as a responsible Government we believe that it is important to take forward appropriate measures. The Bill, and the clause, will ensure that we can broadly continue reciprocal arrangements with the EU where agreed, or, if necessary, with individual EU states on a bilateral basis. The Bill will support the potential strengthening of existing reciprocal healthcare agreements with countries abroad and around the world, and will potentially add to their number as part of future health and trade policy. I am grateful to my hon. Friend the Member for East Renfrewshire, who supported this facet of the Bill on Second Reading.
Facilitating the provision of healthcare for UK nationals abroad can be incredibly complex, and the scope of these powers necessarily reflects that. For example, the EHIC system is a broad and generous scheme for all UK and EU nationals. It covers a variety of different types of care, including emergency care, ongoing routine maternity care or a trip to a GP while abroad for someone with a chronic condition.
As I mentioned, it is our intention to negotiate a future arrangement with the EU that provides broad continuation of the current reciprocal healthcare system, including our participation in the EHIC scheme. That is a complex arrangement to provide for, and requires suitable domestic implementation to ensure that it operates effectively. It is therefore necessary and appropriate for the Government to seek suitably flexible powers to make regulations and directions that will allow us to implement such a scheme. It is also appropriate that these powers should afford us the capacity to implement and make provision for similar arrangements with other countries all over the world where this would be cost-effective and would support wider health and foreign policy objectives. The powers in the clause ensure that we are taking the appropriate measures to be able to respond to multiple EU exit scenarios, including the making of regulations for, or in connection with, the funding of provision for healthcare abroad and for implementing healthcare agreements.
Justin Madders (Ellesmere Port and Neston) (Lab)
It is a pleasure to serve under your chairmanship, Mr Stringer. First of all, I join the Minister in thanking those witnesses who came and gave evidence on Tuesday. There were certainly some helpful comments that we will no doubt return to in Committee.
As was made clear on Second Reading, this is a very important piece of legislation. More than 190,000 UK expats live in the EU and of course there are 50 million British visits within the EEA countries each year: all those people want clarity about what the arrangements are in the event that they will need healthcare. So we do not oppose the principle of the Bill. We absolutely agree that it is important that there are arrangements in place after 29 March 2019 and into the future. However, we are concerned about a number of issues, some of which I referred to on Second Reading and some of which we will discuss today.
It is fair to say that there are concerns about the breadth of powers that the Secretary of State is requesting in clause 2; I do not believe they would be countenanced at all under normal circumstances. I appreciate that we are not in normal circumstances and I am grateful to the Minister for setting out how he envisages those powers will be used in practice. We are not here to judge things just on what the situation is at the moment, but on how the powers could be used at some point in the future. With regard to that, the Minister referred to this Bill being used possibly to further foreign policy and trade objectives. When he responds, I would be grateful if he expanded on what he has in mind.
To compound our issues about the scope of the regulations, we are also concerned about our lack of opportunity to scrutinise them; we will return to those concerns when I move amendment 2 to clause 5 later on. Of course, we are not alone in having concerns about the scope of this clause and the lack of clarity about how the powers might be used. In the evidence session, Raj Jethwa, Director of Policy at the British Medical Association, said:
“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6.]
We will certainly push for that today.
The Delegated Powers and Regulatory Reform Committee in the other place went further than that, describing the scope of clause 2 as “breath-taking”. As that Committee correctly pointed out, there is no limit to the amount of any payments, to who can be funded or to the types of healthcare being funded. The regulations can confer or delegate functions to anyone, anywhere, and primary legislation can be amended for these purposes.
It is also worth noting that although this legislation has been presented as a Bill to enable us, as far as possible, to retain the arrangements that we already have—who would disagree with that?—the powers conferred by the clause, as I think has been conceded by the Minister, can go far beyond the current EU and EEA countries that we are primarily concerned about.
We consider the powers in the clause to be inappropriately wide, if they are not going to be subject to the correct levels of scrutiny. At this eleventh hour, we understand why a certain level of flexibility is being sought by the Government, but with that request comes a responsibility to ensure that proper parliamentary scrutiny is exercised.
Rather than oppose the clause in its entirety, we believe that the appropriate remedy would be to ensure that any regulations introduced under the Bill will be subject to the affirmative procedure. We will return to that point when we consider amendment 2 to clause 5.
Stephen Hammond
The hon. Gentleman is right to say that these powers are flexible. Part of the reason for that is that there may well be a need to anticipate the sort of bilateral arrangements that we put in place in the future—notwithstanding our hopes that we will secure a continuation of the current reciprocal healthcare arrangements, which is our ambition. When we come to debate not only the hon. Gentleman’s amendment, but clause 5—when the discussion on scrutiny of these arrangements should take place—I will seek to reassure him that the procedures in place will allow for the usual and appropriate parliamentary scrutiny of the Bill.
The hon. Gentleman talked about the powers being too broad. The Bill has a very focused purpose: to ensure that the reciprocal healthcare arrangements, which benefit UK nationals abroad and also EU and non-EU nationals in the UK, are continued. He also challenged me on the issue of potential future trade or foreign policy objectives. As he will know, we already have arrangements with a number of countries outside the EU, and the Bill must have the flexibility for the continuation and updating of those arrangements. The matter will clearly be of operational importance—potentially, it will be a policy decision after exiting the EU. Were a UK holidaymaker going abroad to a non-EU country, they would clearly expect the Government to have in place—or to have the potential to put in place—the reciprocal healthcare arrangements that would allow them to be treated should that be necessary.
I hope those words will satisfy the hon. Gentleman that the clause needs to stand part of the Bill. We can have the appropriate discussion about scrutiny in somewhat more depth when we debate clause 5.
Question put and agreed to.
Clause 2 accordingly ordered to stand part of the Bill.
Clause 3
Meaning of “healthcare” and “healthcare agreement”
Question proposed, That the clause stand part of the Bill.
Stephen Hammond
Mr Speaker—sorry, Mr Stringer: although who knows what may happen later next year?
Stephen Hammond
One that I am sure would be welcomed by Members on both sides of the Committee.
Clause 3 is very simple and sets out the definition of “healthcare” and “healthcare agreement” used within the Bill. The definition of healthcare is modelled on the definition provided in the Health and Social Care Act 2012, which we have adapted to include the additional element of ancillary care. That is to reflect where current arrangements provide for ancillary costs, such as travel, which do not fit strictly within the definition of healthcare. As in France, this is for use in circumstances where residents are reimbursed a contribution of their travel costs when attending healthcare appointments.
