Health and Social Care Bill
Moved by Earl Howe
That the Bill be now read a third time.
Amendment to the Motion
Moved by Lord Owen
To leave out from "that" to the end and insert "the Bill be not read a third time until the House has had an opportunity to consider the detailed reasons for the first-tier tribunal decision that the transition risk register be disclosed and the Government's response thereto, or until the last practical opportunity which would allow the Bill to receive Royal Assent before Prorogation".
Lord Owen (Crossbench)
My Lords, this is rather a strange situation. We are coming to the end of an extraordinarily long process of debate, yet there is still one element that is not directly related to the Bill and much more concerns constitutional questions and the Freedom of Information Act. Throughout the Bill, various attempts have been made-mainly by those on the Cross Benches and the Opposition, it must be admitted-to use the Freedom of Information Act to reveal more information. That is a common situation that will be familiar to all Peers: in opposition we seek to use the Freedom of Information Act and in government we tend to try to clamp down on it. I myself tried to obtain the legal advice to the previous Labour Government in 2006 on the implications for introducing "any willing provider" provisions and other aspects as regards EU legislation. The Information Commissioner rejected my application. I accept that because the Freedom of Information Act has been very well established, with a commissioner who makes recommendations. These can be challenged by government or any other interested party. The commissioners can then decide on whether to uphold them and then there is a further appeal.
What is extremely unusual about the request that this register be disclosed-the transitional register, which relates more to the legislation-is that two decisions under the Freedom of Information Act have upheld disclosure. It was a surprise to quite a lot of us that the first decision by the Information Commissioner was that the register be disclosed-in fact, there are two registers. What became interesting was that the tribunal was going to have the matter referred to it. I pay tribute to the noble Earl, Lord Howe, who, on behalf of the Government, recognising the dilemma that we might be in in this House, having come to our normal discussions on the Bill and wanting to hear a decision, asked the chairman of the tribunal, Professor Angel, to bring forward his hearings. That was done and the tribunal sat on the 5th and 6th of this month. Again, its decision was against the Government and was that this register which relates to the peculiar circumstances of this very complex and long legislation should be disclosed.
It is fair to say that the Government have another appeal procedure open to them. There is another tribunal that they can go to. I make it clear that I do not believe that any Freedom of Information Act worth the name would ride roughshod over the legitimate case of the Government to hold back information and, furthermore, to receive information that is confidential to them during the process of legislation or of good government. As we know, the previous Cabinet Secretary went to the tribunal and argued-and I do not disagree-that civil servants, when asked to make risk assessments, wanted to feel confident that they could raise the unspeakable, if you like, with Ministers and not feel hesitant about bringing forward risks.
However, risks go to the core of this legislation, and that is the most important thing about it. The issue before the House is whether the risks of continuing with the legislation-no one believes that there are no risks-are greater than the risks of stopping the legislation. Few would disagree that there must be some risks in stopping legislation, having continued with it this far. This is, if one likes, a balance of judgment. My premise and my plea to the House is that, before making a final decision, all those who respect freedom of information and the world that we now live in with a viable Freedom of Information Act should at least await the decision of Professor Angel and the tribunal. That is all I ask for.
The question is a practical one. Are there enough weeks or days available to the House before Prorogation? I took soundings and it was very clear-certainly among Cross-Benchers, who I am bound to talk to more than others-that there was no belief that this issue should block the legislation; they did not think that it would be appropriate. There was a lot of substance in their argument. Whatever one's views about the Bill, that can be discussed at Third Reading. The question here was whether we could frame an amendment that would give the Government the freedom to bring this issue back before Prorogation. I used the words,
"until the last practical opportunity which would allow the Bill to receive Royal Assent before Prorogation".
We are not therefore discussing whether the Bill should go forward. This is not by any standard a blocking measure. Nor, I suggest to the House, would we really be sensible to make a decision in principle whether the tribunal's judgment should be upheld. It is anyhow, as I said, open to the Government to go to another appeal.
What seems to me pretty important is to listen to what the tribunal has decided. It has made a complex judgment, because it decided that the overall risk assessment should not be published but the transitional risk assessment should. A lot of people are still not sure how that distinction could have been made, but it has. We passed the legislation for freedom of information. I think it was an extremely good piece of legislation. It was put on the statute book in 2000 and was modified in 2005. As I said, it is not a complete licence for anyone to go in to get everything published that they might want. There are checks and balances. It seems to me that we should respect those checks and balances and await the decision.
There is a political and practical reason also, quite outside that. Those of us who have spent many hours and days on the Bill know that we can easily be in a bubble in which we discuss the line by line amendments and the practical wording of the legislation, but I suggest to the House that we are in a very unusual situation. On Friday, the result of a poll held among members and fellows of the Royal College of Physicians was announced. I have an interest to declare. I am a fellow of the Royal College of Physicians and I voted. Thirty-five per cent voted, which, given the circumstances-ballots also go to overseas members-was a pretty high poll, and 69 per cent voted that the legislation should not go forward. Only 6 per cent believed that it should.
Everyone in this House makes their own judgment about a Bill. Pressures from outside, electronic petitions and opinion polls among royal societies come and go and we still make our decisions. I have no complaints about that and I do not believe that the medical profession has any particular monopoly of wisdom on this issue. What is staggering about the legislation is how it has been opposed by practically everybody who works in the health service. I refer not just to unions such as the BMA and the Royal College of Nursing, which have dual functions, both representing their professional bodies. Every royal college that balloted its members has come up with that conclusion.
All I am saying to the House in all sincerity is that we should follow due process on this Bill. Let us demonstrate to everybody that, even if they disagree with it, if the Bill is passed, they must co-operate with the legislation of the House. They must accept it in good will as the judgment of Parliament and they must work within the legislation. But do not leave unfinished business, do not leave out one massively important issue, which is to hear the view of the tribunal that we erected in the legislation and gave the freedom to make a judgment, and which has twice opposed the Government's judgment. I rest my case.
Lord Fowler (Conservative)
My Lords, I intervene briefly. I listened carefully to what the noble Lord said, but I am not sure that this is just a matter of practice, as he said at the beginning-although by the end he was coming very firmly round to the view that he was an all-out opponent of the legislation itself. I think that there are questions of principle here as well, and not just the principles that he enunciated.
I am not a member of the "keep everything secret" brigade-rather the opposite. If we had taken more notice of the Information Commissioner's report in 2006 on the unlawful trade in professional information, we might not have had to wait until 2012 for the inquiry into phone hacking, and the rest. I also argued against the 30-year rule for the disclosure of Cabinet papers as wrong and unnecessary and remain critical of the previous Government's response to that, which to reduce it to 20 rather than 15 years, as recommended. I think that had more to do with disclosure on Iraq than it did a matter of principle.
I also believe that when it comes to the publication of risk registers, other issues need to be taken into account, not least the relationship between Ministers and civil servants. I suggest that this is why no Government in the past has agreed to a policy of publication. In my view, Ministers are responsible for the decisions taken, and it is for civil servants to advise. That is their skill and their role, and anyone who has ever put a Bill through Parliament knows well enough that if they are any good, civil servants do not simply sit there saying, "Yes, Minister". They debate and argue with the Minister and warn of the risks as they see them. It is one of the very good features of the relationship between Ministers and the Civil Service in this country.
The problem with publishing all the risks, from the possible to the highly improbable, is that the relationship itself seems to be brought into some doubt. Civil servants, whether they liked it or not, would be dragged into the debate. We all know exactly what would happen: the risk register would be used to undermine the measure being proposed. The aim would be to show that Ministers were in conflict with their own staff. The opponents of a Bill such as the one before us today could say that not only was the BMA against the Bill-it is not exactly news that the BMA is against any new measure put forward since 1947-but also, by selective quotation, that the Civil Service itself had profound doubts. Whether one liked it or not, the Civil Service would be brought into controversy and people would try to portray conflict. I do not see, frankly, how that is in the public interest.
The party opposite has not shown any interest or inclination in the past to go down this road as a general policy line. This would simply place new obstacles in the way of legislation and change. I wonder how a risk register could have been used at the inception of the health service in the 1940s. Doubtless it would have pointed to the problems implicit in such a massive reorganisation and to the risks that costs could escalate. Not every civil servant would have shared ministerial confidence that a better health service would mean improved health and therefore a reduction in costs.
It comes down to the fact that in these cases there is a matter of judgment on the part of Ministers, having listened to the arguments and the advice of the Civil Service, in putting their proposals before Parliament. I entirely understand the later amendment of the noble Baroness, Lady Thornton, which seeks to deny a Third Reading to this Bill. That is perfectly straightforward: she sets out the reasons for it. I do not happen to agree with her, as she knows, but I do not have any doubt about her right to this. Frankly, however, I cannot see the value of this amendment seeking delay on grounds that I do not believe to be in the public interest.
Lord Mackay of Clashfern (Conservative)
My Lords, since Second Reading in this Chamber, this House has carried out a very thorough public scrutiny of this Bill. In doing so, it has had the advantage of the expertise of practitioners and former practitioners with great experience from across the medical, surgical, nursing and social work professions, and also those with experience of administration of those services. Further, it has had the advantage of former health service Ministers and of the skilled, eloquent probing of the Bill's provisions by the opposition Front Bench: the noble Baroness, Lady Thornton, the noble Lords, Lord Hunt of Kings Heath and Lord Beecham, and the noble Baroness, Baroness Wheeler. We have also had the expertise of the noble Lord, Lord Owen, himself not only a former Health Minister and writer on health matters, but also a director of a large American pharmaceutical company for quite a number of years. In addition, as the Bill has proceeded, we have received detailed briefing from many people currently working in the health and social work services.
The scrutiny was completed last week. In that situation, we would grossly underestimate the breadth and depth of that scrutiny if we accepted that a register, prepared 15 months ago by civil servants in the privacy of the Department of Health before the Bill was introduced and before the very large number of amendments were made to it, could add substantially to our understanding of the Bill. Therefore, in my submission, at this stage this amendment to the Motion is inappropriate. At the very best, it refers only to the tribunal's decision; it does not refer, except indirectly, to the register. In my submission to your Lordships, the register prepared so long ago in privacy by civil servants cannot be expected to add substantially to what we know already.
Baroness Jay of Paddington (Labour)
My Lords, as the House knows, I chair your Lordships' Constitution Committee, which has produced two reports on the Bill. As everyone has said, the Bill is enormously complicated and very detailed, and we have been very detailed in our consideration of it.
I support the amendment of the noble Lord, Lord Owen, because the noble Earl the Minister has, as we all know-and we have all paid due respect to him on this-been enormously helpful to the House's consideration and the production of amendments. The Constitution Committee itself produced very important amendments on the Secretary of State's role on this. All this has demonstrated the very sound, elaborate and good processes by which this House and its Select Committees, as well as the many experts, as the noble and learned Lord, Lord Mackay of Clashfern, has just mentioned, have contributed to the debate. We have proceeded on this in an extremely sensible, measured and considered way.
The Government have been very generous and the Minister has been particularly generous in accepting amendments and entering into discussion. Having listened to the noble Lord, Lord Owen, I think he is saying that the House should continue to follow the very good process that we have had in formulating our opinions on the Bill. We have taken time and have deliberated very carefully. The House has listened to many views, including those of its Select Committees and of its many expert Members. As the noble Lord, Lord Owen, said, we have also listened to many people outside.
Over the weekend, I have been particularly amazed at the last-minute contributions from, for example, the Royal College of Physicians. The noble Lord, Lord Owen, mentioned one online petition, and I have received another from the organisation Avaaz, signed by 110,000 people. The cumulative figures suggest that in the past few days more than 500,000 people have signed online petitions specifically relating to the amendment of the noble Lord, Lord Owen, not to the more general point.
I say to the House that we have followed the processes very well indeed in relation to this Bill. We have agreed to disagree on some things, and the Government have accepted amendments where they have accepted the arguments. In following the processes, which this House has created very successfully over the years, we have used our best efforts with regard to the Bill, and we can lose nothing by continuing to follow those processes and, finally, by taking note of the tribunal's report, as the noble Lord, Lord Owen, has suggested.
Lord Birt (Crossbench)
My Lords, I rise to underline some of the arguments articulated by the noble Lord, Lord Fowler. A risk register is a key prerequisite of any effective organisation, whether public or private. I have had experience of a variety of registers in both the public and private sectors. When I worked at No. 10, I was a member of the Cabinet Office Strategy Board, and one of the tasks of that board was to consider what was effectively the national risk register.
What is the purpose of a risk register? It is to identify all risks. Every risk register that I have ever looked at has been kept highly confidential because it has always been gory and hair-raising to read. The purpose of identifying worst-case risks is to do your best to prevent them and, if you do not prevent them, you need to work out, in advance, what you will do if bad things happen. To create an effective risk register, you need to-
Lord Birt (Crossbench)
I shall come to the risks of publication in a second. What are the means of creating an effective risk register? You need to involve those in governance and delivery and you need absolute candour and trust in the process. The consequence of making any risk register public is that it will be anodyne and the risks would simply cease to be managed, which is not in the public interest. I would hope that Governments of any persuasion would resist the notion of publishing any risk register. It is a matter of regret that one risk register in respect of Heathrow was published. It follows from that that I am unable to support the amendment.
Lord Peston (Labour)
I support the noble Lord, Lord Owen, in what I regard as a special case. I think he, too, is arguing that this is a special case. As background, perhaps I may refer to my experience last week when I spent quite a long time at St Thomas's Hospital, where I think the noble Lord, Lord Owen, was a most distinguished graduate. I was an NHS patient and my experience was of a service working exceptionally well medically, not wasting resources, and staffed by people devoted to the care of patients. Those to whom I spoke told me that that was why they had entered the medical profession; they wanted to work in hospitals. In other words, my experience was diametrically opposed to the basis on which this whole Bill is put forward by the Secretary of State, who constantly attacks the NHS, constantly argues that it wastes resources and constantly argues that it needs private sector involvement in order to make it work properly.
The reason for wishing to see the risk register, which I regard as fundamental in this case, is to ask the question: was the Secretary of State warned of this? Did anyone place before him the information and the argument that his account of the NHS does not correspond to reality as experienced by those of us who use it? That is why it seems to me that the noble Lord, Lord Owen, is asking to see the documentation. Those of us who have advised Governments are perfectly well aware that Ministers have many different views put before them. We are perfectly well aware that civil servants have their own agendas and there is nothing surprising about that. Equally, those of us who have advised Governments know that all decision-making involves risks, so to try to pretend that there is no risk and that there is a case for keeping it secret seems preposterous.
Last week, we heard the approach of those who are still dyed-in-the-wool opponents of anything appearing in the public domain. I hate to say it but such people were involved with our own Government not that long ago, although I thought that we had abandoned those days and that openness had become our touchstone. Last week, I said to the Minister that when I gave advice, I would have been insulted at the suggestion that I did not say to a Minister what I actually thought and, if I were told that what I had said was in the public domain and asked to tone down my remarks that what they were thinking of was stupid, I would not have done so. Addressing the Minister directly, I add that the 30-year rule has given some of us considerable embarrassment. Some of the things I said in the past turned out to be absolute balderdash but I can live with that because it is what I thought at the time. It turns out that I was wrong.
The path that the noble Lord, Lord Owen, wants to take us down is, as a special case, precisely the correct one. I do not think it will destroy our Civil Service; it will not cause honest men and women suddenly to start telling lies in order to ingratiate themselves with the Minister. I am absolutely certain this is a special case which your Lordships should espouse.
Lord Deben (Conservative)
My Lords, I would like to share with your Lordships' House, for the first time, my experience of trying to deal with the complicated matter of BSE as it makes clear this distinction. I committed myself to total openness; I knew nothing that the public did not know. It was the only way in which one could be sure of obtaining people's trust. Nothing was hidden. We did not have risk registers in the sense that we do today but it would be quite wrong to say that we had not considered every possible risk.
I put it to your Lordships that there is a difference between what you know and the extreme cases which you ask about in order to make sure that what you know covers everything that you could know. If in the middle of that terrible crisis newspapers more interested in their numbers of sales had accused the Minister of uncertainty because he had asked about risk-and I do not need to go into the kinds of risk you had to ask about-it would have been impossible to make what were already difficult enough decisions. It turns out now, 20 years later, that the decisions were right but at the time they could only be what you knew, and what I knew I shared.
Consider also what it meant for my civil servants. Do your Lordships really believe that your civil servants would be able to be as frank and direct and complete if they found themselves and their relationships being used as part of a battle? There were some terrible battles at that time between people who had all sorts of other interests. Compare this to another case, which out of kindness I will not be too detailed about. For many years in the ministry of agriculture a particular view had been upheld and we had been told that it was true. When I sought further information I discovered it was not. It was at that point that I tried to establish a very clear distinction between what you know and what you have to ask about which you do not know.
The risk register has come into our governmental structure largely from private business. I sit on the boards of a number of companies and chair several; in all those cases we have a risk register. That risk register is only useful if it is kept entirely to the company itself, because you want to ask questions of a very extreme kind. I ask the noble Lord, Lord Owen, whether he can imagine a Foreign Secretary who had to reveal his risk register asking what would happen if this or that Government did this or that, or what would happen if some Middle Eastern state refused to allow our ships into the Strait of Hormuz at this moment. Would any Foreign Secretary be able to be Foreign Secretary?
Lord Deben (Conservative)
I would not dream of suggesting that I know what the tribunal and the commissioner have taken into account. All I am saying is that if they have taken it into account and come to this decision, I think it is wrong, and if they have not taken it into account they ought to have done. That is why I come to the point that the noble Baroness raised when she said that it is all very good because the National Health Service has risk registers and publishes them. They are not risk registers, not in the sense that a business has risk registers. They are not risk registers in the sense that the Foreign Office has risk registers. They are such risks as the National Health Service believes will stand being in the public domain. The risk registers that a Government have are a wholly different kind of thing and need to be. I believe that we must protect them.
Lord Harris of Haringey (Labour)
Baroness Williams of Crosby (Liberal Democrat)
My Lords, what the noble Lord, Lord Deben, said is well worth listening to, but I shall add one other important factor before I come on to the amendment moved by the noble Lord, Lord Owen. As the noble and learned Lord, Lord Mackay of Clashfern, pointed out-and it is a crucial factor in our discussion-the risk register that was drawn up in autumn 2010 took no account of the changes made by your Lordships' House. It could not because it could not foresee the future. That means that the risk register of 2010, the transitional register to which the chairman of the tribunal referred, is almost useless in enriching and informing the debate we are having in this House. Therefore, far from being helpful, it will in many ways be extremely misleading because it will confirm the incorrect beliefs of many members of the public who have not understood what has happened in this House. You only have to read the newspapers to see how widespread is the total ignorance of what we have done here, whether we talk about competition, training or constitutional change. That is the crucially troubling aspect of what we are discussing. It leads the general public and Members of this House and elsewhere back to an out-of-date and anachronistic finding.
I have one more thing to say about the amendment moved by the noble Lord, Lord Owen. The House needs to recognise that he has made a very substantial change of great importance in it: he has accepted that there will be a Third Reading in this House. He has accepted that the outcome of the Third Reading will be binding upon everybody in this House and beyond because it will be part of the system of law. What he has asked for is more time and opportunity to have the finding of the tribunal discussed in this House. In that, he is absolutely correct. I do not believe that we have gone anything like sufficiently far in trying to accommodate that reasonable request because there is time left in this Session of Parliament. It ought to be possible to transfer a day or two from the Scotland Bill to the health Bill so that it could be properly discussed; or there is something that the noble Lord indicated he would accept, which is a very narrow redaction of anything in the risk register that would be seen as desperately dangerous to public trust in the NHS.
My view is a rather curious one. It is that the noble and learned Lord, Lord Mackay, is right in pointing to the real dangers of treating the risk register as a source of knowledge and truth, but I also believe that the Government should have gone further in trying to find time somewhere, if necessary-dare I say it?-even taking a day off the sacred Easter Recess to enable this House to discuss in detail what is coming out of the chairman of the tribunal's decision on the risk register so that we can get it straight.
Lord Wilson of Dinton (Crossbench)
I add my support to what the noble Lord, Lord Fowler, and others who have spoken against the Motion said. I am deeply concerned about the implications of the Motion for the Civil Service.
Every day in government, Ministers consider policy issues and depend on the Civil Service for advice. Anyone who has been a Minister understands the private space in which civil servants give their best advice. There is a major public interest in advice being given without fear of it becoming part of the political arena, in the press or in Parliament. If risk registers are published, the very act of publishing them will draw them into the public arena and politicise the advice. This is not about lying, or about being dishonest in any way, but the duty of civil servants is to the Ministers they serve and to the Government of the day. They have a job to do and they must do it to the best of their ability, but they must do it in a way that does not cause difficulty for the Government.
