I beg to move, That the Bill be now read a Second time.
The covid-19 pandemic has tested our country like never before, and nowhere more has this been seen than in our health and care system. Everyone delivering health and social care in this country has risen to meet these tests in remarkable new ways. We have seen bold new ways of working, of overcoming bureaucracy and of people working seamlessly across traditional boundaries. New teams were forged, new technologies adopted and new approaches found.
There is no greater example of this than the extraordinary success of our vaccine roll-out, where health and care colleagues have been able to draw on the collective scale and strengths of our Union to deliver one vaccination programme for the whole of the United Kingdom. Today, I can confirm to the House that two thirds of adults have received both jabs against covid-19 one week earlier than planned. It is a remarkable achievement. Everyone working in the NHS and social care can be proud of what they have achieved, and we are all in this House very proud of them.
As we look to the post-pandemic world, we know there is still no shortage of challenges ahead—an ageing population, an increase in people with multiple health conditions and, of course, the chance to embrace the full potential of data and technology.
Recent statistics show that over 40,000 people under 65 in the UK have dementia, and many more have not been diagnosed as of yet. It would seem that these figures are not addressed in the Health and Care Bill, so can I ask the Secretary of State what more will be done to offer support to those suffering with dementia and Alzheimer’s in the UK through this social services care Bill?
I am pleased that I gave way to the hon. Gentleman as he raises a very important issue. In this Bill, as I will come to, one of the central themes is integration. When I come to that, I hope he will see how that integration between NHS and social care will help to deliver a better service for those with dementia.
Everything I refer to—these challenges—are all in addition to the challenges of the pandemic that of course we still face and the elective backlog that we know is going to get worse before it gets better. Meeting the future with confidence relies on learning lessons from the pandemic—what worked and what did not work—and building on a decade of innovation in health and care.
Sometimes the best intentions of the past cannot stop what is right for the future. Bureaucracy can still make sensible decision making harder, silos can stifle work across boundaries and sometimes legislation can get in the way. We have seen how unnecessary rules have meant contracts have needed to be retendered even where high-quality services are being delivered, we have seen the complicated workarounds needed to help the NHS and local government to work together, and we have seen the uncertainty about how to share data across the health and care system. People working in health and social care want the very best for people in their care. That is what they have shown time and again, not least in the way they have embraced integration and innovation to save lives through this pandemic. They want to hold on to the remarkable spirit of integration and innovation, but they want to let go of everything that is holding them back and we want to help them to do it.
On that point of bureaucracy, I recently saw the apotheosis of the NHS, where an Anglican church had draped an altar with a flag saying, “O Praise the NHS”. So when we have a new Secretary of State, can we have a really hard-hitting attitude to NHS bureaucracy? We all praise our doctors and nurses, but the fact is that, like any other bureaucracy, it is prone to underperformance, waste and incompetence. There is no harm, as long as we preserve the principle of being free at the point of delivery, in having innovative private sector solutions.
I hear what my right hon. Friend has said and I think that, as I progress through my opening remarks, he will like what I have to say about integration and cutting bureaucracy.
All these things that I refer to and all these changes we want to make are exactly what this Health and Care Bill will do. I want to thank the thousands of hard-working staff who, through two years of consultation and engagement, have come forward and told us what they think works and what they think needs to change. In the words of Lord Stevens, chief executive of the NHS, the overwhelming majority of these proposals are changes that the health service has asked for. The Bill supports improvements that are already under way in the NHS. It builds on the recommendations of the NHS’s own long-term plan. It is a product of the NHS, it is for the NHS, and it is supported by the NHS.
I am grateful to all the organisations that have helped to shape these important proposals—everyone from the NHS Confederation to the Local Government Association. I have spent many of my early days in this job talking to them, and they have all told me the same thing, which is that they are ready to take forward the reforms. I want to continue to work with them and to listen to their specific concerns, just as much as I want to listen to the concerns raised by hon. Members across the House and by Members in the other place.
The Secretary of State referred to Lord Stevens and what the NHS has asked for in trying to get rid of things that stand in its way. Something that it has not asked for is a massive power grab by the Secretary of State, which is in the Bill and will lead to political interference in day-to-day operational and reconfiguration decisions, which may not always be in the best interests of patients. Why does he think that that is a sensible way forward and something that the NHS wants?