I would like to clarify that access to social care in England would not be provided for through any reciprocal healthcare agreement. It is up to each individual country to determine what is available through the public healthcare system, just as we do with the NHS. The clause would enable individuals to access healthcare on those terms.
A healthcare agreement could be made either bilaterally or multilaterally, or it could be an agreement between states, countries or multilateral organisations. Such agreements provide access to agreed forms of healthcare when individuals from one country seek healthcare in the other, and vice versa. They also provide for how the funding will be shared between parties. Funding could mean a direct payment, arrangements to waive or set off costs, or other arrangements to cover costs. Clause 3 is short but important.
Question put and agreed to.
Clause 3 accordingly ordered to stand part of the Bill.
Clause 4
Data processing
Julie Cooper (Burnley) (Lab)
I beg to move amendment 1, in clause 4, page 3, line 17, leave out paragraph (d).
It is a pleasure to serve under your chairmanship, Mr Stringer, and I am pleased to have the opportunity to speak to clause 4. At this time of great uncertainty, when the nature of our future relationship with the European Union is still unknown, we welcome the intention outlined in the Bill to give some confidence to those who currently rely on the reciprocal health arrangements between the UK and the nations of the EU and EEA. We are only surprised that the Bill has taken so long to come before us.
The scope of the Bill is designed to cater for all possible outcomes of the UK and EU negotiations. The intention is that, deal or no deal, the Bill will empower the Secretary of State to negotiate future reciprocal healthcare arrangements between the nations of the UK and the EU, and any other such nation as is desired. Providing for pensioners, visitors, students and workers to live, work, study and travel in EU member states with complete peace of mind regarding the provision of healthcare is a priority for Labour. We therefore recognise the need for the Bill.
While understanding that any future agreement must allow for the smooth transference of data for the achievement of the best possible outcomes for patients, we believe it is also crucial that the Bill provides robust powers to protect personal data. Health records contain both personal and sensitive data, and access to such information must be allowed sparingly and only for medical purposes. Access to personal data should be available to health professionals who are bound by a duty of confidentiality on the basis of need to know. The Data Protection Act 2018 outlines the key principles relating to the protection of data; compliance with the spirit of those principles is fundamental to good data protection practice, and embodies the spirit of lawful, fair and transparent use of data.
Currently, the General Data Protection Regulation places restrictions on the transfer of personal data to countries outside the EU and EEA. As the UK leaves the EU, we will not automatically enjoy existing protections; indeed, this Bill provides powers for negotiations to take place with nation states across the world, to reach agreement on a bilateral basis. That makes it imperative, in our view, that the Bill protects against potential misuse of personal data.
Clause 4 outlines the detail of how data will be processed for the purposes of the Bill. We have noted the wide-ranging powers to be given to authorised persons, who may
“process personal data held by the person in connection with any of the person’s functions where that person considers it necessary for the purposes of implementing, operating or facilitating the doing of anything under or by virtue of this Act.”
We are not satisfied that sufficient safeguards are in place when defining an authorised person for the purposes of the Bill. We have listened carefully to the concerns of the British Medical Association, and share that organisation’s concerns about the lack of detail in the definition of “authorised person” in subsection (6). Mr Jethwa, representing the BMA, said in his evidence to this Committee that data
“has to be accessed on a need-to-know basis, and only when it is in line with patients’ expectations. Data sharing has to be transparent. We would be absolutely concerned that any safeguards meet those criteria and principles. I do not think the details in the Bill make that clear at the moment. We would like to see more clarity and detail about that in future.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 5, Q14.]
Mr Henderson, from the Academy of Medical Royal Colleges, said that although he recognises that there must be a “free flow” of data,
“individual patients’ data must be protected”,
and that
“it is slightly hard to say whether there is sufficient protection there or not”.––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 5, Q13.]
He is correct: it is hard to see that there are sufficient protections in the Bill. This is a hugely important issue that needs to be fully addressed.
With that in mind, we are of the view that subsection (6)(d) should be deleted, principally because it gives the Secretary of State a power—to authorise private health companies to access patient data—that is far too wide ranging. We believe that removing that paragraph protects personal data and achieves a balance, giving more confidence to patients while allowing the smooth transfer of data to designated qualified personnel.
The right to privacy and access to healthcare are rights that we value, and the one should not be conditional on the other. We wish to ensure that the Bill gives UK patients, and patients from the EU, full confidence that their personal information will not be shared inappropriately. That remains the case whether healthcare is received in the UK or overseas as part of a reciprocal healthcare agreement. As we leave the European Union, citizens accessing medical care as part of a reciprocal health agreement need to be sure that their personal data will not be shared inappropriately. Without that assurance, citizens may be discouraged from seeking medical assistance.
Stephen Hammond
I thank the hon. Member for Burnley for moving this amendment, because it gives me the opportunity to set out clearly and in some depth why we have chosen to include clause 4(6)(d) in the Bill. I want to lay out the reasoning for our concerns about this amendment. I hope that I will be able to reassure her of the vital importance of paragraph (d), and that it is necessary and appropriate, because we will be unable to accept the amendment.
Reciprocal healthcare agreements are made possible by close, consensual co-operation of different parties and bodies, such as the Department of Health and Social Care, the Commissioners for Her Majesty’s Revenue and Customs, Ministers of devolved Administrations, healthcare providers and all their opposite numbers in EU and EEA countries. Since the Bill is about the provision of healthcare, it would be remiss of Her Majesty’s Government to exclude healthcare providers, either those in the United Kingdom or those in other countries, from the list with authority and sanction to process and share data. Given that it is the Government’s position that in the agreement with the EU, future arrangements for the provision of healthcare abroad will reflect existing ones, it is worth reflecting on the place of healthcare providers in these processes, to illustrate the role they play in the commission and delivery of healthcare abroad.
Under the S2 route, a UK resident may decide to seek planned treatment abroad. As part of the ordinary procedure, the UK resident must visit a healthcare provider in the UK. The clinician would then provide written evidence that the person has had a full clinical assessment, which must clearly state why the treatment is needed in their circumstances and what the clinician considers to be a medically justifiable time period within which they should be treated again, based on their circumstances. As is clear under existing arrangements, this function can only be served by a medically trained healthcare provider. This paperwork is then passed on to NHS England or the comparable authority in the devolved Administrations for further processing. Many of those organisations are provided for by subsection (6)(c). Members will, I hope, understand that the lack of qualification around the term “provider of healthcare” is appropriate and necessary at this stage, given that future arrangements are not yet clear.