It is in all our interests that risk registers are honest and look at the worst case, and put it in terms that leave the Minister in no doubt about the risks that are being taken. If those documents are going to appear in the public arena, they are bound to be sanitised in some form. Advice will either be put in a way that does not fully expose the dangers, or worse still it will not be given. There is a real risk that important advice will be driven off the paper into oral remarks, which are not what the Minister needs. The Minister needs a document that he or she can read after the meeting, and ponder and mull in the stillness of their own room. If we push these documents into the political debate, we will lose a crucial part of the role of the Civil Service. If we do it a lot, over time there is a real risk that Ministers will want around them civil servants who are themselves political, because they have become part of the political debate.
This is a very dangerous pressure to put on the constitution. I understand the worries about the Bill, but this is not the right way to attack it. It would be a dreadful mistake if this House were, in the heat of the moment, to set a precedent that affected the Civil Service in its ability to serve the Government of the day.
Across all parties there is an understanding about the need to observe the conventions under which the Civil Service operates. I appeal to the House not to add its weight to this issue of the risk register in a way that might do damage, because the damage would be not only to this Bill and this department. Whitehall is watching; it is really concerned about this issue, and if this goes the wrong way it will have implications and reverberations across government in ways that I am sure this House would not want. I urge the House not to support the Motion.
Baroness McIntosh of Hudnall (Labour)
Would the noble Lord share with the House his view as to what weight should be attached to the Information Commissioner's judgment on this particular risk register? Is it his view, in the light of his remarks, that the views of the Information Commissioner should be ignored, overridden, or appealed on to the point at which they are no longer relevant? That appears to be the course of action the Government are now trying to take.
Lord Wilson of Dinton (Crossbench)
It is not for me to advise the Government on what to do, but I hope they will appeal, because the issue involved is of huge importance. I read the Information Commissioner's first judgment and I do not find it satisfactory. It is written in a way that suggests that it does not understand the issues in government. I think the issue at stake is of sufficient importance for the Government to fight its corner, and for this House not to add its weight to it.
Baroness Murphy (Crossbench)
The risk register is a complete red herring and we all know that this is an attempt to delay the implementation of the policies in the Bill. The Bill has received extraordinarily careful scrutiny. In fact, it has received better scrutiny and a warmer response from government Ministers in addressing amendments proposed by all sides of the House than any Bill with which I have been associated in the past eight years. At the moment, I can think of nothing worse for the National Health Service than to have these policies delayed yet again by further uncertainty and greater procrastination.
The risk register saga was so obviously a political ruse from the beginning that I did not even bother to speak on it when it was first introduced. It was so obviously a red herring, produced for the benefit of the House to debate a slowing down of the Bill, that it was not worth addressing.
Baroness McIntosh of Hudnall (Labour)
Would the noble Baroness explain to the House whether it is her view that the Information Commissioner has deliberately delayed the progress of the Bill? That seems to be the implication of her remarks.
Baroness Murphy (Crossbench)
That is not the implication of my remarks at all. The Information Commissioner has not released his full judgment and will not release his reasons for some time, so we cannot debate that.
This comes back to what my noble friends Lord Birt and Lord Wilson and the noble Lord, Lord Fowler, said about what these risk registers contain. I know very well because I have written risk registers for the National Health Service. I have sat down with my chief executive, and with my chairman when I was a chief executive, and we have written these things for public consumption. The Cabinet Office has a very nice risk register, but it is for public consumption; it is not to do with the private discussions between senior civil servants or advisers. I have worked as an adviser at the Department of Health, and this is not the kind of thing that comes up in conversations between Ministers where you want to be really frank.
We now have an out of date, almost two years' old risk register that will not be relevant to the passage of the Bill. We have assessed the detailed risks of the Bill better in this House than in any other forum I can imagine. Those who have sat through the progress of the Bill, line by line and word by word, know very well that we have improved it. I am sure there are areas that many of us would still like addressed, but for all kinds of reasons we are not able to do so. I beg the House not to delay the Bill. If we delay it further we will have no guarantee that we will be able to get it through before Prorogation. I see this simply as a ruse not to implement these polices. We would gravely let down the National Health Service by not implementing them, and I urge noble Lords not to support the Motion of the noble Lord, Lord Owen.
Lord Falconer of Thoroton (Labour)
I support the Motion of the noble Lord, Lord Owen. I understand that he is saying, "Let us look at the reasons for saying that the risk register should be made public". He understands that it must be done before Prorogation, so I am not entirely clear why the noble Baroness, Lady Murphy, is saying that this will cause delay. I hear what the noble Lord, Lord Wilson, says-you do need to strike a balance between appropriate confidentiality in relation to what the Government do and the need for openness.
The Freedom of Information Act was passed so that it would not be government Ministers or civil servants who determined what was kept confidential but an independent tribunal. We have reached the position on this issue at which Professor Angel, who is regarded as probably the best chair of an information tribunal that there is, has struck the balance. Take it from me that Professor Angel very well understands the need for proper confidentiality in relation to government. He and his tribunal are not remotely people who would make everything public. They well understand that lots of government matters have to be kept under wraps for the purpose of good government. If a tribunal chaired by Professor Angel said that we should see this, and he reached that conclusion on the basis not of politics but of good government, my instincts are that we should listen more to what he said than noble Lords around this House who have an interest in trying to rush the Bill through. I am struck by the modesty of the amendment by my friend, the noble Lord, Lord Owen. It says that we should see what Professor Angel said before we reach a conclusion. I strongly urge the House to take that course.
Lord Martin of Springburn (Crossbench)
My Lords, I have sat for many hours with my noble friend Lord Owen on this Bill. We both have an appreciation of the health service that came from our parents. My noble friend's father was a medical practitioner while my mother and grandmother spoke of how things were before the National Health Service came into being. I have no desire to do any disservice to the health service. In fact, in the amendments put before this House, I voted contrary to the wishes of the Government.
Yet, on this matter, there is a point that information passed between civil servants and their Ministers should be kept confidential. The argument has been put about the Information Commissioner. Is anyone suggesting that the Information Commissioner is doing something wrong? The answer is no. The Information Commissioner works from a piece of legislation that both our Houses gave him. That basically says that if information is in data-in written form-then it should be made public. What will now happen is that when Ministers go to get advice, they will not get written advice. Ministers and other high officers of state are entitled to advice from their civil servants or officials. They get confidential advice. Freedom of information does not cover all information, only written information. No one can force a Minister or any other officeholder to hand over information given orally. That is exactly what will happen now: information will be given orally. That is not helpful to the quality that we look for. When a civil servant or officer puts something down in a document, they give a lot of thought to it. As the noble Baroness, Lady Murphy, said, there are several people behind that document when it is published. It is there for the Minister or officer to look at. On this matter, I cannot support my noble friend Lord Owen. I support the Government.
There was a previous debate on this matter. It was stated that the previous Labour Government should give the risk register for, I think, the third runway at Heathrow. Justine Greening was the MP who pushed for that. First, the Government did not hand over that information in a matter of minutes. It took a long time for them to hand it over. Secondly, this was leading up to a general election where parliamentary incumbents around Heathrow and parliamentary candidates in the Labour Party were deeply worried about that risk register.
I have been very supportive of my friends in the Labour Party, and they know that. In fact, I have a better voting record with the Labour Party than some of its card-carrying members. However, they should ask themselves when the road to Damascus came about. It did not come about two years ago. Every time I granted an Urgent Question to a Minister or to the House, there was a Minister complaining that they did not want to give information to the House but would rather give it to a television studio.
I have had a great deal of criticism-costly criticism-about going to an appeal, so I know about appeals.
Baroness Royall of Blaisdon (Labour)
My Lords, it is not just a question of the road to Damascus. When the Information Commissioner ruled about the Heathrow third runway we then made the report available. There is also one more difference I would point out to the noble Lord. At that time there was no Bill going before Parliament to which the risk register was pertinent. They are the two key differences that I wish to bring to the House's attention.
Lord Martin of Springburn (Crossbench)
The noble Baroness makes a valid point but I am giving many examples of where certain individuals, such as some of her Cabinet colleagues, were not too keen about the Information Commissioner's instructions to this House and the other House. She will know that. In fact, some of her fellow Cabinet colleagues came to me and said, "Good luck, we want you to appeal.". I do not know whether it was discussed in Cabinet but I know that the sparks started flying. What do they say about failure? Failure is an orphan.
I will not go down that road too far except to say that it certainly has been a road to Damascus. There have been a lot of decisions by the Information Commissioner that the noble Baroness and her Cabinet colleagues did not want. I am prepared to put them down item by item and to tell her about the Cabinet Ministers, some at very high level, who were prepared to go against an Information Commissioner's decision.
Lord Martin of Springburn (Crossbench)
Not on a Bill. The noble Lord, Lord Owen, says it is not about the Bill; he says we should wait for the Bill until we get an appeal decision. If people are opposing an Information Commissioner's decision, it still has consequences for legislation whether it applies to a Bill or not. Let us not kid ourselves. It may not apply to a Bill but on other pieces of business, the Minister concerned is going to say, "Give me that information orally-I do not want anything at all in writing". Information Commissioners have gone on record to say that if information is in data they want to release it.
Lord Walton of Detchant (Crossbench)
My Lords, I have the greatest respect for my noble friend Lord Owen-a noted Health Secretary and Foreign Secretary, and someone who made a major contribution towards peace in the Balkans. He became, obviously, one of the glitterati of British politics. Many of your Lordships may not be aware that he began training as a registrar in neurology at St Thomas's Hospital and I often contemplate what might have happened to his future career if he had stuck with neurology and not turned to politics.
While I talk of neurology, may I just say to the noble Lord, Lord Deben, that I was the neurologist on the Southwood working party on BSE which gave advice to the Government on that tragic, difficult problem in 1988? I am very glad that we got that advice right-we learnt a lot about the assessment of risk at that time.
To return to this Bill and the amendment moved by the noble Lord, Lord Owen, which, with some difficulty, I feel that I cannot support, I am a fervent supporter of the National Health Service. I spent much of my professional life working in it and in academic medicine, and when this Bill was introduced into your Lordships' House I joined with the voices of the BMA, the royal colleges, the nursing organisations and many others in saying that in my opinion the Bill was potentially damaging to the NHS and that it was unacceptable. However, we have moved on. I have been involved with many of your Lordships in the lengthy, at times almost interminable, debates which have improved this Bill beyond recognition. It is not perfect, and there are still issues which perhaps need to be handled by regulation, but it is an infinitely better Bill than the one which came originally into this House. For that reason, any further delay would be unacceptable.
Having said that, I was greatly touched by the wise words of the noble and learned Lord, Lord Mackay of Clashfern, and by the very wise words of the noble Baroness, Lady Williams, who has been a tower of strength throughout all the debates in this House. I genuinely believe that if the medical organisations which are continuing to express their complete opposition to the Bill had fully appreciated the enormous number of amendments that have been carried and accepted by the Government in this House, they would not be continuing to take their stance as fiercely as they are. The Bill has been transformed; for that reason, if your Lordships will forgive the cliché, enough is enough. We are where we are. It is time to give this Bill a Third Reading.
Lord Clement-Jones (Liberal Democrat)
My Lords, it is a privilege to follow the noble Lord, Lord Walton, who, as we all know, carries such respect on health matters in this House. I do not doubt the sincerity of the noble Lord, Lord Owen, in his fundamental opposition to the whole Bill. Indeed, he expressed it very clearly in his Observer article yesterday. He put the arguments very fairly on his Motion, but I have absolutely no hesitation in disagreeing with it today-and I say to him, in his capacity as a doctor, that I feel no physical or mental discomfort with a whipped vote on the matter, for the very key reason that my noble friend Lady Williams mentioned.
The risk register whose publication is being requested was written as long ago as November 2010. It will certainly not relate to the Bill being considered today, as it was drawn up many months before the pause in the Bill's proceedings. Many changes to the Bill were made as a result of the Future Forum process, headed up by Professor Steve Field. The Bill was then changed significantly in Committee and on Report in this House, as the recent House of Commons research paper makes absolutely clear. The risks identified in the register are therefore those of the old Bill, long since superseded, or even of the White Paper which preceded it. It will have been based on worst-case scenarios-
Baroness Tonge (Liberal Democrat)
In all sincerity, if the risk register is so totally out of date and bears no relevance at all to the new amended Bill, would its publication not be a wonderful opportunity for this side of the House to show how much it has improved the Bill and dispatched all risks?
Lord Clement-Jones (Liberal Democrat)
My Lords, my next sentence was about to deal with precisely the point made by my noble friend. It can therefore be argued that publication now by the Government could, and would, wholly distort rational discussion about the Bill in its present form. The job of scrutiny carried out by your Lordships' House is to look at every scenario and from the experience of its Members, which is considerable, suggest amendments which mitigate the problems identified. That is precisely what this House has carried out and, I would say, to good effect. However, the Motion is not suggesting that we delay the current Bill against the remote possibility that there is some risk in it which the Department of Health has identified and this House has not. It is saying that we should delay it pending the First-tier Tribunal's reason for its decision being published.
What will passing this amendment to the Motion therefore achieve? When we know the details of the decision, the Government will still be fully entitled to appeal. They have already won with the strategic risk register, and may well take the view that they will be able to overturn Professor Angel's decision on the transitional register. Do we want to deny them the right to appeal in the face of the very fact that with one limited exception, which the noble Baroness, Lady Royall, has mentioned, the Labour Government did not publish these risk registers when they were in government? Where would that leave us, even if the detailed reasons become available?
I was slightly taken aback by the use of the expression "rush" from the noble and learned Lord, Lord Falconer of Thoroton. I submit that a debate over revealing an up-to-date risk register might just have some merits, but not in these circumstances, where its contents are of historical interest only.
Lord Campbell of Alloway (Conservative)
Thank you very much. I will make one short point. All your Lordships, wherever you may sit in this House, know perfectly well that if this Bill is delayed, urgent requisite reform cannot be used or done, to the detriment of the public. For that reason alone, I oppose this amendment.
Lord Grocott (Labour)
My Lords, I am sure that we are about to reach a conclusion. I want simply to make an obvious point which may have been missed. It is that we have had an interesting debate, going on now for the best part of an hour, most of which has not been about the amendment on the Order Paper. I know that this can be disturbing at times, but I would like to remind the House of what it is going to make a decision about-or, perhaps, what it is not making a decision about. It is not making a decision about the freedom of information legislation, on much of which I might find myself in complete agreement with my noble friends Lord Butler and Lord Wilson. It has many problems and difficulties associated with it, not least for Ministers. Ministers in this Government are finding that, just as much as Ministers in the previous Government did. However, it is not about the merits of the Freedom of Information Act-that is for another time. It is not about the merits of risk registers, good, bad or indifferent, and there are all those categories of risk registers. It is not about the merits of the Bill, where we are considering whether it should have a Third Reading now. It is about the momentous decision that the House must reach shortly: whether the Third Reading of this Bill should be delayed for, in my estimate, three weeks. That is the decision we are being asked to make.
With respect to previous speakers, that makes one or two of their contributions problematic, if not redundant: those who have suggested that somehow it will be very serious, if not cataclysmic, for the health service in this country if the Bill is further delayed. I have not been involved with the debates on the Bill, but it already seems to have been going on for most of my life, as far as I can see; certainly for 12 months. Are we really being asked to accept the proposition that a further three weeks-that is my estimate, and I will come to my question to the noble Earl, Lord Howe, in a moment-will somehow traumatise the health service? That is an unsustainable proposition. I would not have voted for the amendment had it not referred to the specific point at the end, which is that the House must be able to reach a decision on Third Reading before prorogation. That is what we are being asked to do. As we all know, the Queen's Speech is in May-I cannot remember the date-so prorogation is not too far away.
I know that the House will not vote on the basis of the point that I am making. The proposition is simple and straightforward, and I cannot believe that it is of the cataclysmic significance that one or two speakers have suggested. I have no doubt that we have reached the stage, which we have all been around long enough to recognise with this kind of legislation, where government supporters just want to get it over with, for which I do not blame them, and the Opposition want to ensure, even at this eleventh minute of the eleventh hour, that they have a few more opportunities to point that this really is a bad Bill-a view held not only by the Opposition but by the whole of the medical profession and, as far as we know, most of the public.
This is not about the merits of the Bill but about a delay of, in my estimate, three weeks. Would the Minister please-there are no business managers alongside him on the Bench at the moment-put to us his estimate, if this amendment were passed, of the last possible date when Third Reading would have to be considered in order for the Bill to have the opportunity to become law during this Session? My estimate is three weeks but no doubt the Government have a more specific one. When he has given us that estimate, will he explain what damage would be done to the parliamentary procedures of this House or, far more importantly, to the health service should the amendment be carried? That is all that we have to consider today. If he gave us an answer to that question, that would enable those of us who intend to vote for the Motion, as I certainly do, a lot more justification for doing so on the basis of how he replied.
Lord Phillips of Sudbury (Liberal Democrat)
My Lords, I would like to add to the question well raised by the previous speaker and ask the Minister to go one step further. I reread the wording of the amendment of the noble Lord, Lord Owen, and I am not entirely clear what the effect would be if, when the Tribunal's detailed reasons were made available, the Government then decided to appeal that decision. Would that put an end to the noble Lord's attempt to have the risk register available before we finalise the Bill or would it mean, as I think from the wording that it would, that the matter was at an end and we would proceed to Third Reading?
Lord Armstrong of Ilminster (Crossbench)
My Lords, I support the noble Lord, Lord Fowler, and my noble friend Lord Wilson of Dinton in advising the House not to support the Motion. I do not want to go into any more detail on the risk registers. They need to be comprehensive and candid; if there is a risk of publishing them, the compilers will be less likely to make them as comprehensive and candid as they need to be in order to be of value. When the Information Commissioner suggests that, even if this is published, people will be equally comprehensive and candid in future, I am afraid that I think he is guilty of wishful thinking.
There is a process with this risk register. I understand that we have not yet seen the reasons for the decision reached by the Tribunal. When that is known, the Government have the right to appeal. I hope that they exercise it because the considerations against publication, as they have been stated more than once today, are very cogent. That process is likely to take a great deal longer than the three weeks that the Motion of the noble Lord, Lord Owen, gives the Bill. The only sensible course now is to disentangle the business of the risk register and the business of passing the Bill, to let the Bill go forward and not to support the Motion.
Baroness Thornton (Labour)
My Lords, little needs to be added to the eloquent and succinct arguments deployed by the noble Lord, Lord Owen, and built on by my noble friends Lady Jay, Lord Peston and Lord Grocott, and my noble and learned friend Lord Falconer. These arguments are in the best liberal tradition and should be supported by anyone who genuinely believes in openness and transparency.
Many people inside and outside the House have expressed concerns about the risk posed by this Bill, especially the implementation of the biggest-ever reorganisation of the National Health Service. It was those fears that led to the initial request by my right honourable friend John Healey 18 months ago. I do not think that even the noble Baroness, Lady Murphy, could imagine that it was a plot of some kind to delay the Bill at this point. I can assure the noble Baroness that that it is not the case. What is being considered here is a risk register maintained for the transition programme; for the work necessary to implement the changes in the Bill. That is going to be done together with delivering the Nicholson challenge, so there are huge challenges to our National Health Service. It is not the same as a departmental risk register, which might be closer to policy matters and advice, and the concerns expressed by many noble Lords, particularly those who have been Ministers and Permanent Secretaries.
My noble friend Lord Grocott is right. What is being asked for here are three weeks to see what this says. Surely the balance of public interest lies in disclosure, to enable consideration of this Bill to be as effective as possible. In short, we needed it in November to do our job adequately and we still need it. Noble Lords have said that it will be now out of date, but that is a question I asked many months ago and I was assured that it would not be the out-of-date register that would be available, but the most current. I say to those representatives of Permanent Secretaries in your Lordships' House that the last time they engaged with this matter-never with the Bill, but with this matter-I quoted "Yes Minister" at them. I shall be less elevated this time. I shall use the Mandy Rice-Davies defence and say, "Well, they would say that, wouldn't they?".
I agree that it is time to move on. The issue is simple enough; we need to understand the risks in order properly to consider the Bill. We did need them. We have time to take this matter in hand. The answers are very clear and we should support the noble Lord, Lord Owen.