Clinical decisions should always be made by those with clinical expertise—I think everyone in the House would agree on that—and that should be independent of any outside interference. The Bill does nothing to alter that. What it does is recognise that the NHS is one of the public’s top priorities. We spend over £140 billion of taxpayers’ money on the NHS, and it is right that there is proper accountability for that spending to Ministers and therefore to the House. I think that most people would welcome that.
The Secretary of State has talked about people he has consulted, so would he confirm that he has consulted the trade unions, particularly on schedule 2, which says that integrated care boards may appoint employees to address remuneration, pensions and terms and conditions. Can he confirm that that is a departure from Agenda for Change terms?
There have been wide-ranging consultations on the Bill, as I mentioned, which have taken place over the past two years. While I cannot say specifically which trade union or which particular organisation has been spoken to, as I was not in the Department at the time, I know that the conversations have been wide ranging.
The Bill is not the limit of our ambitions on the nation’s health. We are also transforming public health; we are bringing the Mental Health Act into the 21st century; and, by the end of this year, we will set out plans putting adult social care on a sustainable footing for the future.
We are also ambitious for our workforce. I have commissioned Health Education England to refresh its strategic framework for health and social care workforce planning. HEE will work in partnership across the sector and gather views from the widest possible range of stakeholders to help us to shape a workforce with the right skills, the right knowledge and the right values for the year ahead.
My right hon. Friend has set out his plans to introduce a plan for social care by the end of the year, and I know that he is looking for a cross-party solution. In a joint inquiry by two Select Committees—the Housing, Communities and Local Government Committee and the Health and Social Care Committee—one of the recommendations was a system with a German-style social care premium. Would that potentially feature in his recommendations, and does he agree that that is a much fairer system than a Dilnot-style system that incentivises people to spend their assets or move them somewhere where they cannot be touched?
First, my hon. Friend is right to say that it would be great if all or most Members of this House, and certainly the different parties, could agree on a new system. I look forward to speaking to all hon. Members about what a future social care system could look like. In terms of the detail, I am afraid that he is just going to have to wait a moment longer, but I agree that the work by the Select Committees will, of course, inform our decisions.
I turn in a little more detail to the measures and themes that are captured in the Bill. The first is more integration. We know that different parts of the system want to work together to deliver joined-up services, and we know that, when they do that, it works. We have seen that with the non-statutory integrated care systems in the past few years. They have united hospitals and brought together communities, GPs, mental health services, local authority care and public health, and it works. We recognise that there are limits on how far this can go under the current law, so this Bill will build on the progress of integrated care systems by creating integrated care boards and integrated care partnerships as statutory bodies. England’s 42 ICSs will draw on the expertise of people who know their areas best. They will be able to create joint budgets to shape how we care for people and how we promote a healthy lifestyle. With respect to the specific geographies of the ICSs themselves, as I have said elsewhere, I am willing to listen.
In passing, may I congratulate my right hon. Friend on his appointment? I also very much welcome part 4 of the Bill, which introduces the health services safety investigations body. This is a great innovation that was promoted by the Public Administration Committee and scrutinised by the Joint Committee that I chair. Can I just reinforce the points that I know he is now receiving from NHS England with a warning about changing the boundaries of the integrated care systems that are already operating? In Suffolk and north-east Essex, we have a very high-functioning de facto integrated care system operating already. Please will he not change it?
My hon. Friend has raised an important point, and this may be on the minds of other hon. Members as well. It is important to point out that several factors will be helpful in fostering stronger partnerships between the NHS and local authorities, including the alignment of boundaries. Earlier this year, the former Secretary of State asked NHS England to conduct a boundary review of integrated care systems, to understand the best way forward and the best alignment where local authorities currently have to work with more than one ICS. I have met my hon. Friend and other hon. Members, and I know that hon. Members may have made representations to my predecessor. I have been informed of those, and where the information might not be remembered easily, I am sure we can get hold of some video evidence. [Laughter.] I want to thank all hon. Members for their input into this, and I stress that no final decisions have yet been made on the boundary review.