If the Government are adequately to fulfil the purposes outlined in clause 1, they need to be able to facilitate and fund healthcare for UK persons, for whom they feel responsible, whether the provider is based in the UK or overseas. In that connection, I think it is worth pointing out that the current reciprocal healthcare arrangements allow UK persons to access treatment from providers of healthcare in another country that are not NHS bodies or comparable state providers in another country, as defined by UK healthcare legislation. That might include an optometrist or a dentist, many of whom fall outside the state healthcare system.
Subsection 6(d) proposes to ensure that other types of healthcare providers are authorised to process personal data under the Bill, but most importantly that NHS bodies are able, where necessary, to share personal data for the purposes of the Bill with healthcare providers based outside the UK. Simply, if such providers were not also considered authorised, it would be impossible for healthcare commissioned, implemented, facilitated or funded by the UK to be authorised to be rendered abroad.
The hon. Lady is concerned that the clause will allow private providers access to patient data and the powers to process it. She should be reassured that that is already legal and proper under existing arrangements governed by EU regulations. Under existing reciprocal healthcare arrangements, UK persons are able to receive treatment in another country on the same basis as a local resident of that country. That includes healthcare or other treatments given by healthcare providers other than those that fall within the scope of domestic UK healthcare legislation.
After the fact and on return to the UK, the person would be able to seek reimbursement, where appropriate, from the relevant UK authorities. It is worth noting that the person who sought treatment abroad would typically only be reimbursed up to the amount it would have cost under the NHS. It would be for the person, not the Department of Health and Social Care, to bear the financial risk of any additional cost.
Since our desire to continue existing arrangements is shared by those on both sides of the House, I do not feel that the clause has inappropriate powers. To further allay any other fears, I remind members of the Committee that the clause contains safeguards to guard against any misuse of data. The Bill gives powers to providers, either in state healthcare systems or private ones, to process solely where it is necessary for the limited purpose of funding or arranging healthcare abroad—nothing more.
All processing of the data by all parties must also comply with existing data protection legislation. That is a crucial safeguard under UK data legislation. Data concerning healthcare is personal or specific category data. That can only be processed where specific conditions are met, namely that processing is necessary for the purpose of healthcare and in the public interest. Members will recognise that clause 4(6)(d) does not represent a deviation or new departure from existing arrangements and simply allows for the Government to maintain or improve those arrangements in whatever circumstances we find ourselves in after exit.
In closing, were the amendment agreed, it could risk patient outcomes by excluding providers of healthcare from the list of authorised persons. The hon. Lady expressed some concerns, and I hope that my response has allayed them. I offer to make my officials available to provide a briefing on this matter to her and any other member of the Committee who should so wish, so that they can be completely reassured that the normal data protection legislation will apply to the Bill. The exchange of data may happen only for a limited and focused purpose. The hon. Lady was right to express her concerns, and I hope she will be reassured by my words and that she will not feel the need to press her amendment to a Division.
Julie Cooper
I am grateful to the Minister for those explanations, and I welcome him saying it is a very limited and focused use of the data. I would be happy to take a briefing from his officials, but further to that, to give assurance to our side, I would be grateful if he will undertake to go further on Report and outline the scope of the subsection. If he will do that, we will not press the amendment to a Division.
Stephen Hammond
We will carefully consider what the hon. Lady has said and her request for further details on Report. I have listened and have offered that briefing, and I hope that is sufficient for her to decide not to press the amendment to a Division now.
Julie Cooper
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Question proposed, That the clause stand part of the Bill.
Stephen Hammond
I will try to limit my comments, given that we have already had discussions on the amendment. I am sure that will be welcome on this cold November day in a rather warm room.
Clause 4 provides a clear legal basis for processing personal data under the Bill for the purposes of UK data protection legislation. At present, the EU regulations provide a lawful basis for processing data for the purposes of reciprocal healthcare. Personal data is integral for providing healthcare abroad. It is vital that authorised persons in the UK can process data for that purpose. The clause ensures that, after exit day, there is a clear and transparent basis for processing personal data for the purposes of providing healthcare abroad, as required by UK data protection legislation. Clause 4 will ensure that safeguards are in place for that processing.
Subsection (1) limits processing to that which is necessary for the purposes of the Bill. Subsections (2) and (3) ensure that any such processing must remain in compliance with UK data protection legislation and the Investigatory Powers Act 2016, and any other relevant restrictions. Finally, the persons who can process data under the Bill are limited to those authorised in subsection (6), which we have just discussed.
The safeguards limit the scope of clause 4 to what is necessary and proportionate to provide healthcare abroad. For reciprocal healthcare, personal data is required to process reimbursements to and from other countries, and where reimbursement is made to a person as well. It is also sometimes necessary for healthcare providers to share medical information to facilitate treatment. The clause ensures that the Government can continue to process personal data as necessary, after exit day, in an effective and lawful way. Personal data transferred from outside the UK will remain subject to the need for safeguards to be put in place before it is transferred. Those safeguards will not be able to be contracted out as part of any healthcare agreement with the EU or member states or third countries.
As I said a moment ago, subsection (1) provides for an authorised person to process data related to the provision of healthcare abroad. Personal data is defined in the GDPR as data that relates to a living person who can be directly or indirectly identified from the data. Specific category data is personal data containing health and genetic data. At present, there are different routes for providing healthcare abroad, such as the S1, S2 or EHIC routes, and each route requires different forms of personal data.
Subsection (2) disapplies the duty of confidence and any restriction on the processing that would otherwise apply. The exemption ensures that data can be disclosed where it is necessary for the limited purposes of the Bill. The measure is necessary and appropriate. For example, authorised persons may need to share data if a person is unconscious and therefore not in a state to provide it themselves. Importantly, as expressed in subsection (3), data processing must continue to comply with the UK data protection legislation, which ensures there are further safeguards around data processing. The GDPR also governs data transfers between the UK and other countries. All EU and EEA countries are bound by the GDPR, which means the relevant national data protection safeguards in each country are adequate, allowing the free transfer of data between countries.
Subsection (3)(a) expressly requires that the processing of data does not contravene existing data protection legislation, and subsection (3)(b) requires that the processing of data must comply with parts 1 to 7 or chapter 1 of part 9 of the Investigatory Powers Act 2016. The only purposes for which investigatory powers may be required are to investigate and tackle suspected cases of fraud and error relating to healthcare abroad.