Earl Howe (Conservative)
My Lords, as ever I am grateful to the noble Lord, Lord Owen, for speaking in such clear terms to the amendment he has tabled. I am equally grateful to other noble Lords who have contributed to this debate, on both sides of the argument. At the heart of this, I suggest that the noble Lord, Lord Owen, is putting forward two propositions. The first is that the Government have concealed the nature of the risks associated with the Health and Social Care Bill and therefore the House has a right to be made aware of what the department's transition risk register contains. The second proposition is that the Government's refusal to publish the risk register is inherently improper under the terms of the Freedom of Information Act. In other words, the alleged sin of concealment on the part of Ministers is compounded by an unreasonable obduracy in not complying with the decision of the Information Commissioner and now the First-tier Tribunal. It will not surprise the House to hear that I fundamentally reject both propositions. First, the suggestion that the Government have consciously set about concealing the risks associated with the NHS-
Lord Owen (Crossbench)
Before the noble Earl continues on that path, I have never used the word "concealment" in any of the many speeches I have made on this Bill. I also do not believe that it is improper for the Government to appeal on both those points. I do not mind my argument being destroyed, but if there has been any lack of clarity, I have said neither of those propositions.
Earl Howe (Conservative)
I accept the first point. In his article yesterday in the Observer, he called it "constitutional outrage"- or words to that effect-which was the point of my second proposition. Other noble Lords have made the accusation that the Government have consciously set about concealing the risks associated with the NHS reform programme, but that allegation does not stand up to a moment's scrutiny.
The Bill was published some 14 months ago. During that time it has been subjected to a level of analysis, both inside and outside Parliament, that is without recent precedent. I am not just referring to the Bill's impact assessment, which runs to 200 pages and dissects the risks, costs and benefits of the Bill clearly and meticulously. Nor am I referring only to the two successive NHS operating frameworks of 2010 and 2011, which lay out for all to see the risks of putting the NHS reform programme into practice, and how the service can best mitigate those risks. Nor do I wish to highlight only the extensive oral and written evidence that we provided to two House of Commons Select Committees, whose reports took apart a very wide range of risks to which the reforms give rise and made recommendations on the back of that. As much as any of these documents, it is the debates that have taken place in Parliament that have aired the risks associated with the Bill. When added together across both Houses, those debates have been of unparalleled duration and scope.
Noble Lords may recall the statement that I made on
"how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively".
Noble Lords will need no reminding of the amendments that we agreed across the House on the chain of accountability in the NHS or the lengthy debates that preceded them. A further risk area was,
"how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board".
We have debated and passed amendments on health inequalities, conflicts of interest, research, education and training and a whole lot more, all of which will directly contribute to those worthwhile objectives. Another area was how,
"to ensure that the new system delivers future efficiencies".- [Hansard, 28/11/11; col. 16.]
Our debates on integration, the tariff and many other topics have focused on that theme, and there are more such examples. Therefore, I cannot accept for one minute that without sight of the transition risk register the House has somehow been denied a deep insight into what the Bill means for the NHS. It is an absurd proposition.
Why, then, is there such an issue over the release of the risk register? We heard the answer to that from the noble Lord, Lord Wilson of Dinton. We are dealing here with something for which I make no apology-namely, a point of principle. It is very firmly the view of the Government-here I refer to departments right across Whitehall-that the release of departmental risk registers would seriously undermine the work of civil servants if it became an accepted practice. Civil servants need to be able to formulate policy advice for Ministers fully, frankly and without fear that what they say may be exposed to the public gaze. The moment that officials feel inhibited in setting out the possible risks attached to a course of action in worst-case terms, the process of policy formulation becomes weaker and good government inevitably suffers. It is our belief, as it has been the belief of successive Governments, that to agree to the release of a risk register such as the one associated with the Bill would be to cross a Rubicon. It would remove the safe space that Ministers and civil servants need to do their job thoroughly and properly.
The potential for making that judgment was explicitly recognised and allowed for in the Freedom of Information Act. Indeed, our decision to invoke the Act in order not to release the department's strategic risk register was upheld by the First-tier Tribunal. We await the tribunal's reasons for arriving at this conclusion, and for arriving at the opposite conclusion, with regard to the transition risk register. When those reasons are before us, the Government will need to take a decision on whether there may be grounds for a further appeal. Until then, no one can tell what the legal basis of the judgment is.
The judgment is puzzling, in that the arguments we advanced in defence of our appeal were exactly the same in both cases. That was no accident, not least because substantial areas of the transition risk register are covered in the strategic risk register. There is a large overlap between the two documents. The tribunal chairman, Professor Angel, has said that the case is complex and that the reasons cannot therefore be produced within a short timeframe. Equally, that very complexity will almost certainly mean that the Government will need to take the time allowed for them to consider their options, once the tribunal's reasons are before us. I contend that it is perfectly legitimate for the Government to exercise their right to do that, and the Bill should not be held as a hostage to that process.
Indeed, this decision will have implications not just for this Government but for all subsequent Governments. This is not and should not be a decision taken in haste. The Government may well require the full 28 days available to them in order to make a decision. At this point, I cannot rule out that Ministers may choose to appeal again. This is not a simple matter to be resolved quickly. If any noble Lords, such as the noble Lord, Lord Grocott, are harbouring such a belief, I would respectfully encourage them to think again.
Lord Grocott (Labour)
The point was not about any length of time that the process of appeal might take. This Motion specifically rules out any delay on that basis. It states that Third Reading should take place whichever is the sooner-when the decision is made or whenever is the final date for consideration of Third Reading before the end of the Session. I put it again to the noble Earl: what is his estimate of the last date that we could consider the Third Reading in time for the Bill to become law in this Session?
Earl Howe (Conservative)
My Lords, I take that to be the meaning of the Motion; in fact, it presents the House will an either/or decision, which if passed, would leave us in an uncertain situation. However, I take it that the Motion of the noble Lord, Lord Owen, means that, failing the first alternative, the second applies.
I have discussed the parliamentary timetable at length with my noble friends, as might be supposed. I am advised that in reality there is little time left in this Session, but there is a great deal of business left to complete: the Legal Aid, Sentencing and Punishment of Offenders Bill is on Report; the Scotland Bill is still in Committee; and we await our amendments to other Bills to come back from the other place, whose own schedule is complicated by the Budget, Easter and the Finance Bill. The clear advice that I have received from the business managers is that to delay Third Reading to await the tribunal's reasons and a government response would put into serious jeopardy all the excellent work that this House has done to make this a better Bill.
I put it firmly to the House that we need to get on with the Bill. Today is the 25th full day on which we have been discussing it, and during that time it has been greatly improved. There is no major issue in it to which the House has not done justice. Delaying Third Reading would, in my submission, be wrong and wholly unwarranted. We need to get on with it, and the NHS needs certainty-the certainty of the Bill being on the statute book. I therefore urge your Lordships in the strongest terms to reject the Motion of the noble Lord, Lord Owen, and allow Third Reading to proceed this afternoon.
Lord Owen (Crossbench)
My Lords, we have heard a lot of speeches and I do not intend to take long, but I reiterate-if any noble Lord has come in late to this debate-that they should again read the amendment. It makes it clear that what we are trying to do is find enough time-a matter of a few weeks-to hear the opinion of the tribunal that has found against the Government on the disclosure of the risk register. That is a provision within the Freedom of Information Act and follows the earlier decision against the Government arguing for the disclosure of the transitional risk register by the commissioner.
It is pretty unusual for the Government to find two such rulings against them, and it seems perfectly legitimate, before making a final decision-which I readily concede has to be made before prorogation-to give the courtesy, let alone anything else, of hearing the judgment. It is almost as if we are afraid of the judgment.
In fairness to Professor Angel, we heard from the former Lord Chancellor about his credentials. People do not sit on the tribunal for freedom of information just on one case. They have made many different judgments; they know the issues. With respect to the former Permanent Cabinet Secretaries who have spoken, those who sit on the tribunal know the issues-I do not say as well as former Cabinet Secretaries, but they were looking at it from one side of the equation, the well-being of the Civil Service and the service and information they gave to Ministers. The Freedom of Information Act looks at it from a wider perspective. It looks at it for the good governance of the country as a whole. It urges people to look at why we have open government and greater transparency: because people find it much easier then to accept democratic decisions. This is about a democratic process.
Lord Alderdice (Liberal Democrat)
My Lords, I have listened carefully to what the noble Lord, Lord Owen, has said. My understanding from his earlier intervention was that he felt it important for your Lordships' House to understand what was in the transitional risk register so that that would inform its debate on Third Reading. In the light of what my noble friend Lord Howe said-that it is almost certain that that material would not come into the public domain over the next few weeks, as I think that the noble Lord accepts-all that would come into the public domain over the next few weeks would be the reasons why the judgment was made, not the content of the transitional risk register itself. Therefore, I just want to be clear that the noble Lord is saying that all that your Lordships' House could do would be to debate the reasons of the tribunal, not the content of the risk register. I am not clear how the reasons of the tribunal would inform our Third Reading debate.
Lord Owen (Crossbench)
It is exactly the wording of the amendment,
"to consider the detailed reasons for the first-tier tribunal decision",
if there is sufficient time. This is the issue of freedom of information. I have already openly admitted that Governments tend to restrict information and Oppositions want the maximum amount of information. That is the inherent tension which the Freedom of Information Act was established to try to resolve. It seems wiser to listen to those voices.
The noble Earl raised the question of constitutional issues. The Bill raises some serious constitutional issues. The Government have no mandate for the Bill. They specifically went to the electorate and said that there would be no top-down reorganisation of the National Health Service. That is considered by a lot of people outside this House to be a flagrant lie. That is one constitutional issue.
Lord Owen (Crossbench)
I said that people outside this House consider it to be a flagrant lie. I have been around Parliament long enough to know what I cannot say and what I can.
There is another aspect to the Bill. The Government also fought an election on the basis of a constitutional promise that there would be no increase in the powers of EU legislation unless there was a referendum. There are very serious questions about the Bill as to the impact on EU legislation and the extent to which we will see the Commission making decisions on the National Health Service that it has not hitherto thought it either wise or, possibly, empowered to make. That is the second big constitutional question.
Lord Owen (Crossbench)
No, the noble Lord has had his say. All I am saying now to the House is that this is a decision on which there are strong opinions in many ways. A lot of Members will vote just on the basis that under no circumstances do they want risk registers published.
I say only this-that when companies are having an IPO, we legislate for them to produce the fullest, most detailed risk register of this. We also empower them in their annual, and in the case of America in their quarterly, statements to reveal risk registers at a penalty of going to court if they lie about it. There were times in this debate when I almost thought we were being asked to give a complete carte blanche to the Civil Service to say what it liked irrespective. I hope that is not the position of the Cabinet Secretaries and the Permanent Secretaries. It is possible that either a commissioner or a tribunal might look at a risk register and think that there were flagrant factual errors.
I think it is very dangerous to use "principle" on this question, if I may say so to the noble Earl. The principle surely cannot be that under the Freedom of Information Act some risk registers might never need to be published in the public good. That is a judgment on which, as he says, one can then go to appeal on. However, there comes a point when one would have to judge against the background of repeated demands for disclosure. It is on this that the House must make up its mind. Can we wait a couple of weeks-three at the most-before the House prorogues to hear the words of the chairman of the appeal tribunal to whom we in the Freedom of Information Act gave the power to make that decision? The fact that it is against the Government does not mean we should give them a carte blanche, and I hope that this House will not do so. I wish therefore to test the opinion of the House.
Lord Patel of Bradford (Crossbench)
My Lords, I speak to Amendments 1 to 6 in respect of Clause 8 of the Bill. As noble Lords will no doubt have realised, Amendment 1 is slightly different from the one that was debated on Report and I will explain why my noble friend Lord Noon and I have tabled it.
VAT recovery for charities is an important issue and one that has received considerable support. Indeed, my previous amendment to the Bill was passed. I will not repeat all the arguments made on Report but given the changed nature of the amendment I feel I should explain some of the differences.
I am very indebted to Sue Ryder Care for its support and invaluable information in preparing this amendment. It stems directly from its campaign, which started in 2011, to raise awareness about the problem of irrecoverable VAT for charities providing healthcare services. For example, the NHS is able to recover VAT on certain non-business supplies that charities cannot. This may hinder them from taking full advantage of the Government's agenda, which will see more services outsourced from the NHS to other providers. It can be seen as a significant barrier to entry for charities which may be forced to use their charitable funds to pay the VAT.
Of course, each service has a different VAT bill and recovery rate based on their expenditure on a range of non-business supplies. However, last year Deloitte estimates, produced for Sue Ryder, suggested that in future every £10 million spent by PCTs or the NHS in outsourcing to the charitable sector could result in an additional VAT burden on these charities of £400,000. However, while the VAT question remains paramount, since that amendment was passed, two additional issues have become increasingly clear to me. First, it is not just charities that see VAT as a barrier to entry in this instance. Other providers, such as social enterprises, co-operatives and mutuals, are also disadvantaged in the same way. Secondly, VAT is not the only barrier that exists for these organisations. Wider issues, such as TUPE liabilities, the ability to access or repay capital and contractual arrangements are just a few other examples.
For this reason, I have chosen to broaden the scope of this amendment, and I am extremely grateful for the Minister's support in this. This amendment now calls for the production of a report with recommendations to be laid before Parliament by the Secretary of State within a year on any matters that may affect the ability of charities, social enterprises, co-operatives and mutuals to provide healthcare services for the NHS. There are clearly significant barriers for charities and other not-for-profit agencies seeking to take on the provision of health services, most notably the kind of end-of-life care services that are provided by organisations such as Sue Ryder.
I shall briefly just remind noble Lords why these services are so valuable. A recent survey for Sue Ryder shows that 40 per cent of people in Britain would turn to a charity for support if they were diagnosed with a life-changing illness. Part of the reason for that is the high-quality personal care they would receive. Sue Ryder hospices support people to continue to be able to do the things they want to do when they are facing the most difficult times of their life. This includes a wide range of activities from facilitating weddings and christenings to working to fulfil an individual's last wishes.
One example I heard of, which struck me particularly, is of an inpatient who loved playing in the snow and wanted to build a snowman. She was too ill to do so herself, so two nurses went out and built it for her. They built it right outside her room so she could see it from her window. Three years later, it is still this additional touch that her husband remembers. Another example is an 18 year-old man who was admitted to the hospice as an inpatient. His main interest was flying model helicopters, and the nursing staff helped him to make a helipad and placed it on one of the desks in the hallway outside the bedrooms. At night, he was able to fly his helicopter around the unit with much amusement and without disrupting anyone else. The nurses even turned the lights out at night to make it more of a challenge for him. I could give many more examples of extraordinary care and imagination in what must be among the most difficult times of people's lives. Clearly, we want to see more of this kind of care and to remove any or all barriers that may exist to prevent this across the not-for-profit sector.
The growing not-for-profit sector is an important part of our social fabric. The desire for service users to exercise more choice and control over the services they receive will result in the inevitable diversification of this sector. It has also become increasingly clear that the general population see a role for charities in the delivery of health services. This will bring about profound changes in the shape of the sector as more small providers start to take on the delivery of services.
However, it is important that we not only encourage charities and other not-for-profit agencies but that we ensure the full playing field they enter into is fair. Since our previous debate, the Minister and officials in the department have been extremely co-operative and are as keen as I am to see the barriers broken down for the full range of providers. There are indeed a number of additional barriers. I shall highlight a handful by way of example that I believe the report laid by the Secretary of State should address.
The barriers include, for example, burdensome liabilities and delays in taking on TUPE responsibilities. The Government clearly recognise that TUPE does not work as smoothly as intended, and in November issued a consultation on the effectiveness of its regulations. TUPE liabilities can be unpredictable and overly bureaucratic with room for interpretation. In fact, a recent response to the BIS consultation on TUPE regulations from the Voluntary Organisations Disability Group stated:
"Many social care organisations will now take the decision not to proceed with tenders due to the specific requirements of the TUPE transfer involved, or the lack of clarity surrounding it".
Current TUPE regulations require information on transferring liabilities under TUPE to be provided just 14 days before the transfer. This can leave little time to consider the information, examine its impact and plan to mitigate any problems that can arise. In addition, the Voluntary Organisations Disability Group report highlights that this can make it difficult to negotiate the right price paid or the contract fee negotiated for the takeover of the service.
Access to, and use of, capital can also act as a barrier. Clearly, capital investments should be used for service innovations rather than the day-to-day running of a service, and while access to capital for the not-for-profit sector has undoubtedly been improved in recent years, it still experiences problems due to the time afforded for charities to raise this capital. For example, Sue Ryder has a capital appeal underway for the building of a new state-of-the-art hospice in Peterborough that will increase patient choice and the quality of care provided. This appeal needs to raise £6 million over a number of years.
It would not be possible for any sector other than the charity sector to raise funds in this way, and there is no doubt that it brings hospices an extra boost for this sort of work. However, unlike in the private sector, this sort of money raising can take time. This can act as a disadvantage to smaller organisations' ability to engage in the delivery of services, as they may be discounted by commissioners on the grounds that they do not have sufficient capital reserves. This is another issue that could be and should be examined by the review undertaken by the Secretary of State, with commissioners encouraged to look at the long-term picture in terms of service delivery.
The capacity and ability of the sector to take on certain risks is also problematic. I heard of one charity that wanted to take on a residential service but was given only a three-year contract, despite the risk liability on the lease of the building being for 25 years. I am not suggesting that charities should be given a 25-year contract, but there should be a fair consideration of this kind of risk attached with service transfers if the playing field is to be level. It is also the case that too many smaller charities and social enterprises are still being given only one-year contracts, despite this being against the Voluntary Sector Compact.
I have highlighted some of the wide range of issues that a report into matters which may affect the sector's ability to provide healthcare services should cover. I have no doubt there will be many others. All of these issues need to be considered and that is the purpose of this revised amendment.
My intention is clear: that the report that the Secretary of State should lay before Parliament will look at the issues of entry into the healthcare market in relation to charities, social enterprises, co-operatives and mutuals. It is not my intention that the amendment will look at the issues which may affect the private sector, although I would welcome consideration of those issues where the private sector may be far more favourably treated and thus disadvantage charitable and voluntary sector providers. I should be grateful if the Minister would confirm that this is also the Government's intention.
I realise that this will be dependent on the terms of reference for the Secretary of State's report and I would be more than happy to offer any assistance in drawing up these terms if the Minister feels that that would be helpful. I would also like the Minister to ease any anxiety from the sector and confirm that the recommendations from this report will not in any way financially disadvantage charities, social enterprises, mutuals and co-operatives. The intention is to look at how we bring down existing barriers and not to create new ones. I beg to move.
Lord Noon (Labour)
My Lords, I speak in support of Amendments 1 to 6. I add my thanks to the Minister for his support in seeking to improve this Amendment, which I believe has been done in a number of ways. I should also declare an interest in these matters as chair of the Noon Foundation, which provides financial support to charities and other not-for-profit organisations, including those caring for people in end-of-life situations, such as the Marie Curie Cancer Care charity.
As a philanthropist and a businessman, I understand very well the importance of having a level playing field. We all know the immense value that is provided by charities, social enterprises and small voluntary agencies. I believe that they form the bedrock of our society. They provide essential support and care to those who are most in need, and do so on a daily basis.
The VAT issue for me is very clear. As someone who provides funding for charitable work, I do not want to see those funds taken up paying VAT that was not charged to the NHS when it provided the service. However, we need to go beyond VAT and look at all the barriers faced by the not-for-profit sector. As a business man, I understand the significant risks taken on in any new enterprise. There must be adequate time to accumulate capital, contracts must be fair and any additional undertaking such as the transfer of staff must be fully funded. So why should we expect any less of the charitable and not-for-profit sector? Is it fair that those organisations which exist solely for the benefit of those they serve should be penalised for not being wealthy private enterprises?
Even an issue such as insurance can be difficult. Most of these organisations rely on volunteers, people who have chosen to freely give their time because they want to give something back to society. However, as more services are taken on with a wider range of activities, the risks increase and so too do the insurance premiums. These increased costs are not always taken into account in contracts and can represent an excessive and increasing burden for charities.
However, this is not only about levelling up the playing field to be fair; this is about the kind of healthcare organisations we want to see thrive. At a time when government resources are severely challenged and shrinking-we cannot hope to manage solely on charitable donations-bringing the not-for-profit sector more firmly into mainstream provision of services is one of the ways in which we can continue to provide much needed care, but this will work only if we ensure that these organisations can enter the market fairly and with fully costed and supported service contracts.
In supporting these amendments, the Government are accepting that this is a vital issue and they have made a commitment to provide a report with recommendations within a set timescale. This represents a significant move in the right direction and I commend the amendments.