Order. Just a reminder that interventions need to be short and to the point, because there is a lot of pressure on time in this debate.
My point is about boundaries. Lancashire and south Cumbria have a perfectly reasonable boundary, but does the Secretary of State agree that there is concern that, because most rural communities are attached to bigger, more populated urban ones, that can lead to an imbalance in decisions? One of the proposals that our community faces is that the Preston and Lancaster hospitals could be replaced by a single super-hospital somewhere in the middle. HIP2—the health infrastructure plan 2—is a good thing, but that would be very bad thing, because it would mean that people in south Cumbria could have a two-hour round trip just to get to A&E. Will he intervene and ensure that any proposals under HIP2 that undermine access to healthcare in rural communities are taken off the table?
I listened carefully to what the hon. Gentleman said. As I have said, no final decisions have been made, but if he would like a meeting with a Health Minister, we can arrange that so that the matter can be discussed further.
I am also very grateful to another of my predecessors, my right hon. Friend Jeremy Hunt, first for his leadership of the Health Committee, whose valuable report and recommendations we have taken on board, and secondly for his tireless dedication to the cause of patient safety, which sees its culmination in the Bill’s creation of the Health Services Safety Investigations Body. We must continue, in his words, that quiet revolution in patient safety. I have asked my officials to consider whether the Care Quality Commission could look broadly across the integrated care systems in reviewing the way in which local authorities and providers of health, public health and social care services are working together to deliver safe, high-quality integrated care to the public.
The Secretary of State talks of patient safety. May I ask him why the Bill contains none of Sir Bruce Keogh‘s recommendations on the cosmetic surgery industry, which are now 10 years old? In response to questions that I have asked, Ministers keep saying that the recommendations are going to be implemented. Could this not be an opportunity to improve patient safety in that area?
The right hon. Gentleman has raised an important matter. There are issues surrounding the cosmetic surgery industry, and I know that he has spoken eloquently about them in the House before. I do not necessarily agree that this Bill has to be the vehicle for any change, but if he wishes to discuss the matter further, I should be happy to meet him in due course, because it is important and it does require a fresh look.
Whenever the NHS is subject to change, it is tempting for some, who should actually know better, to claim that it is the beginning of the end of public provision. We know that that is complete nonsense, and they know it is nonsense, but they say it anyway. So let me very clear: our integrated care boards will be made up of public sector bodies and those with a social purpose. They will not be driven by any private interests, and will constantly make use of the most innovative potential of non-NHS bodies.
The spirit of this Bill is about holding on to what is best about the NHS and removing what is holding it back. That is something that we all want, and I am looking forward to a mature debate—[Laughter.] Perhaps that is too much to ask in this Chamber with this Opposition Front Bench, but I hope for, and I think the public expect, a mature debate on the Bill and on how we can achieve these sensible changes together.
In that spirit, the second theme of the Bill is cutting bureaucracy. As we have been tested during these past months, we have looked at the rules and regulations through new eyes. It has become increasingly clear which of them are the cornerstone of safe, high-quality care, and which are stifling innovation and damaging morale. It is that second group of rules and regulations that the Bill strips away, removing the existing procurement regime and improving the way in which healthcare services are arranged. Yes, this is about how we deliver better value for the taxpayer, but fundamentally it is about how we can free up NHS colleagues to deliver better care. We know that patients are better served when experts are free to innovate unencumbered by unnecessary bureaucratic processes. That is why the Bill will repeal section 75 of the Health and Social Care Act 2012, giving the NHS the flexibility for which it has been asking. I know that this is a point of agreement with the Labour party—
The Labour party said it not just 10 years ago but in 2015, 2017 and 2019—in all those manifestos—so I am sure that its members agree with this direction. [Interruption.]
Order. If Members want to intervene, let me say to them that the Secretary of State has been very generous in giving way, but just shouting at him is not working.
They are excited, Mr Deputy Speaker, and I understand that. Let me excite them much more.
The third theme of the Bill is greater accountability. We have never seen so clearly as we have in the past 16 months how critical the health of our constituents is for the House. The Government of the day always work hand in hand with the NHS to deliver that priority. That is what people would expect from a responsible Government. People also rightly expect there to be clear lines of accountability for how this priority is delivered. Accountability is the foundation of our democracy, and on that I hope we all agree.