As set out in subsection (1), the processing of data under the Bill is limited to authorised persons who, as we have discussed, are defined in subsection (6). The list reflects those persons and bodies currently involved in processing data, including personal data under existing reciprocal healthcare arrangements.
I mentioned that, for clarity’s sake, subsection (6)(a) lists
“the Secretary of State, the Treasury, the Commissioners for Her Majesty’s Revenue and Customs, the Scottish Ministers, the Welsh Ministers and a Northern Ireland department”.
Healthcare abroad is entirely managed and operated by the Department of Health and Social Care in co-operation with the Executives in the devolved Administrations and their local healthcare systems. Although the Bill is about the provision of healthcare abroad, it is vital that the Executives of the devolved Administrations are considered authorised persons, since healthcare abroad is often facilitated in co-operation with them. Under subsections (6)(b), (c) and (d), healthcare bodies and providers are considered authorised persons as they are directly involved in the provision of healthcare.
Finally, subsection (6)(e) gives the Secretary of State the power to add to the list of authorised persons, which will ensure that the Government can respond appropriately, whatever the outcome of EU exit. It is also deemed necessary to allow the Secretary of State to respond to the changing demands of systems and operations. In future, duties may change and adding to the list will be difficult, so it is necessary to have the power in place.
Clause 4 is an important component of the Bill. It provides the Government with the necessary power to process and share data that relates to healthcare provided abroad. Therefore, I recommend that the clause stand part of the Bill.
Question put and agreed to.
Clause 4 accordingly ordered to stand part of the Bill.
Clause 5
Regulations and directions
Justin Madders
I beg to move amendment 2, in clause 5, page 3, line 44, leave out subsection (5) and subsection (6) and insert—
“(5) Any statutory instrument which contains regulations issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a resolution of each House.”
This amendment would make all regulations issued under this Act subject to the affirmative procedure and require approval from Parliament before they become law.
This amendment is probably one of the most important items that we will discuss in Committee. As I made clear when we discussed clause 2, there are widely held concerns about the scope of the regulations, which are exacerbated by the fact that these extraordinarily wide powers, necessary as they may be in the circumstances, are subject only to the negative procedure.
As I referred to earlier, the Delegated Powers and Regulatory Reform Committee in the other place clearly set out the potential impact of my amendment not being accepted when it said:
“If, without such amendment, the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure. Of course, these examples will not be priorities for any Secretary of State in this country.”
I hope that is the case, but we are here to look at how the powers could be used over, possibly, the next 100 years, and not just how we would expect them to be used in the foreseeable future.
Nobody knows where this process will take us, and when examining legislation there is always merit in considering the unlikely as well as the stated intentions of the Government at the time. The Minister’s comments about wider objectives reaffirms the importance of our scrutinising the regulations as much as possible. We find ourselves in an unprecedented situation in Parliament, and it is therefore important that we consider all eventualities.
If Committee members need further persuasion that the amendment should be carried, that Lords Committee set out a devastating list of reasons why the negative procedure is inappropriate. It said:
“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere. The regulations can delegate functions to anyone anywhere.”
The Committee concluded:
“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”
The most significant reason why we do not object to the legislation is that the biggest risk at this stage is that arrangements are made that do not safeguard the ability of our constituents, when they travel abroad, or of UK citizens who currently live overseas to access healthcare, as they do now. However, because of the way the Bill is drafted, we will find that we are unable to debate whether those safeguards are in place as a matter of course. We have heard many references to the 190,000 UK expats living abroad and the 50 million or so nationals who travel to EEA countries every year. These are huge numbers of people, and the impact of the legislation on them is potentially huge. We owe it to all those people to ensure that any future arrangements are properly scrutinised.
We also need to consider the impact of any new arrangements on the NHS. As Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, set out in evidence on Tuesday:
“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]
He went on:
“In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 4, Q9.]
If we do not agree to the amendment, Parliament could end up in that scenario without any voice.
While there is scope for the affirmative procedure to be used in cases where Henry VIII powers are invoked to amend primary legislation, I think it is pretty clear that potentially the most significant changes to reciprocal agreements that could be enacted under the legislation are those that are subject only to the negative procedure. As we know, the negative procedure means that an instrument is laid in draft and cannot be made if that draft is disapproved within 40 days, normally via a prayer against, which is usually by way of an early-day motion. If that does not happen, the legislation is then passed. That is a 40-day process in the best-case scenario.
If I am correct, and if we leave without a deal, the Secretary of State will have to reach agreement with each of the 30-plus countries no later than Friday 15 February, assuming that Parliament does not sit on the following Sunday. At this stage, who knows where we might end up, but we will assume for now that the sitting days are as set out, so Friday 15 February will be the last day that an instrument can be laid that will pass before 29 March, assuming that it is not prayed against. Hopefully the Minister will be able to advise whether my understanding of the timetable is correct.
Will the Minister concede that, on a practical level, it would be better for regulations moved under the Bill to be moved using the affirmative procedure? We could then get them through scrutiny in both Houses much quicker than the 40-day procedure currently allows.
Stephen Hammond
The hon. Gentleman raises some important issues, including the issue at the heart of the clause—the appropriate, necessary and correct scrutiny arrangements for Parliament. Let me be clear at the start: the Government absolutely recognise the importance of appropriate levels of scrutiny of the Bill and its subsequent secondary legislation. It is clearly the hallmark of any effective parliamentary system that there are processes in place by which we draft, consider and test legislation. After all, that is what we are doing today.
The appropriate parliamentary procedure for the scrutiny of regulations made under the Bill that do not amend, repeal or revoke primary legislation is the negative procedure. If I am not able to reassure the hon. Member for Ellesmere Port and Neston and he chooses to press the amendment to a Division, I am afraid the Government will resist it.
Justin Madders
I am afraid the Minister has not managed to reassure me, despite his best efforts. When a Bill would confer power on the Executive, we have to be very careful about giving that power away. It cannot be done without good reason, even in these extraordinary times. I have not heard any justification for giving such sweeping powers to the Secretary of State without adequate scrutiny. No matter how well-intentioned the Minister is in his responses—I acknowledge his sincerity —we do not know who will be doing what in 12 months’ time. As we said earlier, we could be handing a future Secretary of State the ability to enter into arrangements for hip replacements in Australia or such like.
As the Minister said, the regulations will enable the Government to enter into detailed and complex arrangements on future healthcare. That is precisely why we need them to be subject to the affirmative procedure. I appreciate the point about the treaties possibly containing more detail, but this is about how Parliament will be able to scrutinise and challenge those arrangements.