Lord Newby (Liberal Democrat)
My Lords, I strongly support the noble Lords, Lord Patel and Lord Noon, in seeking to promote the role of the not-for-profit sector within the NHS, as indeed I do across the whole of the public sector. They have given reasons why within the NHS, particularly at this point, the not-for profit sector can play a valuable role. As the noble Lord, Lord Patel, pointed out, there are a number of serious technical problems facing the sector in successfully bidding for contracts, and he has dealt with some of them.
I remind the House that least week Royal Assent was received for the Public Services (Social Value) Bill which requires all procurers, including those in the NHS, to consider the social value of a tender as well as its financial value, in such explicit terms, for the first time. This is one of the pieces of the jigsaw which I hope will mean that the not-for-profit sector finds it easier to successfully bid for business. The Bill lays a requirement on the public sector, but the problem is whether the public sector will implement the Bill and take the provision seriously. It would be relatively easy for it not to.
Therefore, I and other noble Lords, including the noble Baroness, Lady Thornton, who have been supportive of this principle and the Bill, seek to ensure that the Government put in place specific measures to ensure that procurers take account of the Bill rather than it simply lying idle on the statute book. When we debated this issue at an earlier stage in your Lordships' House, the Minister suggested that it might be possible to refer to this in the draft commission of procurement regulations, and I hope that he will be able to confirm today that that is the Government's intention.
Lord Warner (Labour)
My Lords, I commend the Government on making a move in the right direction with these amendments. At earlier stages in the Bill, I tried to raise the whole issue of barriers to entry for new providers of services. This amendment helps in some respects but the noble Lord, Lord Newby, made an extremely important point. How will we know whether the culture has changed not just in relation to not-for-profits and social enterprises but for new providers, sometimes from inside the NHS? There is a deep conservatism-with a small "c"-about how the NHS goes about allowing new players to come into the game. We need the Government to give assurances that they will keep a close eye on this. As I put forward in a previous amendment, they must get Monitor to keep a close eye on the extent to which anti-competitive behaviour by the existing NHS stops new providers from whatever source-not-for-profit, social enterprise, charities, the private sector and from within the NHS-being able, when they offer a better solution to patients' problems, to make their pitch for an alternative way of doing business.
Baroness Finlay of Llandaff (Crossbench)
My Lords, I very much welcome the fact that these amendments have the Minister's name on them. He has already made some concessions in relation to indemnity for these providers where they provide services for and on behalf of the NHS for patients. It seems completely right that some of the difficulties that they have faced in being able to provide flexible patient and family-focused services should be considered and looked at separately. As has already been said, in end-of-life care the charitable sector has completely revolutionised what is available to patients. I know that Marie Curie has done that. They even admitted a dog so that a patient would come in, and allowed that dog to be formally adopted, which enabled the patient to die peacefully because the dog was the only person that the man really loved in life. That flexibility makes all the difference. You would not find that provision or ability to meet an individual patient's needs in many other parts of the sector.
This group of amendments is really important and to be welcomed. This morning, I was with Help the Hospices, which expressed concern on behalf of some very small organisations as to how they would cope in the new world in being able to continue providing the services that they want to. This group of amendments will provide them with a great deal of assurance.
Earl Howe (Conservative)
My Lords, I am pleased to conclude what has been a very good and constructive debate. I am extremely grateful to the noble Lord, Lord Patel of Bradford, for raising these important issues, both now and in Committee. As he stated, since his original Amendment 46 was introduced in Committee, we have worked together on this alternative amendment. While this has to some extent been a joint venture, all credit for the inspiration behind it must go to the noble Lord-along with the noble Lord, Lord Noon, whose strong commitment to the charitable sector is well known.
I can add little more to what the noble Lord has said, but it might be helpful to clarify a small number of points. First, I reassure the House that the Government are committed to a fair playing field for all providers of NHS services. We are particularly keen for voluntary sector organisations and social enterprises of all types and sizes to be involved. These providers are often among the most innovative and can offer highly personalised and bespoke services that meet the needs of local people. We understand that it is not just charities but the full range of voluntary sector providers-mutuals, co-operatives and social enterprises-that noble Lords are keen to see delivering NHS services. The new amendment enables a fair, transparent and impartial consideration of the issues, addressing all providers and possible means of responding to their concerns. I can confirm that the full intention is to look at how existing barriers can be removed, not to create new obstacles.
Secondly, as noble Lords are aware, a variety of barriers affect different providers. This includes not only payment of taxation but also access to and the cost of capital, the difficulty of securing appropriate insurance and indemnity, and the difficulty of bidding due to the scale or scope of contracts. The amendment therefore relates to a review of the full range of issues that affect the ability of providers or potential providers to deliver services for the NHS. I am sure noble Lords will agree that the potential is truly enormous.
We are clear that this is an important issue, which is why we want the report to be statutory and therefore accountable to Parliament and produced within 12 months of Royal Assent. Equally, it is crucial that the duty for the Secretary of State to keep these matters under review is in the Bill.
I can also assure noble Lords that the preparation of the report will involve full engagement with providers from all sectors, commissioners, and other stakeholders, such as Members of this House, to ensure that the full range of issues are considered and each of the concerns addressed. In particular, it will ensure that concerns around treatment for VAT of supplies of healthcare services or associated goods to the NHS by charities, including hospices, are considered. In response to the specific question of the noble Lord, I can confirm we would not see this review as in any way being slanted towards giving private sector firms a 'leg up'.
This review will look at the barriers to achieving a fair playing field, and recommend actions to be taken to address them. We are already well aware that a number of the most deep-seated barriers affect voluntary sector providers, not those from the private sector. While I would not want to prejudge the result of the review, I fully expect that it will put forward a number of actions which could be taken to remove such barriers, thereby better enabling third sector providers to compete fairly with other providers of NHS services. I hope this reassures the noble Lord that, while I think we should look across all providers, it is our view that barriers facing voluntary sector providers are greater than those facing the private sector and we expect the review to focus accordingly on those.
I turn to the separate but related issue raised by my noble friend Lord Newby. We have also listened to the matters raised in other debates during this Bill and during the passage of the Public Services (Social Value) Bill, about the need to take social value into consideration in public sector procurement more generally. The Government agree that a wide-angle lens on the extended social, economic and environmental benefits when conducting procurement exercises can only be helpful. Today I am going further and put on the public record that the Secretary of State for Health is committing that the requirements in the public services Bill will be fully applied in relation to commissioning of NHS services through the procurement guidance that the board will produce on this. These were issues that were raised very compellingly by the noble Lord, Lord Mawson, and I pay tribute to him for his powerful and consistent advocacy on this theme.
I hope very much that your Lordships will find the amendment of the noble Lord, Lord Patel of Bradford, agreeable and I will be happy to support it.
Lord Patel of Bradford (Crossbench)
I am very grateful for the Minister's support in this and for taking it a lot further than I had done initially. I have learnt an enormous amount while we have been discussing these issues and I am sure that the not-for-profit sector will be very grateful for the support provided by the Government on this issue. I am sure it will raise a number of very important factors that will improve service provision for those areas.
Amendment 1 agreed.
Amendments 2 to 6
Moved by Lord Patel of Bradford
2: Clause 8, page 4, line 18, leave out from beginning to second "the"
3: Clause 8, page 4, line 19, leave out from "must" to "within" in line 20
4: Clause 8, page 4, line 21, leave out "this Act" and insert "the Health and Social Care Act 2012"
5: Clause 8, page 4, line 22, leave out from beginning to end of line 24 and insert "of NHS healthcare providers as respects any matter, including taxation, which might affect their ability to provide health care services for the purposes of the NHS or the reward available to them for doing so."
6: Clause 8, page 4, line 24, at end insert-
"(2) The report must include recommendations as to how any differences in the treatment of NHS health care providers identified in the report could be addressed.
(3) The Secretary of State must keep under review the treatment of NHS health care providers as respects any such matter as is mentioned in subsection (1).
(4) In this section-
(a) "NHS health care providers" means persons providing or intending to provide health care services for the purposes of the NHS, and
(b) "health care services for the purposes of the NHS" has the same meaning as in Part 3 of the Health and Social Care Act 2012."
Amendments 2 to 6 agreed.
Clause 23 : The NHS Commissioning Board: further provision
Moved by Earl Howe
7: Clause 23, page 23, line 8, after "13E" insert ", 13G"
Earl Howe (Conservative)
My Lords, I will speak also to Amendments 9 and 10. The three amendments in this group share a common purpose in strengthening the duties on the NHS Commissioning Board and CCGs in relation to reducing inequalities. I am grateful to my noble friend Lady Tyler for highlighting on Report the need to ensure this, and I promised at the time to introduce the necessary amendments at Third Reading to achieve it.
New sections 13G and 14T place duties on the NHS Commissioning Board and CCGs to have regard to the need to reduce inequalities between patients with respect to their ability to access health services, and to the outcomes achieved for them by the provision of health services. As the Bill stands, the NHS Commissioning Board and CCGs must assess in their annual reports how they have discharged this duty. However, they are not explicitly required to plan for this and, in the case of CCGs, not specifically assessed on this in the board's annual performance assessments. These amendments introduce explicit requirements on these points. They require the board to include in its business plan, and CCGs to include in their annual commissioning plans, an explanation of how they intend to discharge their inequalities duties. I remind noble Lords that CCGs will consult on their commissioning plans with those for whom they are responsible, and must involve each relevant health and well-being board in preparing and revising their plans.
The amendments also require the board to specifically assess in its annual performance assessment of CCGs how they have discharged their inequalities duty. So CCGs will have to set out in their plans how they will take account of the need to reduce health inequalities and report on how they have done this in their annual reports, which is of course already a provision in the Bill. Their performance on this will then be one of the factors taken into account by the board when it assesses their performance. Together, these amendments ensure that from the development of the plans to the reporting on their effects, having regard to the need to reduce inequalities will be given particular emphasis and importance by commissioners. I beg to move.
Baroness Tyler of Enfield (Liberal Democrat)
My Lords, I shall speak to government Amendments 7, 9 and 10, to which my name is attached, and in so doing I thank the Minister for tabling them. As he has explained, they all relate to health inequalities; I would like briefly to place them into a wider context. In doing so, given that this is Third Reading, I make one general point. My view from the outset has been that this Bill should be judged ultimately by the health outcomes it produces-essentially, whether and how it improves people's lives, particularly the most vulnerable. Because so much of the debate over the past year has-necessarily, I guess-been about structures, I sometimes feel that we have rather lost sight of this fundamental point. One specific point that has not received enough airspace in our deliberations, perhaps until today, is about reducing health inequalities-or, put another way, doing something real about unequal life chances. At the very outset, I felt that the fact that this legislation contains a landmark legal duty for the Secretary of State to reduce health inequalities was really significant.
As the noble Earl has explained, as the Bill has progressed through its various stages this duty has been strengthened at various levels in the new structure, so that reducing health inequalities now runs through the whole fabric of the health system in a way that we have not seen before. I will not repeat precisely what these amendments do, because they have been very ably set out. Briefly, however, in relation to the requirement that each CCG's performance is assessed each year by the board and includes the progress made in reducing health inequalities, we all know that what gets measured gets done. That is what makes this significant.
However, we should not look at these specific duties in isolation from other key aspects of the Bill on accessibility and integration. New duties to join up services between health, social care and other local services, such as housing and homeless support, will have a crucial role to play here. The role of health and well-being boards in promoting joint commissioning should enable more integrated services, particularly, for example, for older people and people with learning disabilities. Finally, the much stronger focus on public health-I greatly welcome its return to local authorities-will be key to tackling issues such as obesity, smoking, drug and alcohol abuse and sexual health, which make a real difference in reducing health inequalities. This all adds up to a much stronger package than we have had before. Of course, the proof of the pudding will always be in the eating, but this very welcome shining of the spotlight on health inequalities has the potential to be a game-changer for some of the most vulnerable.
However, in case noble Lords think that I am being too uncritical, I finish on a point of concern. Local authorities are well placed to tackle inequalities, due to their responsibilities for education, housing and other factors which impact on health. The current proposition for holding councils to account for this is through what the Government call a health premium, to give extra money to those areas that reduce health inequalities. We need to be careful that this does not simply reward those areas where it is easiest to tackle inequalities and divert money away from areas where more fundamental problems may slow down progress.
In thanking the noble Earl most sincerely for tabling these amendments and paying tribute to his strong personal commitment on these issues, I respectfully ask him whether he will keep the health premium under review as it is rolled out.
Earl Howe (Conservative)
My Lords, I am very grateful for the helpful and supportive comments that have been made by my noble friend. I can give her the assurance that she sought in her closing remarks that we will certainly keep the health premium under review. However, she will know that the design of that premium is work in progress at the moment and I take fully on board the point that she made about it.
It is perhaps helpful if I make it absolutely clear that the duties on commissioners in respect of reducing inequalities are intended to be as important as any other duty on a CCG, and are most definitely not subordinate to other duties. In particular, I would like to make it clear that they are not secondary to the duties in relation to patient choice.
I hope that noble Lords will recognise that these amendments give a central place to the duty in relation to reducing inequalities within the arrangements by which the board and CCGs will plan for, and be held to account for, their commissioning activity. I hope that for this reason noble Lords will give them their support.
Amendment 7 agreed.
Clause 26 : Clinical commissioning groups: general duties etc.
Moved by Baroness Finlay of Llandaff
8: Clause 26, page 39, line 24, at end insert-
"( ) the provision of integrated urgent and emergency care at all times."
Baroness Finlay of Llandaff (Crossbench)
I am grateful to the Minister for meeting me with the President and Vice President of the College of Emergency Medicine and for listening so attentively to the concerns raised. This amendment comes from those discussions and aims to resolve the potential lacuna around the commissioning and the provision of unscheduled urgent and emergency care at all times of day and night.
Emergency medicine departments-commonly known as A&E-see 15 million patients a year, of whom about a quarter are children. About 7.5 million patients arriving in A&E are not ambulant. Typically one-third of these on a stretcher need to be admitted, most frequently into an acute medical bed. The extent of seriously ill and injured attendees is illustrated by the fact that one in 50 will need high levels of care. A quarter of all intensive care admissions come through A&E and seriously ill patients go straight to coronary care and high dependency units from the resuscitation room in the emergency department.
The full spectrum of integrated services has to involve acute medicine, acute surgery and orthopaedics, paediatrics, obstetrics and gynaecology and is crucially underpinned by critical care and anaesthesia.
These very seriously ill patients need integrated services along the whole care pathway; care cannot be broken up. The full spectrum of back-up services with radiology and laboratory services needs to be there 24/7. The best outcomes-and we were talking just now about patient outcomes-for trauma and stroke victims are absolutely reliant on immediate cross-sectional imaging, ideally co-located in the emergency department.
There is a need for closer integration and improvement of the services needed to care for emergency department patients. For example, those with mental health problems, both acute suicidal ideation and acute psychosis, and those with drug and alcohol problems, need a comprehensive integrated psychiatry service, as they are a very vulnerable group. Improving primary care, both out of hours and alongside emergency departments, is essential if departments are to deliver the best care and not be overwhelmed. This will require close collaboration, integration and accurately informed commissioning.
Emergency departments are the 24/7 final safety net for all other services in the healthcare system and they are the last open-access point of call. Escalation of a problem, failure in community care and inadequate out-of-hours primary care support all result in urgent presentation out of hours. Such patients often arrive at night, are unstable clinically and cannot be sent home again, as they are alone or unable to monitor the condition reliably. These 7 per cent to 8 per cent of attendees need to be observed for up to 24 hours in a clinical decision unit, where there is twice daily consultant input, either until they are stable enough to be sent home, or until deterioration indicates admission and ongoing management.
Emergency departments are busy places, providing 24/7 care, looking after patients with wide-ranging needs from resuscitation to reassurance, and interacting with many specialties to ensure the best care. The seriously ill initially need the close interaction of typically three to four specialties; any fragmentation threatens the quality of care.
Commissioning of services in emergency care is optimised by direct and close working between those specialists responsible for delivery and the local commissioners. Given the size and complexity of urgent and emergency care, this should mandate such a specialist on the local commissioning board.
The challenge to us with this Bill is to ensure that commissioning processes recognise that patient choice in emergency care is inappropriate, as every patient needs access to a quality service that is fully integrated with pre-hospital services such as out-of-hours primary care and ambulance services, and with all the back-up and specialist services that patients are moved to for ongoing management.
The national Commissioning Board must work very closely with the College of Emergency Medicine to ensure that commissioning guidance drives up the standards of weaker departments, that the integration of services is included in the commissioning and that the urgent and emergency service for a population has the full skill set to deal with the full range of undifferentiated clinical problems that arrive at the only open access point of care. It is key to local commissioning that specialists in urgent and emergency care are directly involved. Without that, we will replicate Mid Staffordshire, but it may not be evident until unnecessarily large numbers of lives are lost. I beg to move.
Baroness Hollins (Crossbench)
My Lords, given the concerns among the medical profession which are still evident, I ask the noble Earl for reassurance that, for those services where commissioning is appropriate, competition will always be on the basis of quality, not price, and that providers will not be able to cherry-pick lucrative parts of the care pathway to the detriment of vulnerable patients, such as people with learning disability or severe mental illness-people that I am particularly concerned about as a psychiatrist. The health and well-being of these patients depends on the effective delivery and co-ordination of complex care pathways.
According to the Guardian, NHS Devon and Devon County Council have shortlisted bids to provide front-line services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as child protection, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, palliative nursing for dying children, and so on. On the shortlist for the £130 million three-year NHS contract are two private profit-making companies as well as the Devon Partnership NHS Trust, which has been bidding along with Barnardo's and other local charities.
The contract will apparently be awarded, according to the criteria, to the most economically advantageous bid, which appears to be possible under current commissioning arrangements. I seek reassurance from the Minister that the new safeguards in the Bill also prevent such commissioning decisions risking the perceived risks raised by my noble friend with respect to the commissioning of integrated care pathways in emergency care. I am referring not just to the emergency care part of the pathway but to the whole care pathway, which inevitably requires stable working relationships across organisational boundaries.
Earl Howe (Conservative)
My Lords, this is an important topic. The noble Baronesses, Lady Finlay and Lady Hollins, have eloquently set out the important role that emergency care services play for all of us, and I could not agree more.
The Government are clear about the need to strive continuously for improved quality of urgent and emergency care. The move to clinical quality indicators for A&E and ambulance services will ensure a better reflection of the quality of the services that patients receive, rather than encouraging an isolated focus on time factors. Furthermore, the introduction of the NHS 111 service supports the commitment to develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care.
I hope that I can reassure the noble Baroness about how clinical commissioning groups will be supported in commissioning high quality emergency care. The NHS Commissioning Board will produce commissioning guidance, and also may produce guidance on the exercise of CCGs' duty to obtain advice under new Section 14W. Both of these will reinforce the importance of effective and informed commissioning of emergency care. We have had many debates about clinical advice for commissioners during the course of our deliberations and, as I have previously mentioned, we anticipate that the clinical senates and networks that the Board will host will provide a resource of expertise, including in urgent and emergency care, on which CCGs can draw to inform their commissioning decisions. Equally, in order effectively to discharge their own duties with regard to obtaining appropriate advice, the NHS Commissioning Board would also need to take advice from a range of experts in order to assist them in producing such guidance. I understand that the College of Emergency Medicine has already engaged in useful conversations with the Commissioning Board Authority about how such engagement could work as it moves forward.
I reiterate the framework within the Bill for ensuring the accountability of CCGs in relation to the discharge of their duty under new Section 14W. CCGs must demonstrate, as part of authorisation, that they have the competence to carry out their functions effectively, and they will be held to account on that. As part of the authorisation process, the NHS Commissioning Board would need to be satisfied that a CCG can effectively commission the full range of services that its populations are likely to require, which of course would include urgent and emergency care services. It would also need to be satisfied that a CCG had the appropriate mechanisms in place to ensure that it could discharge its duty to obtain the appropriate level of advice in relation to these services. I also reassure the noble Baroness that the performance assessment of CCGs by the NHS Commissioning Board will look in particular at how they have discharged their duty to obtain advice.
The noble Baroness suggested that we should mandate that an emergency care specialist should have a seat on the CCGs' governing body. As your Lordships are aware from our previous debates on membership following the NHS Future Forum report, we committed to use regulations to specify a minimum membership for CCG governing bodies. We plan to specify that each body should include at least two lay members, at least one registered nurse and at least one secondary care doctor. This secondary care doctor may well be an emergency care specialist, or a CCG may choose to add additional specialists to its body should it wish to do so-there is nothing in the Bill to prevent that. However, in terms of going further and specifying that an emergency care specialist must sit on these bodies, I am afraid I cannot go that far.