Stephen Hammond
The hon. Gentleman will have heard that the treaty arrangements will be subject to parliamentary scrutiny in the normal way. We are discussing the regulations as to how we enact those treaties. I was hoping that he might be reassured by that.
Stephen Hammond
Having failed to reassure the hon. Member for Ellesmere Port and Neston, I will have another attempt in this stand part debate. Clause 5 supplements the substantive regulation-making powers in clause 2. It provides detail on the parliamentary procedure, as we have already discussed, that will apply to regulations made under the Bill. Subsections (1) and (2) introduce standard provisions, and are consistent with regulation and direction-making powers in many other Acts of Parliament, such as the Health and Social Care Act 2012 and the National Health Service Act 2006.
The clause is required to ensure that regulations and directions made under the Bill will be fit for purpose. As I have said, the powers in the Bill provide the Government with the flexibility and capability to ensure and implement detailed and complex arrangements concerning healthcare abroad. For example, the Government may use regulations to confer different functions on different bodies, in order that they may implement and operate effectively what may be provided for in an agreed reciprocal healthcare agreement. We do that now in relation to the EHIC scheme, which, as I said earlier, the NHS Business Services Authority administers on behalf of the Department. That administration includes the registering and issuing of EHICs and the processing of EHIC claims.
Future administrative arrangements to implement reciprocal healthcare agreements may reflect the current situation, or may involve conferring different functions on other bodies, as appropriate. Once the arrangements are negotiated, we will be in the best position to decide what the appropriate bodies to administer those arrangements are. We will be able to provide for the practical processes and implementation arrangements through the regulations. Clause 5 provides the Government with the flexibility to ensure that any healthcare arrangements can be implemented effectively and efficiently.
Subsection (3) provides that regulations made under clause 2
“may amend, repeal or revoke primary legislation…for the purpose of conferring functions”,
or
“to give effect to a healthcare agreement.”
I want to try again to reassure the Committee about that. The Government are conscious that Parliament rightly takes an interest in this area and, of course, we share the view about the importance of scrutiny.
This is a consequential power to make amendments to primary legislation, which is limited to three restricted uses: for the purpose of conferring functions, to give effect to a healthcare agreement and to make modifications to retained EU law. It is not a free-standing power; it is a focused power to ensure that we can implement healthcare arrangements effectively. That may involve conferring functions on healthcare bodies, which could involve amending primary legislation.
Subsection (4) provides that:
“Regulations under this Act may amend, repeal or revoke retained EU law”,
which is the body of existing EU law that the European Union (Withdrawal) Act 2018 will convert into domestic law, together with the laws we have already made in the UK to implement our EU obligations. It is vital that the regulation-making powers extend to amending, repealing and revoking retained EU law, because the bulk of the existing provisions that relate to current reciprocal healthcare arrangements with the EU will be EU retained law.
Subsection (4) will ensure that domestic legislation in that area is clear and accessible. It will allow us to amend EU retained law, where appropriate, to give effect to new reciprocal healthcare arrangements. It would be an oversight if the Bill did not provide for such amendment, given that current reciprocal healthcare arrangements with the EU are entirely bound up in EU law.
I stress again that, of course, Parliament will be given the opportunity for the appropriate scrutiny of regulations made under the Bill that amend, repeal or revoke primary legislation. As such, subsection (6) makes it clear that regulations that contain provisions that make modifications to primary legislation will be subject to the affirmative resolution procedure and, therefore, Parliament will have the opportunity to debate them. That is the parliamentary scrutiny procedure befitting Henry VIII powers, and one that allows for proper scrutiny.
Regulations made under the Bill that do not contain provisions that amend, repeal or revoke primary legislation will be subject to the negative resolution procedure. It is our job—and I think it is only right—to ensure that legislation is afforded the appropriate level of scrutiny. Therefore, regulations that are made under the Bill that do not amend, repeal or revoke primary legislation should be subject to the negative procedure, as is normal.
The remit of our regulating powers is focused. They can be used only to give effect to healthcare agreements or to arrange, provide for or fund healthcare abroad, as is clear in the enabling powers found in clause 2(1). Where the UK negotiates a comprehensive international healthcare agreement, whether multilaterally with the EU or bilaterally with EU members, the most important element that sets out the terms of that agreement would be included in the agreement itself, as hon. Members would expect. Regulations that give effect to such an agreement would likely focus on procedural, administrative and technical details, such as the types of documents or forms that could be used to administer those reciprocal healthcare arrangements, which is a point I made earlier.
In a scenario where a comprehensive healthcare agreement is being implemented through regulations made under clause 2(1)(c), that agreement would be subject to parliamentary scrutiny under the ratification procedure contained in section 20 of the Constitutional Reform and Governance Act 2010. That ratification procedure provides an opportunity for parliamentary scrutiny of the substance of the healthcare agreements being given effect to in the regulations made under the Bill. It is for those reasons that I rejected amendment 2, which the hon. Member for Ellesmere Port and Neston moved a moment ago.
The final provision of the clause, subsection (7), sets out the definition of “primary legislation”. To reassure the hon. Gentleman, and the Committee, the Government absolutely understand and appreciate the necessity for appropriate parliamentary scrutiny. The level of scrutiny must reflect the substance of the piece of legislation. That is what I believe the clause does, and I therefore recommend that it stand part of the Bill.
Justin Madders
The Minister and I will not agree on that, unfortunately. I will not repeat the arguments that we have already gone through, but I will remind hon. Members that the Lords Delegated Powers and Regulatory Reform Committee described the powers and regulation as “breath-taking”, and said that
“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere.”
The scope of the clause is breath-taking. Although the Minister is trying to reassure us, as parliamentarians, we need the security of the affirmative procedure.
Stephen Hammond
I wish to introduce this short clause, which I suspect will be somewhat less contentious than the previous one. Subsection (1) provides that the Bill extends to England and Wales, Scotland and Northern Ireland. Subsection (2) provides that the Bill will come into force on Royal Assent, which reflects the need to respond to the range of possible EU exit scenarios in a timely manner. Subsection (3) establishes that the short title of the Act will be Healthcare (International Arrangements) Act 2018. With that short explanation, I recommend that the clause stand part of the Bill.
Clause 6 accordingly ordered to stand part of the Bill.