The NHS Future Forum's report states that it would be unhelpful for CCGs' governing bodies to be representative of every group. We agree with that. The prime purpose of a governing body should be to make sure that CCGs have the right systems in place to do their job well. It is these systems that will ensure that they involve the appropriate range of health and care professionals in commissioning. Requiring a bigger group of professionals on the governing body itself would not mean that a broader range were involved in designing patient services; it would just lead to governing bodies that were too large and slow to do their job well.
Turning now to the noble Baroness's points about integration and competition in the context of emergency care, I agree with her about the importance of integration, and the Bill contains strong provisions to encourage and enable the delivery of integrated services. I reassure her again that choice and competition will not prevent the delivery of integrated services where these are in patients' interests. Additionally, it will of course be for commissioners to decide where to make use of choice and competition in order to best meet their patients' needs, and it is clear that this would not always be appropriate. Emergency care is a good example of a service where we would not expect to see competition.
I take this opportunity to respond to related concerns from the noble Baroness, Lady Hollins, who asked about the basis for competition. The Bill is clear that competition will not be pursued as an end in itself and that competition will always be on quality, not price. We made amendments in another place to ensure that this would be the case by removing the ability of Monitor and the board to set maximum prices rather than fixed prices. I hope that that answers the noble Baroness's question on this point.
The duty on CCGs to obtain advice is deliberately wide-ranging in scope purposefully so as to ensure that it covers the full spectrum of services that CCGs will commission. I draw noble Lords' attention to the language of new Section 14W: the advice must be drawn from people,
"who (taken together) have a broad range of professional expertise in ... the prevention, diagnosis or treatment of illness, and ... the protection or improvement of public health".
That is very inclusive and it echoes the approach taken in Section 3 of the NHS Act, which the Bill amends, to establish the fundamental commissioning responsibilities of CCGs.
Noble Lords will wish to note that the interpretation-
Baroness Williams of Crosby (Liberal Democrat)
I am grateful to my noble friend for giving way. I want to ask one question. I recently met a group of general practitioners who claimed that they were too busy to be able to go out and find advice. Is there any central point, perhaps in the cluster or on the Commissioning Board, to which very busy GPs could go to get some idea about where they might obtain advice on, let us say, an unusual condition?
Earl Howe (Conservative)
I reassure my noble friend that there will be no shortage of advice available to CCGs once they are up and running, not only from the NHS Commissioning Board centrally-she will know that a programme of work is in hand on the part of NICE to produce quality standards that will underpin the commissioning guidance-but also from the clinical senates, which will fall under the wing of the board. We envisage that those senates will be a resource on which clinical commissioning groups can draw, not least in the area of less common conditions. We are very conscious that the quality of commissioning needs to be improved in many areas, and this is our answer to that. My noble friend has put her finger on an issue that is of central importance if the new duty to improve quality is to become a reality across the system.
Noble Lords will wish to note that the interpretation section of the NHS Act 2006 states that illness includes any disorder or disability of the mind,
"and any injury or disability requiring medical or dental treatment or nursing".
We are absolutely clear that this covers cases relating both to physical and mental health requiring urgent and emergency care. This definition will apply to the duty to obtain advice in the new Section 14W. I hope I have been able to reassure the noble Baroness that CCGs will absolutely be expected to ensure that they obtain appropriate advice in order effectively to commission emergency and urgent care services; that they will be held to account for doing so; and that the current duty is deliberately drafted to ensure that it covers the full spectrum of services which CCGs will be expected to commission, including emergency and urgent care services. On this basis, I hope that she feels content to withdraw her amendment. I would, however, like to take this opportunity to thank the noble Baroness for our recent conversations on this topic, along with the College of Emergency Medicine.
My right honourable friend the Secretary of State and I both recently met with the college and found these meetings useful in exploring how we can ensure that we make the most of the opportunities presented by the new system in relation to improving the quality of emergency care. We look forward to constructive discussions with the college and with the noble Baroness as we move on to implementing the new arrangements.
Baroness Finlay of Llandaff (Crossbench)
I am most grateful to the Minister for that full reply and for his recognition of the contribution that the new College of Emergency Medicine is making to the urgent care of people who are often in extremis. It is literally the life-saving service for many people every day across the country. I am also grateful for his assurance that the performance assessment of commissioners will include how they seek advice from the appropriate people who really know what they are doing, and that integration is assured. The importance of 24/7 recognition has also been brought out in his answer. I am sure that the College of Emergency Medicine will be delighted with the assurances that he has given, as will A&E consultants up and down the country. I am most grateful to him and beg leave to withdraw the amendment.
Amendment 8 withdrawn.
Amendments 9 and 10
Moved by Earl Howe
9: Clause 26, page 44, line 22, after "14R" insert ", 14T"
10: Clause 26, page 47, line 9, after "14R," insert "14T,"
Amendments 9 and 10 agreed.
Clause 40 : After-care
Moved by Earl Howe
11: Clause 40, page 75, line 24, leave out paragraph (c) and insert-
"(c) after "such time as the" insert "clinical commissioning group or""
Earl Howe (Conservative)
My Lords, I shall speak also to the other amendments in this group: 12, 13, 15, 16 and 18-29. During Report, the noble Lord, Lord Patel of Bradford, tabled an amendment to Clause 40, then Clause 39, relating to Section 117 mental health after-care services. Noble Lords will recall that in recognition of the strength of feeling on this issue, we did not oppose the noble Lord's amendment. In the same spirit, we have now brought forward a set of consequential amendments resulting from the noble Lord's amendment. Some of these simply tidy up the wording of the Bill as a result of the noble Lord's amendment. Others are positive amendments to ensure that those receiving services under Section 117 of the Mental Health Act 1983 are not inadvertently excluded from benefiting from other provisions in the Bill. Specifically, the amendments ensure that Section 117 services are included in determining payments for quality; in special reviews and investigations by the Care Quality Commission; in emergency preparedness planning; in local authority scrutiny of the NHS; in NICE quality standards; and in information standards and information gathering. They also ensure that Section 117 services can continue to be available through direct payments.
I am pleased that the noble Lord, Lord Patel, has welcomed these amendments, and I hope that other noble Lords will agree that it is important that Section 117 services are included in all of these cases and will support these amendments. I also take this opportunity to ask noble Lords to support two minor and technical amendments. These remove an uncertainty about the breadth of the meaning of the reference to the Public Services Ombudsman for Wales in Clause 184, by clarifying that independent advocacy services extend only to certain complaints to that Ombudsman. I beg to move.
Lord Patel of Bradford (Crossbench)
My Lords, I am obviously very happy to add my name to the amendments tabled by the Minister in respect of Section 117 of the Mental Health Act, pertaining to after-care services. I was grateful to the noble Earl and to the noble Baroness, Lady Northover, for not opposing my amendment on this issue. It somewhat caught me off-guard, but I was pleased with that. I was particularly pleased that we have continued to work together to add these technical adjustments today. To remind noble Lords: Section 117 requires primary care trusts and local authority social services to work jointly in providing vital after-care services. These types of services can vary a great deal, including visits from the community psychiatric nurse, attending a day-care centre, administering medication, providing counselling and advice, and most importantly supporting accommodation within the community.
Section 117 provides crucial protection for vulnerable people because it ensures that their local primary care trusts and local authority provider supply that after-care package in an appropriate way, including sorting out the funding on an agreed basis. This means that these essential services cannot be taken away until both the PCT and local authority, in consultation with the patient and their carers or the voluntary sector-the people who are supporting some of these patients-are satisfied that the patient no longer needs their services. The original concern that the noble Lord, Lord Adebowale, and I had was that Section 117 after-care was being unnecessarily diluted, as a joint duty to provide after-care was being changed. To all intents and purposes, Section 117 would have been treated as a duty under Section 3 of the NHS Act, and that would potentially have opened up the possibility of charging.
The noble Earl has laid out the protections set out in additional amendments and they are to be welcomed. They go beyond my original concerns and address a number of important issues. I will not list those listed by the noble Earl, but I was happy about the part of Section 117 arrangements that fall under the remit of the Care Quality Commission, ensuring that the regulator and monitor of services should look across patient pathways. I am particularly pleased about the amendment that ensures that Section 117 services are eligible for direct payments. This is a positive step, because it means that people detained under the Mental Health Act can take more control of the services that they receive after their release.
This is not only the right thing to do, as it will empower people who have been affected by being detained, but it is also likely to help to avoid readmissions by ensuring that people are more satisfied and engaged with services. We still have a long way to go to improve services for people detained under the Mental Health Act; in particular the experiences and outcomes when they return to the communities where they live. However, these amendments are a definite move in the right direction and I must congratulate the Minister for having the foresight and good grace to bring these amendments before the House. I wholeheartedly support them.
Baroness Finlay of Llandaff (Crossbench)
My Lords, in this group of amendments there are two that relate to Wales. On behalf of the NHS in Wales, I am most grateful for the clarification. Could the Minister confirm that the Public Services Ombudsman would deal with complaints by any provider who is providing services for and on behalf of the NHS, irrespective of whether that is an NHS provider or a non-NHS provider? It would be helpful to have that clarification.
Baroness Jolly (Liberal Democrat)
My Lords, I shall speak briefly to Amendments 15 and 16 as well. They seem to be another correction to the minutiae of the provisions to establish a system of "nothing about me without me"-patient and public involvement-which we all support. However, it seems counterintuitive to aim to empower local people to improve health and social care without checking with them on the detail of how that empowerment should take place. The checks and balances of local patient and public involvement will be particularly important as the rest of these reforms are implemented, so we must get it right now.
Most of this part of the Bill was subject to a redraft, just a week or so ago, without any public consultation. Therefore, it would be helpful if the Minister could give an undertaking that there will be public consultation on all the many regulation-making powers within it. Thirty-six provisions are dependent on regulations, as are two lots of statutory guidance and two lots of directions.
In all previous iterations of patient and public involvement structures, there has been consultation on regulations. Given the complexity of the latest set of provisions and the limited opportunity to scrutinise them, it would seem wise to consult on them. I hope that the Minister will confirm that this will be done.
Earl Howe (Conservative)
My Lords, I am grateful to the noble Lord, Lord Patel of Bradford, for all that he said. I hope that the House will accept the amendments, which I assure noble Lords are intended to bolster and support the amendment previously agreed by your Lordships.
To address the issues raised by my noble friend Lady Jolly, as my noble friend Lady Northover said on Report, we have always envisaged that local authorities will have some freedom and flexibility over the organisational form of their local healthwatch, depending on local needs and circumstances. On reflection, we felt the Bill did not provide the right legal framework for this policy to be realised. My noble friend Lady Jolly makes a good point about the need to get this right. I should like to reassure her that we have already begun to engage key stakeholders on the content of the regulations and will continue to do so while they are being developed.
It may also be helpful to point out that we envisage the content of a number of these regulations-for example, those on the duties of service providers to respond to local healthwatch and allow entry to local healthwatch-will be based on the current Local Involvement Network regulations.
The noble Baroness, Lady Finlay, asked me about the Welsh amendments. I can confirm that the ombudsman covers all patients funded by the NHS. It is not something that is judged on an organisational basis. I hope that is helpful.
Amendment 11 agreed.
Amendments 12 and 13
Moved by Earl Howe
12: Clause 40, page 75, line 37, leave out from "Board," to second "to" in line 38 and insert "subsection (2D) has effect as if the reference to the clinical commissioning group were a reference""
13: Clause 40, page 76, line 2, at end insert-
"( ) In section 275 of the National Health Service Act 2006 (interpretation) after subsection (4) insert-
"(5) In each of the following, the reference to section 3 includes a reference to section 117 of the Mental Health Act 1983 (after-care)-
(a) in section 223K(8), paragraph (a) of the definition of "relevant services",
(b) in section 244(3), paragraph (a)(i) of the definition of "relevant health service provider",
(c) in section 252A(10), the definition of "service arrangements",
(d) section 253(1A)(d)(ii)."
( ) In section 48 of the Health and Social Care Act 2008 (special reviews and investigations), in subsection (2)(ba), after "the National Health Service Act 2006" insert "or section 117 of the Mental Health Act 1983 (after-care)".
( ) In section 97 of that Act (general interpretation of Part 1), in subsection (2A), after "section 7A of that Act)" insert "or section 117 of the Mental Health Act 1983 (after-care)"."
Amendments 12 and 13 agreed.
Clause 56 : Abolition of Health Protection Agency
Moved by Baroness Cumberlege
14: Clause 56, page 87, line 3, at end insert-
"( ) On abolition of the Health Protection Agency, the appropriate authority in England will take steps to ensure that any organisation established to assume the Agency's functions (and any others deemed appropriate) will-
(a) have a Board with a non-executive Chair and a majority of non-executive directors;
(b) be able to undertake and publish independent research and to bid for research funding from any source; and
(c) be able to tender for contracts related to its functions."
Baroness Cumberlege (Conservative)
My Lords, Amendment 56 is simpler than the amendment I tabled on Report but it is necessary because I need some undertakings. I know that other noble Lords also seek those. The amendment concerns Public Health England. Both amendments found favour across the House in the previous debate, as I hope Amendment 14 will in this one. I thank noble Lords who have put their names to the amendment. I know that the noble Lord, Lord Turnberg also wished to put his name to it, but there was no room on the Marshalled List.
As I said, the amendment concerns Public Health England, the new body that is destined to take on the duties of the Health Protection Agency, the cancer registries, the National Treatment Agency, the Public Health Observatories and some of the functions of the regional directors of public health and their teams. The staff of Public Health England will number around 4,500 people, so it is an important and considerable agency. The original proposal was that the organisation should be governed by a civil servant acting as the chief executive, without a board to whom he or she would be accountable. It was a model that many of us found very strange and thought unworkable.
At the meeting we had with him and later in correspondence, my right honourable friend the Secretary of State made it clear that he values an unobstructed line of accountability between the individual charged with the day-to-day running of Public Health England and him. However, he agreed in his letter, which I received on
"needs an appropriate level of operational independence for it to be most effective",
"it will be essential for it and the Government as a whole to work together seamlessly and to share a common agenda".
He went on to say:
"I do accept that, if PHE is to achieve our ambitions for it, the chief executive and the Secretary of State should be seen to be subject to frank and expert challenge. To help deliver that challenge I propose to appoint a chair for PHE, through an open and fair competition under the public appointments process, and I will ensure that the PHE board has a majority of non-executives members".
Later, he refers to them as non-executive members, rather than directors, so I seek an assurance from my noble friend Lord Howe that we are talking about directors and not members. Perhaps he will confirm this.
The board will advise on the running and development of Public Health England but my right honourable friend states that he has not yet had time to consider details of this aspect of the chairman's role. Once the chief executive post has been filled, he will discuss the overall governance structure of PHE. He will want to make sure that the expertise and experience of the chair will complement those of the chief executive and other senior PHE staff. He goes on to say:
"The essential point is, that we need to design a role for the chair that is significant enough to attract a high quality, respected candidate without diluting the responsibility of either the chief executive or the Secretary of State".
It is very much my wish that he should involve me further in these proposals. He says that he will write to me, but I should very much like him not only to write but perhaps to seek my views on this aspect of the organisation.
In his letter the Secretary of State writes:
"The chair and non-executive directors will have direct access to Ministers through regular, and if necessary ad hoc meetings".
I very much welcome that. He goes on:
"They will also have editorial control over a section of PHE's annual report".
Could my noble friend tell me what "section" means in this context, as he will know that the annual report will be a crucial document and should be honest and unfettered in its analysis of the nation's health? He continues:
"The annual report will reflect feedback from external agencies and individuals who have significant dealings with PHE ... and PHE data will be subject to the code of practice on official statistics, which severely restricts access to certain material by officials or Ministers before release".
Although I very much welcome this, I wonder whether my noble friend could give me an assurance that Public Health England staff will be able to give professional advice freely to the public. Since they are employed by an executive agency, they will be civil servants-subject to Civil Service contracts and bound by the Civil Service Code. They will be able speak out only if what they plan to say is departmental policy and has been approved by Ministers.
If PHE is to be the voice of public health, as we hope it will be, it will need to be able to advise the public and other professional bodies. The experts and specialists working in the executive agency will on occasions need to give professional advice that has the confidence of the public without its necessarily having been approved by the department.
Public health specialists employed by the NHS Commissioning Board or a local authority will have the freedom to speak out-of course within their professional code of conduct. I am not seeking for the amendment to be placed in the Bill but an assurance that this difficult tension will be addressed.
In earlier debates, the noble Lords, Lord Warner, Lord Patel, and Lord Turnberg, voiced their strong concerns about the commissioning and conduct of research by PHE-in particular, its ability as regards research funding for external organisations. I am sure that those noble Lords will seek assurances on this.
My right honourable friend the Secretary of State writes that he accepts the importance of the issue and will publish a more detailed description of PHE's role in research, including its relationship with academic institutions and other agencies. I am delighted that he is happy to involve me and, I hope, other noble Lords with the Chief Medical Officer in further discussions on this issue.
We have come a long way since Committee in designing a much more robust and satisfactory national board to undertake responsibilities for public health. Public health is sometimes seen as a side show in the maelstrom of issues that dominate the provision of NHS services but it contains the basic principle of social justice. It is to ensure that people have access to the essentials for a healthy and satisfying life, and nothing can be more important than that.
The Secretary of State has throughout sought to make public health centre stage, and I pay tribute to him for his commitment and determination, and thank him for listening to and acting on our suggestions. My noble friends Earl Howe and Lady Northover have been equally diligent and generous with their time in meeting our concerns. I know that the noble Lord, Lord Beecham, and others would have preferred there to be a special health authority. I can understand their wish, but the flexibility that an executive agency gives us might be useful in the future. The Secretary of State has promised post-legislative scrutiny of the Bill, specifically to consider whether PHE would be better served by a different arrangement or a better organisational form. I welcome that.
I have quoted fully and, I suspect, rather boringly from the letter sent by my right honourable friend the Secretary of State because it is very unlikely that my amendment will be in the Bill. I therefore need a record of the changes that have been promised. I do not doubt for a moment that there is any intention to renege on these undertakings, but I know how easy it is for things to go astray. I am therefore anxious to get as much as I can into the pages of Hansard as a reference for the future. I very much look forward to hearing the views of other noble Lords and my noble friend's reply. I beg to move.
Lord Warner (Labour)
My Lords, I have put my name to the amendment and pay tribute to the hard work put in by the noble Baroness, Lady Cumberlege, on making progress in this area. It has occasionally seemed a little like trudging through the Somme mud, but we have made some progress. I share her view that we want to hear at length from the noble Earl about the assurances promised by the Secretary of State, particularly on the governance issue.
I want to raise in a little more detail the issues in paragraphs (b) and (c) of the amendment, regarding the ability of Public Health England to undertake and publish independent research and to bid for research funding from any source. This remains an unresolved issue. The dialogue is continuing in the Department of Health because in November a joint working party was set up between the Health Protection Agency, which is being abolished, and the department about the research activities of the new Public Health England. I remind noble Lords that this is particularly significant because at stake is the large sum of money that the HPA, as a non-departmental public body, raised for research, its own funding of research, as well as the scientific independence and excellence of its staff. There has been a great deal of concern that creating an executive agency with civil servants would make it difficult for that research quality and volume to be maintained in the new world.
Despite the Health Secretary's assurances, concerns emanating from within the current agency remain around whether things have really been sewn up in terms of the ability of PHA, within the resources available to it, to control its destiny in the future and to go out to seek the research contracts that will enable it to meet the threats and concerns about public health that may have to be faced.
The nub of this issue comes down to a simple matter that I should like to leave with the noble Lord and on which I ask him to provide assurances. My understanding is that the problem at the moment is that the department has taken funds from the Health Protection Agency and Public Health England and made them available only for academic partnership research projects. The concern is that this might lead to Public Health England being prevented from carrying out research if that was not flavour of the month in academic institutions. There could be conflict between the concerns of academics to pursue partnership research and the real needs that the scientists within Public Health England consider to be in the public interest in terms of the research agenda to be followed. That is the main unresolved issue causing concern to the scientists within the Health Protection Agency staff who are soon-to-be-transmogrified into Public Health England.
The more assurances that the noble Earl can give the more they will satisfy not only the signatories to the amendment but the future employees of Public Health England who are to transfer as scientists to the new organisation.
Baroness Jolly (Liberal Democrat)
My Lords, I have put my name to the amendment. Historically, both parties to the coalition were in agreement that there were too many quangos and that rationalisation was required. This is always difficult when it involves an organisation as well respected as the Health Protection Agency and others.