New Clause 1
Annual report on the cost of healthcare arrangements
‘(1) The Secretary of State must lay before Parliament an annual report setting out all expenditure and income arising from each healthcare arrangement made under this Act.
(2) The annual report laid under subsection 1 must include, but is not limited to—
(a) all payments made by the government of the United Kingdom in respect of healthcare arrangements for healthcare provided outside the United Kingdom to British citizens;
(b) all payments received by the government of the United Kingdom in reimbursement of healthcare provided by the United Kingdom to all non-British citizens;
(c) the number of British citizens treated under healthcare arrangements outside the United Kingdom;
(d) the number of non-British citizens treated under healthcare arrangements within the United Kingdom;
(e) any and all outstanding payments owed to or by the government of the United Kingdom in respect of healthcare arrangements made before this Act receives Royal Assent; and
(f) any and all administrative costs faced by NHS Trusts in respect of healthcare arrangements.
(3) The information required under section 2(a) and 2(b) above must be listed by individual country in every annual report.’—(Julie Cooper.)
Brought up, and read the First time.
Julie Cooper
I beg to move, That the clause be read a Second time.
I should stress that we support the intention of the Bill. Providing that UK citizens can live, work, study and travel in EU member states with complete peace of mind with regard to the provision of healthcare is a priority for us. We are aware that, under existing arrangements, the healthcare of 190,000 UK state pensioners living abroad, principally in Ireland, Spain, France and Cyprus, and of their dependent relatives, is protected.
In addition, we seek to ensure that the health benefits currently enjoyed by UK residents who visit the EU on holiday or to study continue, so that they may use the European health insurance card to access healthcare and emergency treatment for healthcare needs that arise during their stay. We also seek to continue the arrangement under which EU nationals receive reciprocal provision when they visit the UK post Brexit.
We note, however, that the Bill is intended to provide for all reciprocal healthcare arrangements in the future, even though we still do not know—even at this late stage, two and a half years after the referendum—whether a satisfactory Brexit deal will be approved by the UK Parliament. Given the possibility of a no deal scenario, where the UK crashes out of the EU and potentially enters a period of unprecedented uncertainty, we are extremely concerned.
We understand and support the Government’s preferred policy position with regard to future reciprocal healthcare agreements, where the intention is to seek a wider agreement with the EU that covers state pensioners retiring to the EU or UK and allows for continued participation in the European health insurance card scheme, together with planned medical treatment. We want to ensure, however, that appropriate safeguards are in place with regard to costs, not least because the Bill provides the authority for the Secretary of State not only to facilitate a continuation of existing arrangements, but to enter into any number of bilateral agreements with individual member states, with no provision for parliamentary scrutiny.
We also note that the Bill provides the authority to strengthen existing reciprocal healthcare agreements with countries outside the EU, or to implement new ones with countries across the globe, in line with the Government’s aspiration to develop trading arrangements with countries beyond the EU. There is, therefore, the potential for the establishment of multiple complex agreements.
As it is not possible to know the detail of those agreements in advance, we cannot assess their likely cost implications. We therefore believe that the Government’s impact assessment is woefully inadequate in that regard. The assessment suggests that the cost of establishing a future reciprocal healthcare arrangement would be £630 million per year, which is the same as the current agreement and takes no account of inflation or future medical developments. The impact assessment’s suggestion that costs might actually be less than those we already incur is not credible.
We will be in uncharted waters, facing the prospect of the necessity to negotiate multiple agreements, some of which may be complex. As the former Secretary of State said,
“It is perfectly possible to agree the continuation of reciprocal healthcare rights as they currently exist, but it is not possible to predict the outcome of the negotiations.”
We agree that it is impossible to provide reliable estimations of likely costs in advance. We are therefore not prepared to give the Government carte blanche.
New clause 1 would provide a sensible requirement for the Government to report back to Parliament on an annual basis. Subsection 2(a) would require the Government to provide details of all payments made by the UK Government for healthcare provided outside the UK to British citizens. Subsection 2(b) would stipulate a requirement to provide details of all payments received by the UK Government in reimbursement of healthcare provided by the UK to all non-British citizens. Subsections (c) and (d) are straightforward and would require details of the numbers of citizens treated under reciprocal arrangements. Subsection 2(e) would write into law a requirement to report on all outstanding payments owed to or by the UK Government.
The Bill provides an opportunity to monitor efficiency in this area and may provide an incentive to address the concerns raised by the Public Accounts Committee in its 2017 report, “NHS treatment for overseas patients”. It stated,
“the NHS has been recovering much less than it should”,
and,
“The systems for cost recovery appear chaotic.”
That is not good enough and we would not want to see that poor level of performance replicated as a result of any new reciprocal agreements.
Currently, the Public Accounts Committee reports that there is no evidence that EU reciprocal health arrangements are being abused. However, there is an increased risk of poor performance on collection targets if there are multiple future arrangements with differential terms. Subsection 2(e) will enable ongoing parliamentary scrutiny of performance levels. While respecting that urgent medical care is provided to any patient who needs it, the NHS and the Department of Health and Social Care must always ensure that money due to the NHS is recovered. We need a system that is fair to taxpayers and to patients who are entitled to free care either by virtue of being a British citizen or under a reciprocal agreement.
It is clear that, even under current arrangements, the collection of moneys owed for healthcare provided to foreign nationals, together with the administration of existing reciprocal healthcare agreements, is an onerous task for hospital trusts. As we leave the EU, it might be necessary for the UK to enter into multiple complex arrangements on a bilateral basis. Indeed, the Bill gives powers to the Secretary of State to enter into any number of agreements, which would introduce additional considerable financial burdens on hospital trusts whose duty it will be to administer the collection of charges for NHS services provided to foreign nationals who retire to the UK or who visit the UK under future reciprocal arrangements. It is likely to be a more onerous process as a series of differential arrangements might be required. The BMA and the Royal College of Paediatrics both agree that, should it be necessary to establish bilateral reciprocal arrangements with EU nations, significant additional costs would fall on the NHS.
Subsection 2(f) would introduce a requirement for the Government to report the detail of all costs incurred by hospital trusts in the pursuance of that duty. Cuts to real-terms NHS funding since 2010, together with increased demand, have pushed many NHS hospital trusts into deficit positions. The NHS is underfunded and understaffed, and hospitals face all-year-round crises. It is therefore imperative that hospital trusts are not required to shoulder additional financial burdens because of the costs of administering the collection of charges. It is absolutely essential that all agreements reached within the remit of the Bill do not direct funds for the treatment of patients to administration.
Ordered, That the debate be now adjourned.—(Wendy Morton.)
Healthcare (International Arrangements) Bill (First sitting)
Stephen Hammond ExcerptsTuesday 27th November 2018
(5 years, 5 months ago)
Public Bill CommitteesRead Full debate Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 View all Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 27 November 2018 - (27 Nov 2018)
The Chair
Q
I remind hon. Members that questions should be limited to matters within the scope of the Bill, and that we must stick to the timings in the programme motion that the Committee agreed for this session. We have until 10.25 am. I hope, because the Minister has to be on his feet on the Floor of the House immediately after this, to cut a couple of minutes off the session to enable him to carry out his duties.
Are there any relevant interests to declare? No. Will the witnesses introduce themselves?
Mr Henderson: Thank you. I am Alastair Henderson, the chief executive of the Academy of Medical Royal Colleges, which is the umbrella body for all the different medical royal colleges and faculties in the UK and Ireland. We represent the range of specialties, particularly on training, education and standards matters.
Raj Jethwa: I am Raj Jethwa, director of policy at the British Medical Association, which is the trade union and professional association for doctors in the UK.
The Minister for Health (Stephen Hammond)
Q
Mr Henderson: Yes, certainly. I think that the feeling of clinicians and health organisations, and also of patients, is that the current regulations work well because they are simple, well understood, easy to operate and pretty well universal in their coverage. We have a good system at the moment that is effective and easy to operate, and going forward we are looking for something that repeats or replicates that as closely as possible.
Stephen Hammond
Q
Mr Henderson: Yes, I do; we are pleased to see that. I suppose our position is that, overall, the best and easiest thing would probably be for reciprocal healthcare agreements to be covered in an overall agreement. That seems to me to be the best thing. If we are not in the position of having an overall agreement, the Bill, which puts in these complementary arrangements, seems to be exactly the right thing. We are very supportive of it and are pleased to see that there.
Stephen Hammond
Q
Mr Henderson: In terms of the overall cost, that may well be the position. It is not known what the arrangements for cost recovery would be. Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive. If all people in this country from the European Union or European economic area have to be charged, what would be the implications for NHS organisations and clinicians?
It is important to say that doctors have had a consistent anxiety about becoming involved in being responsible for either immigration rules or charging rules, which would potentially have a quite adverse effect on the doctor-patient relationship. I think it is really important that whatever arrangements come in are as seamless and as simple as possible, so that they do not take people away from clinical duties or get in the way of delivering care.
Stephen Hammond
Q
Mr Jethwa, good morning. I noticed in your written brief that the BMA stated that the Government should undertake every effort to retain the current model of reciprocal healthcare. My first question is the same as that to Mr Henderson: can you state why you think the current system works so well?
Raj Jethwa: For exactly the same reasons my colleague sets out: the arrangements are wide-ranging, secure and simple. They give security and clarity and are well established. Our view is that the best possible arrangement is for those arrangements to continue. If they cannot, the arrangements that come in their place should mirror them as far as possible.
Stephen Hammond
Q
Raj Jethwa: We largely welcome the Bill for exactly the intention behind it, but because the detail in it is limited we have some concerns about exactly the clarity going forward that the Bill allows for. We support the broad intentions behind the Bill, but we would like to see more detail about exactly how the arrangements will operate in practice, particularly the scrutiny arrangements to ensure there is clarity and transparency in what the arrangements negotiated and facilitated through the Bill would look like.
Stephen Hammond
Q
Raj Jethwa: No, I beg your pardon. We do have concerns about security, but I meant clarity, from the perspective of patients understanding and being secure in themselves about what the arrangements would mean.
Justin Madders
Q
Raj Jethwa: I do not know that, but again we are happy to look into that and to come back to you if we find out that somebody back home does know the answer. I am not sure that I know.
Mr Henderson: It is probably lost in the mists of various previous agreements.
Stephen Hammond
Q
Raj Jethwa: One of the concerns we have is the reference to the authorised person and who could fit into that category. Without seeing more detail about what the arrangements will look like in the future, we do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly what process will be used to, for example, recoup the money or make payments, it is hard to know exactly what those arrangements would look like and on what basis information would be shared. We do have concerns about the authorised person aspect of the Bill, and we need to ensure that we have greater understanding about exactly who would be an authorised person, beyond that list of specific bodies and individuals who are named in the Bill at the moment.
The Chair
Does the Committee have any more questions? No. I thank the witnesses for helping the Committee with its deliberations, and call the next witness.
Examination of Witness
Alisa Dolgova gave evidence.
The Chair
Q
Alisa Dolgova: Hi. I am Alisa Dolgova. I am the manager looking after Brexit at the Association of British Insurers. We are a membership organisation representing more than 250 insurance and long-term savings firms in the UK, ranging across general, life and reinsurance companies.
Stephen Hammond
Q
Alisa Dolgova: I agree with those who gave evidence before me, in that the advantage of the EHIC is that it is a simple, easy-to-understand system. From an insurance perspective, the EHIC covers the medical treatment of UK nationals travelling through one of the covered countries, in the same way as local nationals would be covered in terms of state provision of healthcare. The insurance then covers anything that is not covered by EHIC, meaning things that are not covered by the state healthcare system—some countries have a greater tradition of state healthcare than others—but also things such as repatriation. The advantage of the current system continuing for customers is mainly that it is a system that is well understood, and there is a minimum that is covered for everybody, irrespective of whether they have travel insurance.
Stephen Hammond
Q
Alisa Dolgova: If EHIC were not in place, those costs would be covered by the person’s travel insurance, if they have insurance in place. That means that costs that are currently covered by EHIC would be borne by the insurer. I think £156 million is currently covered by EHIC, so part of that would be covered by the insurer, and that would have an impact on the claims costs for insurance companies—costs that currently are not there. That might have an impact on the premiums that insurers charge their customers.
Stephen Hammond
Q
Alisa Dolgova: That is difficult. Insurers do not know what the impact is going to be, because currently they do not have the data on where the policyholders travel to. By far the most common type of travel policy that is bought in the market is a multi-year insurance policy, which covers an individual who can travel anywhere in the EU—or the rest of the world, for that matter. Currently, because part of that is covered by EHIC, insurers do not have the breakdown, and it is therefore difficult to give a number for what might happen.