Its successor organisation, Public Health England, was going to take over the HPA's and have duties with regard to the new structure of public health at local government level. However, that had no place in the Bill. On these Benches, we welcomed the move to ground public health in local authorities, and we welcome the statements by the Minister about the role, responsibility and duty of this newfound position.
However, we were anxious about public health at a national level. We were not alone, and I pay huge tribute to my noble friend Lady Cumberlege, who took up this cause at Report stage-probably before then-along with the noble Lords, Lord Patel, Lord Turnberg and Lord Warner. The Secretary of State now sees PHE as carrying out his functions. I am grateful for the time that he gave to meet us to explain his point of view and listen. He felt that to make Public Health England an executive agency of the Department of Health it would give it a degree of separation and flexibility. It was argued that PHE needed to have not only an independent chair but a board with a majority of non-executive directors if it were to have credibility with professionals and the public, and for the reputation clearly held by the HPA and others to be maintained in England and abroad. It would need to be able to raise funding to carry out its research on both English and worldwide issues. All this has been ably described by the noble Lord, Lord Warner, and we should be grateful for some clarity from the Minister on the research activities proposed for the organisation. There is clearly intended to be a line of accountability from the Secretary of State through Public Health England to the directors of public health, and it would aid understanding all round if my noble friend could clarify Public Health England's duties and accountabilities at local, community level with the directors of public health and local authorities. The line right the way down needs looking at.
I hope that the Minister will state that the Secretary of State is convinced that all of this is now a shared vision. However, as I stated earlier, none of this is stated in the Bill. My noble friend said that she will not push that, and I certainly will not, but I regret it, as it would be beneficial and make a really bold statement to the world outside that Public Health England is core to the Bill.
Can the Minister confirm the understanding of the Secretary of State's letter and, perhaps, agree to the wording of the amendment?
Baroness Masham of Ilton (Crossbench)
My Lords, the Health Protection Agency is held in high esteem throughout the world. It does the most important work in protecting society from infections and epidemics. The National Blood Service can be the blood of life. It is vital. Can the Minister give an assurance that the HPA will not be downgraded in any way? I support Amendment 14 and hope that the Minister will accept it. If he does, that will give some assurance to some of the people who have concerns about the changes. With so many complicated conditions, research should not be restricted and funding for this must be free and seamless.
Will Public Health England work with other countries? Infections have no boundaries. One never knows what is around the corner. The work of the body should be as independent as possible. Otherwise, we will lose some of our brilliant researchers to countries which will give them more freedom.
Lord Turnberg (Labour)
My Lords, I rise to speak briefly, because much of what I might have said has already been said by the noble Baroness, Lady Cumberlege. I, too, am very grateful for the way that the noble Earl has listened to us and spoken and written to us with helpful comments, which I hope that he will reiterate today. I just want to make one point about the research undertaken by the current HPA. It is directed predominantly to infectious disease and bacterial and viral infections. In that area, it is really world-beating. Recently, two of its members of staff have been elected fellows of the Academy of Medical Sciences, which is quite an achievement. The idea that it should do all this research in academic research partnerships with universities is unhelpful. Although collaboration and co-operation with university departments is enormously valuable, it should not be a precondition that it should be able to do research only in collaboration with universities. I hope that the noble Earl will be able to nail that problem.
Lord Patel (Crossbench)
My Lords, I shall speak very briefly. I spoke at length in Committee and on Report and I shall not repeat what I said. Other noble Lords have referred to the key issues. If Public Health England is to be a strong, high-profile, public health national organisation, it needs strong governance. It also needs the independent ability to bid for research funds, as the HPA currently does, as has been highlighted, both nationally and internationally. At the Report stage, I referred to the fact that the HPA currently gets a significant amount of contract research income from NIH. It is no easy task to get money from NIH for research. If it is forbidden to do that, and, as the noble Lord, Lord Turnberg, said, is allowed to do research only with academic institutions, and not independently, that will be wrong. I hope that the noble Earl, who has listened to the arguments in the meetings we have had, will be able to alleviate those anxieties.
Lord Beecham (Labour)
My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Cumberlege, on the enormous effort that she has put in to moving the Government's position somewhat although, as she says, in the view of some of us, not quite far enough.
The noble Baroness, Lady Jolly, referred to a degree of separation. I would rather that we had six degrees of separation; I think that we will probably have to settle for the current single degree of separation. That is slightly unfortunate, because, as other noble Lords have stressed, the question of independence of the organisation is crucial. In moving the amendment, the noble Baroness, Lady Cumberlege, raised that issue and mentioned the Civil Service code and the possible inhibitions on employees of Public Health England and what was the Health Protection Agency in giving that advice independently and openly.
Bearing in mind the discussions that we had earlier this afternoon about the relationship between civil servants and Ministers, I hope that the noble Earl will address that, if not today in his reply then subsequently, to explain how that relationship will work and to confirm the complete independence of members of staff in advising not only Ministers but, as the noble Baroness said, the public. I reinforce the points made by other noble Lords. I think we got a verbal assurance from the Minister last time, but I would like it fully explained that the research capacity of the organisation will be maintained.
The amendment is slightly more modest than originally proposed by the noble Baroness, and even more modest than some of us would have liked. For the life of me, I cannot see why the noble Earl should not be able to accept it. If he is not prepared to do that, perhaps he will explain why. At the very least, I hope that he gives the assurances and undertakings that the noble Baroness has sought and that we can take forward this part of the Bill, which in turn complements the best part of the Bill, which relates to public health in general.
Earl Howe (Conservative)
My Lords, I am grateful to my noble friend for the opportunity to return to this issue and for the extremely constructive and sincere manner in which she and other noble Lords have pursued it during and between previous debates in this House. My noble friend is anxious for Public Health England to be and to be seen to be a trusted and impartial champion for the protection of the health of the people and free to provide advice based firmly on the science and the evidence. So are we.
The Health Protection Agency has built an enviable international reputation that Public Health England must first live up to and then surpass. I take on board the question posed by the noble Baroness, Lady Masham, about downgrading. No, of course we want to build on the HPA's undoubted achievements and have Public Health England seen as a world leader. All the current activity undertaken by the Health Protection Agency will transfer to the Secretary of State.
With that in mind, we have listened very carefully to what my noble friend and others have had to say and thought long and hard. I am happy to set out to her fresh proposals to meet her concerns and to build on the undoubted successes of the Health Protection Agency and the other organisations that will evolve into the new organisation.
The Bill gives a new and vital duty to the Secretary of State, and only to the Secretary of State, to protect the health of the people of England. To a very large extent, Public Health England will exist in order to help him to discharge that duty. It is for that reason that we feel we must preserve a very direct and clear line of accountability between the chief executive and the Secretary of State. While Public Health England undoubtedly needs operational independence to be most effective-a point raised by a number of noble Lords-it will be essential for it and the Government to work together seamlessly and to share the same objectives. Anything less could severely limit the Secretary of State's capacity to undertake his statutory duty.
This is not, however, to say that the Secretary of State and the chief executive can operate in isolation, or behind closed doors. On the contrary, if PHE is to become a respected world leader-as is our ambition for it-we accept entirely that it must be subject to frank, forthright and expert challenge. My noble friend and other noble Lords have made their case cogently and persuasively, and we agree that this level of challenge can best be delivered by a board with both an independent chair and a non-executive majority. I can assure noble Lords now that that is precisely what we intend to establish within Public Health England.
We intend the board and chair to provide invaluable advice on the running and future development of PHE, but, if my noble friend will permit, we would like to take a little more time to define the role of the chair in more detail. Interviews for the post of chief executive are about to begin, and we want to ensure that the skills and experience of the successful candidate will be complemented by those of the chair. I would be happy to continue discussing this with my noble friend as we take things forward. She asked whether the non-executives on the board will be members or directors. The crucial issue here is what the board will actually do. PHE will not have a board of directors in the way that a private company might. As we have discussed, we are clear that PHE's objectives must match those of the Government, which precludes a board which can make decisions that are binding. We are, however, just as clear that the board must be seen to be providing robust, impartial and evidence-based advice that the chief executive and Secretary of State will find impossible to ignore. I hope that gives my noble friend the flavour of what this board will be tasked with.
We are now in the process of establishing a detailed framework for the way PHE will operate which will address its relationship with local and central government, as well as with the general public. That framework will, of course, be published. However, I can say now that as well as appointing the board and chair we will take a number of other steps to highlight and support the operational independence and transparency of PHE.
Earl Howe (Conservative)
I think that the noble Lord asked me whether the board will be an advisory board or a board. Its function will be to provide advice. It will be a board, but the Secretary of State and the chief executive of PHE will look to the board for that robust challenge and advice that a public health service needs.
Lord Willis of Knaresborough (Liberal Democrat)
I am grateful to my honourable friend-I am sorry, I mean my noble friend; I keep calling him honourable, but I am sure he is as well-for that response to the noble Lord, Lord Turnberg. The issue is really quite fundamental. If what my noble friend has described is a purely advisory board, the board will not therefore be able to take any executive decisions about the nature of the research that it carries out; that will be totally dependent on the Secretary of State passing it down. Is that so? If so, how in fact will it interface with, for example, the new European programme, programme 8, in terms of European-wide research on public health?
Earl Howe (Conservative)
No, my Lords, my noble friend is not correct. It will be able to take decisions. What it will not be able to do is to bind the Secretary of State because, ultimately, if there is an issue of public health importance, it is the Secretary of State who must take responsibility for that. This said, Public Health England will of course be its own master as regards the research that it undertakes, and it will be operationally independent, as I emphasised earlier.
We will ensure the chair's direct access to Ministers through regular and ad hoc meetings. The chair will have its own section in PHE's annual report which it will draft personally and independently, and that report will also reflect the views of external agencies and individuals who have dealings with PHE. I hope that that gives my noble friend additional assurance about the independent voice that we want to see and hear.
My noble friend Lady Cumberlege asked me whether PHE will be able to give professional advice freely to the public. We expect it to do precisely that, in much the same way that the Chief Medical Officer already does. It will be good practice for PHE and the department to consult each other about communications on public health matters, but with a view to agreeing the content, not censoring it.
PHE data will be subject to the code of practice on official statistics, which severely restricts access to certain material by Ministers or officials before it is published. Within three years of PHE becoming operational we will undertake a review of its governance to ensure that it is entirely appropriate and effective.
My noble friend's amendment also addresses the very significant issue of PHE's capability to undertake research and to bid for external research funding-a matter to which the noble Lord, Lord Warner, devoted particular attention. This is something we have touched on in previous debates, and it is clearly vital to PHE's long-term success. We will publish more information about how PHE's research function will work, including its relationship with academic institutions, but I can assure noble Lords that it will be able to exercise all the necessary powers and duties of the Secretary of State in relation to research.
In particular, Clause 6 confers on the Secretary of State a duty to promote research relevant to the health service, which embraces public health services. Clause 11 specifies that the conduct of research is an appropriate step for him to take under his health protection duty. Clause 50 provides that charges may be made in respect of such steps. Clause 17(13) confirms the Secretary of State's power to conduct, commission or assist research relating to health, which includes the power to apply for grants or other funding for the purpose of such research. In addition to the Bill's provisions, the Secretary of State has power to generate additional income for the health service under Section 7 of the Health and Medicines Act 1988, which can be used by PHE to provide research services under contract. I can therefore reassure my noble friend and the noble Lord, Lord Warner, that existing legislation gives the Secretary of State, and therefore PHE, the freedom to bid for research funding and to tender for contracts.
The noble Lord, Lord Warner, asked about external partnerships and whether agencies that currently fund the HPA research will be able to fund PHE in the future. The answer is that we are not aware of any insurmountable obstacle to any of the HPA's current partners choosing to fund PHE, although in some instances PHE may need to collaborate with an academic institution. Of course, we cannot guarantee that they will choose to. All we can do is ensure that PHE remains at least as attractive a partner for health protection research as the HPA has been. I can also say to the noble Lord, Lord Patel, that we will publish more information on this question quite soon, but we have no reason to believe, as I say, that academic institutions will be reluctant to go into partnership with PHE. In fact, the National Institute for Health Research has already announced that it will invite joint bids.
My noble friend's amendment and the powerful way in which she has argued for its objectives-
Lord Warner (Labour)
I am sorry to interrupt the noble Earl. I waited patiently until he had been through the research arguments but I am still not clear. He said earlier that Public Health England would be master of its own destiny in terms of research. The point that I and, I think, my noble friend Lord Turnberg were making was that, if it comes to a tussle between PHE and the National Institute for Health Research over doing research which PHE considers to be in the public interest but there is no academic partner to undertake that research, will PHE's mastery of its own research destiny trump the attempt by the National Institute for Health Research to impose partnership working on the research agenda? That is the issue that I was trying to talk about and which I think my noble friend was also talking about.
Earl Howe (Conservative)
My Lords, although I understand the noble Lord's question, I do not think that I can answer it at the moment, and I am sorry to disappoint him. My advice is that we do not think that partnerships will be necessary in all or every case for Public Health England. Whether the NIHR can insist on trumping the operational independence of Public Health England is not a question that I can answer very readily. The main point is that research would not have to be jointly conducted. The Secretary of State has the power to carry it out on his own. That means that, if there were a tussle between two priorities, the Secretary of State could insist that a certain programme should be prioritised. I think that that is probably as far as I can go in answering the noble Lord at the moment.
My noble friend Lady Jolly asked me some general questions about lines of accountability. I hope that she will have gathered from my remarks today that Public Health England will be accountable directly to the Secretary of State in the first instance. Directors of public health will be joint appointments between local authorities and the Secretary of State, although they will be local authority employees and directly accountable to the authority chief executive. It goes without saying that close joint working between PHE and local authorities will be crucial.
My noble friend's amendment and the powerful way that she has argued for its objectives are a tribute to her and to the noble Lords who have supported her. I believe that I have responded positively to each point that the amendment seeks to establish and that that response can be made comprehensively without amending the Bill. That remains our strong preference. I hope very much that my noble friend is sufficiently reassured by the commitments that I have made today to withdraw her amendment.
Baroness Cumberlege (Conservative)
My Lords, I have no intention of testing the opinion of the House this evening. We have negotiated long and hard with my noble friends Lady Northover and Lord Howe. It has been a very interesting experience. Those noble Lords who have supported me by putting their names to my amendments have tutored me well in the art of negotiation. It has occurred to me that clearly you can negotiate only if both parties are willing to participate, and in this instance that has been the case. The Secretary of State, my noble friend and noble Lords have been more than willing to meet us and to debate and discuss matters with us, putting forward some very strong assurances about the future of Public Health England.
I know that my noble friend Lady Jolly wanted the amendment to be made to the Bill and for those words to be included in the Bill so that the constituency in the country-all the public health people involved-would see what we are trying to achieve. I knew some time ago that that would not be possible, and we have had a very full debate today, albeit at Third Reading, because we are very anxious to get all those assurances articulated and recorded in Hansard.
We will be keeping a very close eye on the development of Public Health England and I shall be framing the assurances that I have been given today. I shall have them on my wall and, when there are new Secretaries of State, I shall present them with this framed undertaking so that we can absolutely ensure that Public Health England goes from strength to strength and, as my noble friend said, is a world leader and, I hope, a world beater. We have a very good reputation in the world on public health. It is something that we must retain and improve upon, ensuring that we have a healthier nation for the future. I beg leave to withdraw the amendment.
Amendment 14 withdrawn.
Clause 185 : Independent advocacy services
Amendments 15 and 16
Moved by Earl Howe
15: Clause 185, page 186, line 44, leave out from "England" to end of line 45 and insert ";
(ca) a complaint to the Public Services Ombudsman for Wales which relates to a Welsh health body;"
16: Clause 185, page 188, line 13, at end insert-
""Welsh health body" means-
(a) a Local Health Board,
(b) an NHS trust managing a hospital or other establishment or facility in Wales,
(c) a Special Health Authority not discharging functions only or mainly in England,
(d) an independent provider in Wales (within the meaning of the Public Services Ombudsman (Wales) Act 2005),
(e) a family health service provider in Wales (within the meaning of that Act), or
(f) a person with functions conferred under section 113(2) of the Health and Social Care (Community Health and Standards) Act 2003."
Amendments 15 and 16 agreed.
Moved by Baroness Emerton
17: After Clause 229, insert the following new Clause-
"Power to register health care support workers in England
(1) Health care support workers in England may enter a voluntary register assured by the Council for Health Care Regulatory Excellence, provided they have attended an assured training programme prior to entry on the register.
(2) The assured training programme shall be mandatory for all new health care support workers from
(3) The Secretary of State shall develop a Code of Conduct for all employees (whether or not entered on the register) who are providing care to NHS patients (including employees of local authorities) who are seeking to develop the necessary competencies for health care support work.
(4) The Secretary of State shall review the procedures for training under this section, and its benefits or otherwise, within three years of this Act receiving Royal Assent."
Baroness Emerton (Crossbench)
My Lords, the amendment concerns the power to register healthcare support workers in England. I shall try to be brief, as we had a long and thorough debate on this matter on Report and I have studied the Minister's response to my amendment at that stage. I have had protracted discussions between Report and now with the noble Earl and officials, and I thank them most sincerely for the time and effort they have put into trying to meet my requests.
Healthcare support workers form a very large part of the workforce, whether they are in the employment of NHS hospitals, community services or local authority services, providing care in people's homes, or in the large number of nursing and residential care homes. We should not forget the role played by social workers, which often overlaps with the role of healthcare support workers, and vice versa.
Many noble Lords have said in previous debates that large numbers of support workers provide high-quality care, and they have received some training in order to do that. It is not likely that this large number of support workers will decrease with a growth in demand from the rapidly expanding number of elderly, frail and vulnerable people who require high-quality care. However, it is also not possible to expect a magic wand-that is, the Government-to provide training overnight for everybody at once. Therefore, it is reasonable to find a way forward that provides a direction of travel that satisfies patients, the public, the professions and employers that the issue is being addressed as a matter of urgency within the economic situation in which we find ourselves.
I shall briefly address each item covered by the amendment. The Minister has indicated that Skills for Care and Skills for Health will be producing an assured training programme, prepared with professional inputs, that will, following consultation, be available for implementation in 2013. This will entitle successful candidates to be entered on the voluntary register if they so wish.
I am aware, and pleased, that the Minister has also agreed that work should proceed on reviewing the research on ratios of registered to unregistered personnel, and that the supervision of work delegated to registrants is vital. However, realistically, in some communities and hospital situations it is not possible for there to be close scrutiny of support workers' performance. The recent report published by Which? clearly demonstrates neglect in the delivery of care to patients and in their safety. Clearly, the Government need a means of early identification of the failings in the delivery of care.
While the training programmes are being developed, perhaps we could ask, through the Minister, that registered nurses and midwives are reminded of their responsibility and accountability, that they have to assure themselves of the competences of individual support workers before delegating a task, and that, once a task has been delegated, it must be supervised. Where that proves impossible because of insufficient registered nurses and midwives, immediate action should be taken by a registered nurse to report to his or her manager and the employers should take action on the level of care that can be delivered in that situation. That will safeguard the safety and quality of care to patients.
I now turn to the second subsection of the proposed new clause. It is recommended that the next logical step would be to aim for the training of support workers to be mandatory. So far discussions on making the training of healthcare support workers mandatory has not found favour with Her Majesty's Government. Many Peers indicated, on Report, the importance of all healthcare support workers receiving mandatory training and that it should be regulated. Although it is recognised that that could not be arrived at tomorrow, if Her Majesty's Government could agree that the training programmes will be mandatory at a date to be determined for implementation, I am sure that the patients, the public and certainly the professions of nursing, midwifery and social care would be satisfied.
Subsection (3) of the proposed new clause requires the Secretary of State to develop a code of conduct for all employees whether they are entered on the register or just providing care. That includes the employees not just in the NHS hospitals but also in local authorities. That would provide clear guidance for employers as well as employees and should assist in ensuring that competences, where lacking, are made good by training modules or by withdrawing the person who does not have the skills or the competences. Without such controls of clearly defined competences being included for practising healthcare support workers and the correct delegation and supervision by registrants, it will be impossible to ensure the high-quality, safe, compassionate care that patients and clients deserve or indeed Her Majesty's Government aim to provide. I hope that the Minister will feel able to provide a positive response to this request.
Subsection (4) requires Her Majesty's Government to carry out a strategic review within three years, as the Minister undertook to do on Report, about whether statutory regulation of support workers is necessary in the light of progress with the proposed training programmes and the introduction of the voluntary register. Perhaps I may suggest that the review of the research on improving the ratios of registered nurses and midwives is also included in this review so that a holistic view can be gained of the future shape of the workforce required to deliver high-quality, safe and compassionate care, with the result of improved clinical outcomes that are cost-effective and of cost benefit. I beg to move.