Stephen Hammond
Q
Alisa Dolgova: Generally speaking, premiums will be higher for two reasons: first, if the chance of the person claiming is higher, and secondly, if the volume of payout is likely to be higher—so, if someone has a condition that is particularly expensive to treat. That is why health is one of the risk factors that may increase premiums. Again, it is quite difficult to say what the difference in the potential increase would be between those who have existing conditions and those who are in good health, because it basically depends on where that group of people is likely to travel to, in terms of how expensive healthcare is in that country. For example, if someone travels to the US, that is a lot more expensive than if they were to travel to some other destinations. I would just say that if you look at countries where you do not have EHIC or reciprocal arrangements, insurance policies are available but it may require a bit more effort to locate the right product for the right individual. We are working with the Financial Conduct Authority, Macmillan and other organisations on that.
Stephen Hammond
Q
Alisa Dolgova: Most private medical insurance policies in the UK are generally designed to cover treatment within the UK. It is relatively rare for the policies to also cover healthcare while you are travelling.
Stephen Hammond
Q
Alisa Dolgova: Yes. It may vary depending on the type of policy, but generally speaking that is the most common situation.
Stephen Hammond
Q
Alisa Dolgova: For health insurance?
Stephen Hammond
Yes, for health specifically.
Alisa Dolgova: The implications for health insurance are a lot less than for travel insurance. Apart from that, health insurance would primarily be affected in the same way as any other insurance in terms of transferring data across borders. I am not sure there is likely to be a significant impact on health insurance if the reciprocal healthcare arrangements are not in place.
Stephen Hammond
Q
Alisa Dolgova: We are supportive of the Bill and giving the Government the powers they need to implement reciprocal healthcare arrangements. From the insurers’ perspective, the most important thing for us is to know as early as possible, whatever the outcome, so that insurers can plan for any changes and so that we can let our customers know what the impact is likely to be.
Justin Madders
Q
Alisa Dolgova: My colleague Hugh Savill gave evidence to the House of Lords, where he stated that there is likely to be an increase of between 10% and 20%. To be honest, we do not really know, because it very much depends on the particular insurer, who it insures and where that specific group of people travels to.
The Chair
Q
Fiona Loud: My name is Fiona Loud, and I am the policy director for Kidney Care UK. We have been around for over 40 years and were formerly known as the British Kidney Patient Association. We are the national kidney patient support charity, so we give emotional, financial and practical help to patients and their families who are affected by kidney disease, but particularly kidney failure.
Stephen Hammond
Q
Fiona Loud: At the moment, 29,000 people in the UK are dependent on dialysis. That is three times a week, about five hours at a time, and those people cannot miss a session, because those sessions maintain their life. If a person is on dialysis and wishes to travel—anywhere in the world, but let us talk about the EU here—whether to meet family, to have a holiday, or to work, they need to be able to pre-book a slot or slots at a dialysis unit that is convenient to the place they are travelling to. At the moment, the EHIC card either covers it completely or, in countries where there is a co-payment because local residents make a co-payment, it covers the bulk of your care. Many patients tend to go to places such as Spain and France, and some go to Italy, because they are holiday-type destinations. It works for them because they get the EHIC, are able to get their life-maintaining treatment and have the opportunity, for themselves and their families, for a much-needed break. That is an example of one of the main reasons people might use that.
So it works well at the moment. It is not completely perfect because sometimes units that were public become private and it may occasionally happen that someone has booked a holiday a long way in advance. But, in general terms, it means that people are able to go away with the confidence that they will be able to be supported and receive the treatment they need.
Stephen Hammond
Q
Fiona Loud: For people with a pre-existing condition, such as kidney failure, we always advise that they take out insurance in addition to having a current EHIC card, because there will be situations in which they may need to cancel their travel at very short notice due to illness. What we regularly hear from patients—this is probably one of the most common questions asked on our closed social media forums, especially at holiday time—is, “Where do I book? Where do I get insurance from? Where do I get the best deal?” My understanding is that some people go to specialist insurers to get their cover—they will be those that we tend to recommend to people because they are much more likely to understand and to be able to support these complex conditions. Whether everyone gets insurance, I honestly do not know. Some people will say that it is so expensive that they cannot afford it, and that could put them off travelling. Other people will say that they have incredibly cheap deals, and I do wonder whether those would actually cover the situation of someone really needing care.
Let me give you a recent example of someone who booked a holiday a year in advance, not in the EU but further away. They took out specialist travel insurance and during that time their transplant failed, which meant that they became dependent on dialysis, were particular ill and had to cancel the holiday for them and all their family. They were able to get all their money back because they had given a clear declaration and that had been accepted. That is how it should work, and it was some comfort to them in what was not a very good situation.
We have people who are taking the option to travel now because they have no idea what will happen after 29 March. For them, the ability to travel with confidence—I think there is something in the Bill about people being able to travel with confidence—is something they can do now, and they are not confident yet that they will be able to do that after 29 March.
Stephen Hammond
Q
Fiona Loud: We understand the reason for it and we support its intentions. You may have seen some of our comments: we want more assurance, some more detail and some things about contingency as well but, yes, we have been hoping for some time that something could be put in place to set this process in motion.
Stephen Hammond
Q
Fiona Loud: The contingency issues would be for people who have holidays already booked for after 29 March. There are people who have already done that and, because their EHIC card has a date of after 29 March—the cards will go on for many years afterwards, as we all know; they are issued for five or 10-year chunks—they imagine that they can go away and receive their dialysis. What happens in the case of no deal, where holidays are booked on that presumption? Will there be cover?
The second question will be about emergency cover. I have just given an example of somebody who was fine when they booked the holiday but who now may not be fine, because people’s health state can change. Generally speaking, holidays are booked in advance. It is basically about looking at what the immediate arrangements would be and to make sure that no citizens are caught in the gap of assuming they have cover and somehow not realising that things have changed. There is an awful lot about Brexit at the moment and this is a very specific detail in a much noisier environment. Those are the people who might be caught out and whom we are concerned about.
Stephen Hammond
Q
Fiona Loud: Yes, it is our conclusion that it would be very hard. It is worth mentioning that at the moment it is generally easier to obtain dialysis at a unit away from your home in Europe than it is in the UK, because we have a heavily pressed NHS. Trying to get capacity in other units is possible with a lot of planning, but if you want to travel for a funeral or for something at short notice, it becomes very difficult to go away for more than one or two days in between dialysis sessions. NHS staff will help and do their very best, but it is easier to go away for two weeks in Europe and take a break in that way than it is to get two weeks in a UK unit, unfortunately.
Justin Madders
Q
Fiona Loud: I have heard it as a comment.