Lord Patel (Crossbench)
My Lords, on Report, I spoke strongly in support of the amendment in the name of my noble friend Lady Emerton. I thank the Minister for the many conversations that he has had with my noble friend and myself to try to resolve some of the issues. Like the noble Baroness, I am most appreciative of his readiness to meet and speak with us on many occasions.
We have about 450,000 healthcare support workers and some have had some training and therefore perform the tasks that they are given with fairly good competency. Others do not have any training and they might perform the tasks that they are given at variable levels. We also heard on Report from the noble Lord, Lord MacKenzie, and my noble friend Lady Emerton about the kind of tasks that healthcare support workers currently carry out. They range from simple nursing care or bathing or feeding duties to cannulisation and bladder catheterisation and even more invasive procedures than that. That should confirm to us that there is a need for some kind of standardised training programme that healthcare support workers must undertake so that their competences are assessed and so that they work to those competences. It is not fair that those healthcare support workers who have had some training and are competent to perform their duties have to work alongside others who have not had any training and, therefore, are lacking in competences.
On Report, one of the many things that the Minister agreed to take forward in relation to healthcare support workers, if I quote him correctly, was to try to establish assured voluntary registration, which the Council for Healthcare Regulatory Excellence will run. If we are to have any kind of register, surely ipso facto certain conditions must be satisfied before someone can go on to the register. Logically, that would suggest to me that there must some form of training. If that is the case, why would we object to having training as a requirement for all new healthcare support workers? I well understand that it is not impossible, but very difficult and expensive, to try to train some 450,000 people who already carry out such tasks. That could be overcome by having a code of conduct imposed on employers; it would be their duty to ensure that whoever they employ has the competencies to do the tasks that they are asked to undertake. It would not be vastly expensive to get 450,000 people trained. Subsection (2) of the proposed new clause refers to "mandatory" training-I use the word "requirement"-for all new healthcare support workers from April 2003 before they go on the assured voluntary register.
I take a slightly different view about whether the register is voluntary or statutory. I know that the word "statutory" to all healthcare workers is important. I am registered by statute to be on the medical register but it is more important that the register has some meaning and that it works. If a voluntary register does not work, it is no good; if a statutory register does not work, it is no good. It is important that people who go on the register are trained and assessed as having those competences. Subsection (4) of the proposed new clause, to which the Minister agreed previously, requires that a review will be carried out for the benefit or otherwise of any kind of register that is established. I hope he will agree to that. I hope that the Minister will be able today to reassure my noble friend Lady Emerton.
I have been very touched by what my noble friend has said in the many conversations that she has had with me. To me, she typifies the attitude of a very caring nurse who is concerned about the poor quality of care seen in daily reports in newspapers; there was also a report yesterday from Which, to which she alluded. That clearly affects her as a professional nurse. Therefore, I strongly support her amendment.
Lord MacKenzie of Culkein (Labour)
I had hoped that the House might have agreed the need for statutory regulation and registration for healthcare support workers, but the Government should at least accept this amendment. It provides for a code of conduct, for mandatory training, which must be to an agreed standard, and for a requirement to have undertaken an assured training programme before one can enter the voluntary registers that are to be set up. These things should all be in the Bill; they are necessary to protect the patient and the public.
Training, in my view, has to be mandatory; it cannot be left to the whims of employers to decide how much or how little training to give to healthcare support workers. I know from nurses, including my step-daughter, who is a registered nurse, that some of that training is good, some of it is patchy and some of it is shockingly poor. Some of it is supernumerary today, on the team tomorrow; see a procedure today, carry out that procedure tomorrow. That old system of training has no place in the modern delivery of nursing care, but it is what many healthcare support workers have delegated to them.
The Minister knows my views about voluntary registers, but I have no wish to see them fail. If they are to succeed, every effort must be made to ensure that those who are eligible get on to these registers. He will correct me if my memory is playing tricks on me, but I seem to recall him saying at an earlier stage that employers could require someone to be on a voluntary register before appointment or promotion. I have no quarrel with that if we are properly to protect the public, but I want to know whether an employer can do that. If, say, there are two candidates for promotion with very similar training and experience on their CVs, but one is on the voluntary register and one is not, will the employer be able to refuse to see the person who is not on the voluntary register? I wonder what an employment tribunal might make of that.
I hope we can have an assurance that employers will be able to discriminate in this way, because I am concerned that everyone who should be on the register is on it. We know that rogues and rascals and those who are less than suitable are the ones who are not likely to want to be on a voluntary register, which is why I prefer the other course. However, we are where we are and I hope that the Minister can at least reassure us on this point.
Baroness Masham of Ilton (Crossbench)
My Lords, I have my name to the amendment. During the passage of this Bill, some of us have been trying very hard to improve the care of vulnerable patients in hospital and in the community. I felt healthcare support workers should be registered and regulated, as many vulnerable patients, being frail and elderly or disabled in many diverse ways, have to rely on their carers. Your Lordships have heard that patients have been put at risk or died through neglect or assault in care homes and hospitals up and down the country. Many people wait in anticipation for the result of the review of the Mid Staffordshire Foundation Trust. This must not be covered up; lessons should be learnt in memory of the hundreds of patients who received poor care, were neglected and died. Surely it is our duty to try to help rectify this deplorable situation.
I have every admiration for the Minister, who has worked tirelessly over this Bill, but I do not agree with him that nurses who have been struck off their register can go back to caring for patients as unregistered healthcare assistants. We are exposing the most vulnerable in our society to greater risks and poorer care if we do nothing to prevent struck-off nurses continuing to work in a caring profession. This amendment is a compromise, but even so it has a very important part. Subsection (2) of the proposed new clause in the amendment states:
"The assured training programme shall be mandatory for all new health care support workers from
Not to train people who care for vulnerable patients is deplorable. Last year I was involved in a case of a person living at home and using a respirator. The patient was left brain damaged when the agency nurse turned off the wrong switch. Adequate, appropriate training should be given; in that case, it was a health care worker who was also a nurse.
Many disabled people are living in the community, which is good, but many of them use technical equipment that needs training and understanding, such as hoists, pressure mattresses, peg feeds, catheters, complicated electric wheelchairs, ventilators, nebulisers, diabetic management, colostomies, adapted vehicles and many other complicated devices. An assured training programme should include where to place a patient's food and drink and to assess whether the patient can feed themselves. If not, the healthcare worker should know how to do this; how to wash and bathe and deal with personal needs such as toileting; how to prevent pressure ulcers; moving and handling; and complications with patients who have problems and may be difficult and have a problem communicating. There are many needs, but kindness and common sense should prevail.
If the Minister and the Government do not agree with this amendment, it will mean they do not understand the needs of vulnerable patients' care. If training is mandatory, I am sure employers will take notice.
Lord Cotter (Liberal Democrat)
My Lords, I thank the noble Baroness, Lady Emerton, for introducing this amendment, which I hope the Minister will agree gives an opportunity for a very important issue to be aired. Many noble Lords have aired it in the past; indeed, I raised it on the very first day of the Bill. It is an area that remains of concern, and I have been pleased to hear from the Ministers that they are well aware of this. I recollect at the beginning of the Bill speaking to a nurse who, with an air of concern in her voice, said that when she asked assistants to carry out work the responsibility remained with her if that work was not carried out correctly. I welcome this opportunity for the Minister I hope to give a very strong response to indicate the Bill will cover this issue. As the noble Lord, Lord Patel, said, we are talking about 450,000 healthcare assistants: many people of varying abilities and knowledge.
I will say no more except to thank the noble Baroness for her amendment and, in anticipation, to thank the Minister for his response, which I hope will be robust and clear as to what we are going to do to address this concern.
Baroness Finlay of Llandaff (Crossbench)
My noble friend Lady Emerton, in tabling this amendment, has come up with something very sophisticated and really rather clever. By requiring education, she will ensure that the next group has its standards driven up. People enter into a caring group and learn from others around them; the problem is that at the moment they are learning bad practice as well as, hopefully, learning good practice.
Making sure that these are assured training programmes is eminently sensible. Modern educational techniques using e-learning, DVDs and other ways of training mean that you do not have to take people away from the job and put them in college. They could be given provisional registration while they worked through some of these training programmes. Modern ways of teaching also allow you to train those with very low literacy skills. It is worth remembering that some of the very high-standard care assistants in the system providing care in people's homes often have low levels of literacy, so they need to be taught using modern techniques. This will allow that to happen. As for tracking their attendance, with electronic records it becomes quite easy to monitor what they turned up for and how they performed and to assess them in the tasks that need to be undertaken.
This amendment seems to meet all the criticisms that the Government laid at the door of previous amendments. I hope that it will get a better reception than its predecessors.
Baroness Cumberlege (Conservative)
As a fellow of the Royal College of Nursing and the Royal College of Midwives, I very much regret that I have been unable to take part in the previous debates initiated by the noble Baroness, Lady Emerton. I regret that for many reasons, not least because I had the privilege of introducing the noble Baroness into your Lordships' House, and what a good thing that was. The noble Baroness is a truly remarkable person. I am not at all surprised that she has crafted this very clever amendment, as the noble Baroness, Lady Finlay, said. I know that the noble Baroness, Lady Emerton, recognises that statutory regulation will not always prevent abuse. Indeed, the chief executive of the Council for Healthcare Regulatory Excellence told your Lordships at a seminar that the regulator is never in the room when abuse occurs.
I understand that the noble Baroness is calling not for regulation but for a voluntary register assured by the CHRE. People will get admittance to the register provided they have attended an assured training programme. The training programme is to be mandatory for all new healthcare support workers from
However, is it not right that good employers should pay the registration fee and have some element of discrimination in deciding who they recruit to a job? The question asked by the noble Lord, Lord MacKenzie, was very apt. My noble friend's answer to it will be very interesting. If individual support workers have to pay the registration fee themselves, it could be seen as a tax on work for people mostly on the minimum wage, and there is an issue about that. It will probably increase the cost of employment, and this is a market in which retail, part-time working and motherhood compete, so we have to be careful.
On Report, the noble Lords, Lord Turnberg and Lord MacKenzie of Culkein, referred to the history of state enrolled nurses. Unlike registered nurses, they were said to be used and abused. I remember that because I served with the noble Baroness, Lady Emerton, on the United Kingdom Central Council for Nursing, Midwifery and Health Visiting where, over time, we phased out state enrolled nurses. They have been replaced to some extent by healthcare support workers, and we are facing almost the same issues again.
In the previous debate, my noble friend Lord Newton and the noble Lord, Lord Hunt of Kings Heath, were very kind to mention my role in nurse prescribing. I am delighted to see the noble Baroness, Lady Jay, in her place. I remember the day when we rejoiced in the fact that nurse prescribing had gone another step on the way. It took me 26 years to get that to happen-a very long time indeed-and we are not quite there yet. It seemed to me that nurse prescribing was extremely obvious. In the light of today's debate on risk and risk registers, it probably would have been seen as a very high risk, but it has not proved to be so-but we are not there yet. I am very much hoping that, with the help of my noble friend Lord Henley and the Home Office, the last piece of this jigsaw will be put into place.
We started very small with nurse prescribing. We started with Bolton. The whole of Bolton took on nurse prescribing. In some parts of the country, the fight was enormous. GPs saw prescribing as their territory, and they did not want nurses to step into it. We managed to achieve it, and one of my real worries is that if we have support workers who, as the noble Baroness told us in the previous debate, are administering some very serious drugs, the work that I have done will be diminished because people will then think that nurse prescribing can be done by anybody with sufficient training, and that is dangerous. It is wrong for patients, and it is wrong for support workers who have perhaps been told that they have to administer these drugs.
I shall finish by reminding your Lordships that when Florence Nightingale visited front-line hospitals in the Crimea, the first question she asked was: who is in charge? For every patient in today's National Health Service, it is as relevant a question as it was 150 years ago. Who is in charge of my daily care? Too often, it is an unsupervised healthcare support worker. That is not right for the patient and not right for the worker. I think we have to do something about this.
The noble Baroness, Lady Emerton, has put so much thought and effort into her amendment, has taken lots of advice and has worked so hard on this issue. We must resolve it. As other noble Lords have said, the code of conduct is a very good step forward, but we have to secure training and ensure that support workers are equipped to do the job and are not put in positions that make them and patients vulnerable.
Lord Hunt of Kings Heath (Labour)
My Lords, the noble Baronesses, Lady Cumberlege and Lady Emerton, and other noble Lords who have spoken have argued pretty persuasively for statutory regulation. I think it is a pity that the noble Baroness, Lady Emerton, did not put her amendment to the vote on Report because there is a great deal of support in this House and outside it for statutory regulation. I do not know whether the Minister will accept this amendment, but if the noble Baroness wishes to put it to the vote, we shall support it.
If we look at the first part of the amendment, as I understand it the Minister gave an assurance on Report that the Council for Healthcare Regulatory Excellence would provide some assurance to voluntary registers. If the council is prepared to undertake the work to provide some assurance for voluntary registers, I cannot see why it could not have done that for statutory regulation. I have yet to hear one argument by that body or anyone else about why there should not be statutory regulation on this.
I note that the assured training programme is to be mandatory. It is all very well to say that it is mandatory to attend a training programme, but I would rather like to hear that someone has passed some kind of examination and achieved a qualification rather than that they merely turned up and got ticked in-although we know about being ticked in in your Lordships' House.
On proposed new subsection (3) in the amendment, my reading is that this will not cover nursing homes. The noble Baroness, Lady Masham, expressed concern that a nurse may be struck off the register of qualified nurses but turn up at a nursing home the next day. However, my reading of this subsection is that it relates only to the care of NHS patients. Clearly, there are large parts of the care market to which this does not apply, and the most vulnerable part of care is healthcare assistants working in the independent sector without much supervision.
On proposed subsection (4), the disappointment is that the noble Earl said that the Government would agree to review this after, I think, three years. That would take us to 2015. We know that it would take two or three years to establish statutory regulation, so we are talking about five or six years from now, according to this amendment, when we would achieve statutory regulation. I am sure that that is the journey that we are on; I am disappointed that it will take so long to get there.
Earl Howe (Conservative)
My Lords, we have already had considerable debate on standards and training for healthcare support workers at both Committee and Report stages and I have set out the Government's view that compulsory statutory regulation is not the only way to achieve high quality care.
We have made it clear that we recognise the need to drive up standards for support workers and to facilitate employers to appropriately employ, delegate to, and supervise health and social care support workers. We have listened to the concerns raised in this House and we have already taken action in a number of areas. We have recognised the concerns about the need for common standards for all those delivering personal care. I believe the steps we are taking will help increasingly to professionalise this set of workers, and ensure that healthcare support workers strive to achieve the best standards of skills to enable them to do their work more effectively.
We have therefore commissioned Skills for Health and Skills for Care to work together to develop a code of conduct and minimum induction and training standards for those support workers working in support of nurses and for adult social care workers. We fully expect this code to make crystal clear the primacy of patient safety, and how support workers must flag concerns to their supervisors. It would also be relevant both to employees and to employers. These will be developed by September 2012, with a view to enabling them to be adopted as the standards for an assured voluntary register from 2013 onwards. They will, for the first time, set a clear national benchmark around the training and conduct of support workers.
In taking that work forward, we expect Skills for Health and Skills for Care to engage with nursing professionals, including educationalists, and the standards will link to the Nursing and Midwifery Council's updated guidance on delegation. We have also said that we will ensure that the delivery of training for healthcare assistants who are entitled to be included on a voluntary register is professionally led. Further, we remain committed to exploring the evidence base relating to ratios of qualified to non-qualified staff, and we will look carefully at the evidence from ongoing work by King's College.
Our proposals stop short of imposing mandatory requirements on employers, as it is our view that assured voluntary registration, underpinned by the Care Quality Commission's registration requirements, is likely to be adequate to assure standards. However, we recognise that there are concerns that voluntary registration may not be adequate and therefore, once a system of assured voluntary registration has been operational for three years, we will commission a strategic review of the relative benefits of assured voluntary registration, compared with statutory registration.
The noble Lord, Lord MacKenzie, asked me whether employers would be able to require workers to be on registers. The answer is most certainly, yes. There are already precedents where employers require, for example, clinical perfusionists or non-medical public health specialists to be on voluntary registers, so we do not see this as a problem.
Turning specifically to the purpose of the amendment, to require mandatory assured training for all new healthcare support workers by 2013, I view that as a big-bang approach-if I may put it in those terms-and I have considerable anxiety that it carries a real risk of overwhelming the system in terms of allowing time for an assured training programme to be developed and implemented. Furthermore, I need to bring to the House's attention that the introduction of mandatory training would have a significant cost impact on employers across a short period.
The department commissioned an independent analysis of the costs and benefits of regulating around 250,000 domiciliary care workers in 2009. This work indicated that, with a requirement that all workers would have to achieve an NVQ level 2 over two years, or have made good progress towards doing so, the costs would be in the region of £435 million over 10 years. The costs of registration, which would have been met by workers, were only around £70 million over 10 years, with the remaining £360 million or so primarily relating to the costs of providing training, which would primarily have fallen to employers.
Therefore, there are good reasons why we cannot just commit to introducing mandatory training in the current difficult public spending environment, without a clear evidence base for doing so. However, that is where the review comes in. I can confirm that we will consider whether there is a case for mandating training as part of that review, and an appropriate timetable if it were to be introduced.
Allowing for a three-year period once such voluntary registers have been quality-assured by the Professional Standards Authority for Health and Social Care is important. The size and complexity of the workforce we are discussing has already been recognised in our earlier debates. Therefore, in order to ensure that the review is fair and evidence-based, we need to allow an appropriate time period for the assured registers to operate and three years from Royal Assent may not allow sufficient time, for the reasons that the noble Lord, Lord Hunt, alluded to, given that it may take some time to get to a point where a register is properly established.
The scope of this amendment is only healthcare support workers, and I understand the reasons why the noble Baroness has raised it in such limited terms. However, as the noble Baroness, Lady Howarth of Breckland, recognised in our last debate on this matter, the care workforce is significantly wider than that of healthcare support workers. Our proposals recognise this and include provision for common core training and a common basis for a code of conduct.
I know the noble Baroness would like us to go further. However, the review to which I have already committed will provide us with a clear evidence base for any further measures needed to assure the standards of healthcare support workers and we will then consider the need for further measures in light of that review. In view of the proposed review and the ongoing role of the Professional Standards Authority in monitoring voluntary registers, I do not see the need to go any further in terms of rolling out the programme with pilots or some such, but we are more than willing to maintain a dialogue with noble Lords and the profession on what is clearly an important issue.
I also listened to the noble Baroness's point about the importance of staffing ratios, particularly with regard to midwives, and I can confirm that we will keep these issues under close consideration.
I hope the noble Baroness will be at least partially reassured-maybe substantially reassured-about the general direction of travel here and of our commitment to strengthening the assurance processes in place for healthcare support workers and that, as a consequence, she will feel able to withdraw her amendment at this point.
Baroness Emerton (Crossbench)
I thank the noble Earl for that summary, and I thank noble Lords who have taken part in this short debate.
It seems as though we have been discussing this very real issue for months. We have spent the afternoon talking about risks and my concern has always been that the result of not providing training and support to support workers is a risk to patient care- and we will be taking a real risk if we have to wait the length of time proposed by the Minister. Work is going on at the moment in preparing the voluntary register, which will be ready in 2012, and I would have thought it would have been possible for the Government to say that from thereon they would expect candidates who are taken on to enter that training.
The public, patients and professions need an assurance that the risk at which we are placing patients is being addressed. The Minister has set out a timetable, but it is a very long timetable for patients who are receiving care today and tomorrow. They are at risk unless there is a registered nurse who is able to assess the competencies and support workers who are competent to deliver.
I appreciate what the noble Earl has said and the situation that we are in-I said in my speech that we have to be aware of the economic situation-and that we have to be assured that whatever we do is of benefit to patients and is cost-effective. However, I am not sure that we will be doing that by accepting the proposed timetable and I would like to test the opinion of the House.
Clause 234 : Quality standards
Moved by Earl Howe
18: Clause 234, page 240, line 7, at end insert "or section 117 of the Mental Health Act 1983 (after-care)"
Amendment 18 agreed.
Clause 250 : Powers to publish information standards
Moved by Earl Howe
19: Clause 250, page 248, line 4, at end insert "or section 117 of the Mental Health Act 1983 (after-care)"
Amendment 19 agreed.
Clause 254 : Powers to direct Information Centre to establish information systems
Moved by Earl Howe
20: Clause 254, page 249, line 36, at end insert "or section 117 of the Mental Health Act 1983 (after-care)"
Amendment 20 agreed.
Schedule 4 : Amendments of the National Health Service Act 2006
Amendments 21 to 23
Moved by Earl Howe
21: Schedule 4, page 303, line 26, leave out sub-paragraph (4) and insert-
"(4) In subsection (4)-
(a) for "a Primary Care Trust" substitute "a clinical commissioning group",
(b) for "the trust" substitute "the group", and
(c) at the end insert "; and the references in this subsection to a clinical commissioning group are, so far as necessary for the purposes of regulations under subsection (2E) of that section, to be read as references to the Board."."
22: Schedule 4, page 304, line 5, leave out paragraph 12
23: Schedule 4, page 329, line 10, leave out paragraph 129
Amendments 21 to 23 agreed.
Schedule 5 : Part 1: amendments of other enactments
Amendments 24 to 29
Moved by Earl Howe
24: Schedule 5, page 333, line 22, leave out sub-paragraphs (2) to (4) and insert-
"(2) In subsections (6A) and (6B)-
(a) after "by a" insert "clinical commissioning group or", and
(b) omit "Primary Care Trust or".
(3) After subsection (6B), insert-
"(6C) The references in subsections (6A) and (6B) to a clinical commissioning group are, so far as necessary for the purposes of regulations under section 117(2E) of the Mental Health Act 1983, to be read as references to the National Health Service Commissioning Board.""
25: Schedule 5, page 346, line 25, leave out paragraph 71
26: Schedule 5, page 354, line 4, leave out paragraph 120
27: Schedule 5, page 359, line 36, after second "under" insert "section 12A or"
28: Schedule 5, page 360, line 2, leave out paragraph 148
29: Schedule 5, page 360, line 7, leave out paragraph 150
Amendments 24 to 29 agreed.
Moved by Earl Howe
That the Bill do now pass.
Amendment to the Motion
Moved by Baroness Thornton
As an amendment to the Motion that the Bill do now pass, to leave out from "that" to the end and insert "this House declines to allow the Bill to pass, because the Bill does not command the support of patients who depend on the National Health Service, the professionals who are expected to make it work, or the public; will not deliver the promised objectives of genuinely empowering clinicians in the commissioning process and putting patients at the heart of the system; will increase bureaucracy and fragment commissioning; will allow foundation trusts to raise up to half their income from private patients; and, despite amendment, still creates an economic regulator and regime which will lead to the fragmentation and marketisation of the National Health Service and threaten its ethos and purpose."
Baroness Thornton (Labour)
My Lords, it is indeed rare for this Motion to be moved in your Lordships' House. We have come to the final stage and the final reckoning of this Health and Social Care Bill. I have thought long and hard about whether this was the right thing to do. We have to balance the reasons for moving this Motion against the reasons for allowing the Bill to pass with the ritual congratulations and mutual sighs of relief. The test for the House surely is whether this Bill will deliver an NHS that is better for patients. Most importantly, does this Bill fulfil the Government's stated policy aims? Much as I wish that were the case, I think that this Bill does not pass that test.
That being said, there is no doubt that the Minister has achieved a remarkable result. No one else but he could probably have achieved so much. The politics of the Bill, and the relationships in this House between the coalition partners and between the Government and the Cross Benches could not have been dealt with more gracefully than by the Minister. The Government owe the noble Earl, Lord Howe, a huge debt of gratitude and, indeed, so does this House.
There is no doubt that this House has made this Bill more respectable in some areas. We know that for example, astonishingly, it came to us with little or no mention of health education, training or research-remarkable, really. We have undoubtedly made some progress on issues such as the Secretary of State's powers and there is no doubt that many noble Lords, particularly on the Cross Benches, have worked incredibly hard and tried to put right as much as they could. I congratulate them all.
The tipping point for me, and what decided me to consider this action, was quite recent. It was when I realised with the further dozens of amendments proposed by the Minister on the arrangements for local healthwatch, the patient's voice, the Government had vanquished all hope of any coherent, strong, local patient organisation. We all recall the mantra at the start of this journey, "No decision about me, without me". At the end of this journey, what do we find? The national independence of the patient's voice, HealthWatch, is a mere sub-committee of the CQC. We have the complete removal of the statutory basis for local healthwatch, which it now appears will be run as some kind of local authority franchise and will not deliver a strong patient voice any time soon. We should stop pretending that, "No decision about me, without me," holds any credibility at all.
The second major platform for the Ministers who introduced this Bill was another mantra-the liberation of GPs and more recently, clinicians. Greater involvement of clinicians in commissioning is a laudable aim, with widespread support. This House should look beyond that aim to ask if the Bill will deliver this in reality. As the Bill has progressed, GPs and other clinicians have become increasingly aware that the promised liberation will not come. GPs have no greater commissioning powers than existing PCTs and less support in delivering their functions and many have come to realise that they are being set up to be the local fall guys for commissioning services from a budget that must be cut by 4 per cent per year. Clinical commissioning groups are complaining that this is not what they signed up for. They are being offered all the responsibility and none of the power.
We need to remember that these two factors-liberating patients and liberating GPs-were the cloak behind which the rest of the Bill stood. However, we on these Benches were never deceived. We have said from the outset that the purpose behind this Bill was to prepare the way for ultimately-though perhaps not for several years-for the fragmentation of the NHS, with hospitals competing instead of co-operating and using the rule of contract and lawyers instead of collaboration to solve problems. The Liberal Democrats have speeded Andrew Lansley on his way.
Thirdly, we were promised less bureaucracy. We now have a veritable alphabetti spaghetti of a structure. We have the Secretary of State, the Department of Health, the national Commissioning Board, four regional hubs, 30 clinical support units, 250 clinical commissioning groups, 50 national Commissioning Board outposts, 15 senates, HealthWatch, health and well-being boards, the CQC, Monitor and the new public health structure. Again, Ministers have comprehensively failed to deliver their own promises of less bureaucracy.
Finally, we have precious little coherence to the interface between health and social care in this Bill. When some of us tried to improve the working together of health and social care, which is vital to the success of both sides, the Minister refused and the government parties voted against it. It is the case that Part 3, the introduction of the forces of market competition into a fragmented NHS, where the inserted duties of co-operation will inevitably wither in the face of competitive commercial pressures, is still there and is still coherent.
The proposed biggest experiment on the NHS ever is reaching its conclusion, but unlike most experiments, we have not been allowed to know all the evidence. Last Tuesday on the final day of Report the Minister made a final and devastating admission, and I thank him for his honesty. He said:
"The Government are undoubtedly fighting a battle to convince the medical community of the merits of the Bill, a battle that we have so far not won".-[Hansard, 13/3/12; col. 258.]
That sends a chilling message from this Chamber to the professions and to the public. We have the cliff edge in front of us and the Government finally acknowledging that nothing they have done has won over those who now have to make this tangled mess work. Nothing has persuaded the professionals or the public-all of this time, the pause, the concessions. Nothing has worked.
Last week the Minister went on to promise more consultation. I have a question for him. Given that the Royal College of Physicians has come out with very grave reservations only this weekend and that No. 10 and Department of Health appear to be refusing to talk to any organisation that has asked for the Bill to be dropped, who is this consultation to be with? Can the Minister confirm that, for example, the following organisations will be on the invitation list this time-the Royal College of General Practitioners, the BMA and the Faculty of Public Health, to name one or two that have made their views on this Bill known?
It is often said that this is a House of wisdom and expertise. I invite noble Lords to listen to the wisdom and expertise of those in the NHS whose message is deafening in its consistency-they do not want this Bill. I would not have thought it possible, but this Bill has been haemorrhaging support for almost two years, and now has very few friends. Despite that, we need to be deeply grateful that we can rely on the professionalism and the conscientiousness of doctors, nurses, physios, surgeons and many others who are now considering how they can salvage this Bill and keep the show on the road.
There is no doubt that many noble Lords have worked incredibly hard to try to turn this sow's ear of a Bill into a silk purse worthy of passing from your Lordship's House. I pay huge tribute to those efforts, to which we on these Benches have contributed. However, improving a bad Bill into a Bill that is marginally less destructive is not a good reason to vote for its passage. We have to look at the whole Bill, not just the parts that individuals have championed, and ask whether we have succeeded. I regret our failure on these Benches, but I regret more that noble Lords on the Liberal Democrat Benches were unable to find their way to vote for measures that could really have protected the NHS. We tried and we failed, but at least we tried. The patients and staff of the NHS know that we have tried and that we have not been diverted from that purpose. The people know that it was the Labour Party which created the NHS. It has been the Labour Party in opposition which has tried so hard to protect our NHS from the worst ravages of this Bill. We have done our duty and people will remember that. I beg to move.
Lord Dubs (Labour)
My Lords, I shall speak very briefly as the House wants to move to a vote. I support this amendment and would like to pay a tribute to my noble friend Lady Thornton for the work that she and her team have put into this. Without the backing of a government department, they have performed heroically and very effectively.
I want to give only one personal reminiscence. The National Health Service started on
"The NHS will last as long as there are folk ... with the faith to fight for it".
Baroness Finlay of Llandaff (Crossbench)
My Lords, it is with a very heavy heart that I feel I must stand up and record that many of the voices outside, who are very scared about this Bill and what it means, are people who are of no particular political persuasion. Yet they are worried about the problem of lack of financial transparency, about the number of private healthcare companies incorporated in offshore jurisdictions-which they see may evade taxes of various types-and about the commissioning process. They are also concerned that the use of public money in the healthcare system will slowly be obscured like a great iceberg wrapped in fog. They will work to deliver whatever is needed for the patients in front of them. The vast majority of them stand to gain nothing by this Bill passing, but to gain nothing either if it does not pass. They want to improve the standards for their patients, and indeed they argue for change.
The noble Earl has worked tirelessly and has confidence across the whole House. Everybody, however much they have been concerned about this Bill, owes him an enormous debt of gratitude for the way that he has listened to every single one of us, at all times of the day and night, and weekends and so on. But we should not let this Bill pass without recognising the enormous concerns there are outside this House among those who will be delivering healthcare, now and into the future, in whatever form it takes.
Lord Greaves (Liberal Democrat)
My Lords, this has been an extraordinary parliamentary process. When this Bill was introduced, I said at Second Reading that it was a bad Bill. It was a bad Bill when it came here; there has been a growing tide of opposition to it and concern throughout the process while it was in the Commons and the Lords. There was the pause in the Commons and the Future Forum, which resulted in a large number of changes, and at that time Nick Clegg said that no Bill is better than a bad Bill. What we all individually have to do now-I speak very much for myself and not my party-is to assess whether it has now moved over from being a bad Bill to perhaps being, as Nick Clegg said last week, a much better Bill.
There is no doubt at all that on a spectrum of bad to good, it has shifted very considerably. It shifted in the Commons; it shifted far more here in the House of Lords. I believe that the process in your Lordships' House has been the House of Lords at its best. This House can be proud of the work that it has done throughout the gruelling Committee stage, then during Report and again today. I regret that I could not take a detailed part in much of that, because I was then spending time as a patient of the NHS, but I have been watching it all and I believe that the work this House has done has been absolutely superb.
If I can make a party political point here for a moment, the work that our team has done on the Bill, led by my noble friend Lady Jolly with all my other noble friends who have taken part, has contributed well. I refer not only to the Liberal Democrats but to Cross Benchers and everybody around the House. Tribute has been paid to the Minister. I pay particular tribute as a Liberal Democrat to our person on the ministerial team, my noble friend Lady Northover, who from our part of view has played a very important part by being a link into the Government and getting many of the changes which have taken place.
It is about not just the changes to the Bill but the implementation-the work that starts after this Bill has been passed, as no doubt it will be today. A huge number of ministerial assurances have been made, which may or may not be put upon people's bedroom walls as the noble Baroness, Lady Cumberlege, wants to do with hers. Nevertheless, this is a Bill which has had more outside scrutiny and involvement from people out there, as far as the House of Lords is concerned, than any other Bill I can remember in 12 years in your Lordships' House. That will continue with the implementation, and it is absolutely crucial how the Government now implement this Bill. Will it be gung-ho privatisation, which is what people were very frightened of when the Bill was first introduced and many are still frightened about, or will it be implemented in a cautious and careful way to allow the health service to breathe and to cope with the changes? This will be absolutely crucial, and we will know the answer to that in a year or two's time.
The noble Earl, Lord Howe, said that we have had debates of unparalleled length and scope, and that is true. However, as I have just said, the public interest and lobbying on this from outside has been unprecedented. One of the lessons that we all have to learn is that we-whether the House of Lords, members of the Government or our party-have not coped with that very well. I do not think that the Opposition coped with it terribly well either because, even this morning, I was getting e-mails telling me what the Bill did, some of which was absolutely untrue. They were still telling me that the Bill removes the duty on the Secretary of State to provide health services. We are still getting that, and the amount of education or information which goes out from debates within this Chamber to the outside world is pretty poor.
Several people have said, "We have been trying to follow this Bill. We have been trying to follow your Marshalled Lists, having discovered where to find them on the internet. We have been trying to follow the parliament channel, and we haven't understood a word of it. It is interesting, but we can't understand it". I have to tell them that that applies to quite a lot of Members of your Lordships' House while the Bill is going through.
Lord Greaves (Liberal Democrat)
I am coming to that. So having said all this, why am I going to vote for the amendment moved by the noble Baroness, Lady Thornton? I will do so very unhappily because I do not like voting against my noble friends, particularly when they have done so much hard work and achieved so much. I do not like voting against the party anyway but, having looked at it, it seems to me that the safeguards which have been achieved are not sufficient. Having read the latest version of the Bill which we got at Third Reading, I think it is inevitable that this Bill will lead to greater commercialisation. It will lead to a greater emphasis on competition rather than integration, and to a continuing incursion of private sector-based companies into the provision of NHS services. It is undoubtedly a radical top-down restructuring, in direct contradiction of the coalition agreement that I signed up to. That is being imposed on the health service at the same time as it is struggling with the biggest financial problems that it has had for many years. This is all in the face of the overwhelming opposition of NHS staff, professional groups, patient groups, public opinion and, indeed, a majority of people in my own party and of people who vote for us.
I believe that the new structures at local level will be no less bureaucratic, less open and accountable-
Lord Greaves (Liberal Democrat)
I am just saying what I think, and I have a right to do that. I believe that my party is being extremely brave in supporting this Bill as it now exists. I also believe that my party has had a bit too much of being extremely brave in recent times, but nevertheless, it is. I voted against this Bill at Second Reading; I will do so again now in favour of this amendment.
Now I feel very much like little Johnny, marching along, and all the rest of my party are out of step. I think that I am in step, and I think very hard indeed about this. Your Lordships' House as a whole, and the Government, are the people out of step-certainly out of step with opinion in the country and in the health service. However, I agree entirely with what the noble Baroness, Lady Thornton, said, about what now matters if the Bill is passed-[Interruption.] I do not know whose phone that is; it is not mine. That is someone who is out of step.
There has been a lot of alarmist talk. It probably will not amount to much, but it is up to everyone in the health service, and to us here as we scrutinise the regulations, to ensure that it does not. I am frightened by this Bill and I shall vote against it.
Baroness Butler-Sloss (Crossbench)
My Lords, I have not yet spoken on this Bill. Could I ask the Minister a very practical question? If the amendment of the noble Baroness, Lady Thornton, is passed, what on earth will happen to this Bill? What I understand might happen is that in due course it would be passed by the Commons but without the amendments of this House. The result of that would mean that the enormous amount of work done by everybody in this House to improve this Bill would be totally lost, and the Bill as it left the Commons would be the same Bill that went through it. Is that what we want?
Earl Howe (Conservative)
My Lords, the noble Baroness, Lady Thornton, made some very complimentary comments about me at the beginning of her remarks and I thank her for those. Therefore, it is a cause for sadness to me that we have reached this final stage of the Bill in a climate of antagonism rather than of the mutual good will that typically characterises the end of a long parliamentary process in this House. That good will is still present, but it has perhaps been temporarily overshadowed.
I am sorry that the noble Baroness, for whom I have enormous respect, has taken the unusual step of tabling this Motion. It will not surprise her to hear that I disagree utterly with her summary of what this Bill will achieve, but it is not my intention to rehearse the arguments for it all over again. I did that at Second Reading and throughout subsequent stages of the Bill, when we debated at length and in depth the detailed provisions within it.
It is disappointing, too, that this Motion, so negative in its tone and content, is the only amendment which the Official Opposition have seen fit to table on our final day of debate. It stands in marked contrast to the highly constructive approach taken to Third Reading by Peers on all Benches, and indeed to the approach of thoughtful testing and challenge to the Government which the Labour Front Bench has adopted hitherto. I believe that we have used today's Third Reading to good and positive effect. The noble Baroness, on the other hand, has chosen today to stand aside from that approach.
Our debates over the past six months have taken a total of 25 days. Over the course of that time the Bill has changed a great deal. From every side of the House amendments have been moved and many of them have been accepted, on all key aspects of our proposals. Indeed, if we cast our minds back to last October, to the distant land of Second Reading, I am reminded of the speech of the noble Lord, Lord Warner, who said this:
"I hope we will find the Minister in a listening and negotiating mood. Perhaps he will recall that when I took another rather controversial health Bill through this House, on foundation trusts in 2003, I moved or accepted some 200 amendments. So that is the benchmark for judging the flexibility of the noble Earl opposite".-[Hansard, 11/10/11; col. 1547.]
In this House I have moved or accepted some 375 amendments, including accepting amendments from all sides of this House. Indeed, I am aware that this represents a quarter of all amendments that have been tabled. We have made a Bill whose key principles command wide acceptance-more joined-up, clearer and, in certain aspects, less risky. That is greatly to the credit of noble Lords and to this Chamber. The scrutiny and improvement which has gone on has shown your Lordships' House working at its very best and I thank noble Lords involved for their constructive participation and debate. There are too many for me to mention by name. However, I will make one exception, because I would especially like to thank my noble friend Lady Northover for her staunch support from the Front Bench, particularly in the light of her other commitments within this House.
My final word of gratitude, however, must go to the Bill team, who have been outstanding throughout the entire parliamentary process-not only in support of Ministers but also being available to assist Peers of all parties and of none in clarifying, informing and explaining whenever they have been asked to do so. They have been tireless and supremely professional over many months and they deserve our warm thanks.
This is not Second Reading. It is not the time to grind axes. It is time to reflect on the past six months, to await the consideration that the other place will give to the substantial efforts that have gone on in this Chamber and to look forward to the close engagement between the Government and all our key stakeholders on how we can collectively make the most of the opportunities that the Bill presents. I will oppose the noble Baroness's amendment, and I strongly urge noble Lords to do likewise.
Baroness Thornton (Labour)
My Lords, the time has come for a vote on this matter. I add my own thanks to all noble Lords for the work that they have done on the Bill. I pay tribute to the huge efforts that have been made and the commitment that noble Lords show to doing their job as legislators. I thank my own support on the Front Bench, my noble friends Lord Hunt, Lord Beecham, Lord Collins and Lady Wheeler. I could not have been better supported.
Unlike the Minister with a cast of thousands, I have had a small but perfectly formed team of about three, led by Jessica Levy in the opposition office and with my intern Tom Woodford keeping my papers in good order. However, we on these Benches have also been supported and sustained in our consideration of the Bill by literally thousands of people across the country. I say to the noble and learned Baroness, Lady Butler-Sloss, that it is actually up to the Government what they do about the Bill if they lose this vote.
Perhaps the Minister might agree that this parallel universe that we inhabit in your Lordships' House, where deals are done and amendments are crafted, is hardly the same as the real world for those who will now manage commissioning, make budget cuts, deploy staff, recruit accountants and try to make sense of the competition and integration strategies and to make the Bill work. I pay tribute to those people.
I feel like saying to noble Lords, "Hands up those who have received letters and e-mails supporting this Bill". I had two, among a torrent of e-mails, tweets, texts and letters asking us to drop the Bill or dramatically change parts of it. We have received thousands of expressions of concern. Noble Lords have reacted variously to that, and I think that the noble Lord, Lord Greaves, is right to say that in some respects parties have reacted well to this but not in others. It is clear that there are thousands if not hundreds of thousands of people watching us and what we do, and it is for those people-the nurses, the doctors, the healthcare assistants, the patients, my mum with her COPD, my cousin whose daughter has just been diagnosed with a brain tumour, and the hundreds of thousands of people who have signed petitions, sent letters, gone on demonstrations and continue to make our beloved NHS work-that I wish to test the opinion of the House.