On the nation’s greatest priority, our health, this Bill sets out clear lines of accountability to the people we all serve. The Bill simplifies what has been a complex structure, bringing the three different bodies that oversee the NHS into just one, as NHS England. NHS England will continue to have clinical day-to-day operational independence, but it is right that the NHS must be accountable to Ministers, and Ministers must be accountable to Parliament, where we are all accountable to the people we serve.
Naturally, that accountability will extend to these integrated care systems. Jonathan Ashworth is on the record, in an interview with the Health Service Journal in December 2019, as saying that he agrees with the principle of the legislative changes that had been put forward by the NHS for “democratically accountable” ICSs. He cannot have any objection to this point. We will see what he has to say from the Dispatch Box.
I hope we can all agree that this is a sensible and pragmatic step. Let me quote once more:
“We will reinstate the powers of the Secretary of State for Health to have overall responsibility for the NHS.”
Those are not my words but the words of the 2017 Labour manifesto. I look forward to working with the shadow Health Secretary on this and other aspects of the Bill, and I urge him to set aside petty party politics and point scoring and do what the NHS wants him to do, which is to back this Bill.
Before I finish my opening remarks, I turn to the reasoned amendment in the name of the Leader of the Opposition and other Opposition Members. What is claimed by the reasoned amendment is entirely wrong. This is exactly the right time for these reforms. The response to covid-19 has quickened the pace of collaboration across health and social care, showing what we can do when we all work together, when we adopt new technology and when we set aside bureaucratic rules. The pandemic has also brought home the importance of preventing ill health in the first place. The Bill lays the framework to achieve all that.
More than that, this Bill is what the NHS has been asking for. It builds on the NHS’s long-term plan and the work the NHS has already started to do voluntarily. We have invested record sums in the NHS, both before and, of course, during this pandemic, and we will continue to do so.
The systems are telling us that they are ready, that they want us to go ahead with this Bill. They do not want to see any delay, which is why this is important work for all of us. Hopefully Parliament can deliver what the NHS is asking for.
The unprecedented challenges of the pandemic have only deepened our affection for the NHS, and it has reinforced the noble idea that the NHS is there for all of us when we need it. I started learning about the NHS from a very early age when I used to go to check-ups with my mum and translate for her. It was there for her, it has been there for me, it has been there for my family, it has been there for my children and it has been there for all of us and our constituents.
Even in this fast-changing world, with the new and evolving threats to our health, the founding principles of the NHS are as true today as they ever were. It is our responsibility to build on this incredible inheritance. Our NHS is the envy of the world, so it is right that this Government should work across health and care to shape a system that is truly fit for the future. Our colleagues in health and social care have achieved extraordinary things in the most extraordinary times, and we in this place must give them the firm foundations they need to build back better in the years that lie ahead.
I beg to move an amendment, to leave out from “That” to the end of the Question and add:
“this House declines to give a Second Reading to the Health and Care Bill, notwithstanding the need for a plan for greater integration between health services and social care services and for restrictions on junk food advertising to improve population health outcomes, because the Bill represents a top down reorganisation in a pandemic leading to a loss of local accountability, fails to reform social care, allows further outsourcing permitting the private sector to sit on local boards and fails to reinstate the NHS as the default provider, fails to introduce a plan to bring down waiting lists for routine NHS treatment or tackle the growing backlog of care, fails to put forward plans to increase the size of the NHS workforce and see them better supported, and fails to put forward a plan that would give the NHS the resources it needs to invest in modern equipment, repair the crumbling NHS estate or ensure comprehensive, quality healthcare.”
Well, the Secretary of State talked a lot, but he did not say very much. Look at the context of where we are. Yesterday, we recorded 36,000 covid infections. Hospital admissions have increased to over 500 a day, up 50% in a week. Waiting lists are at the highest level on record, currently at 5.3 million. Some 336,733 people have been waiting over a year for treatment, over 76,583 people are waiting over 18 months, and over 7,000 people are waiting over two years. Some 25,889 people are waiting more than two weeks from urgent referral to a first consultant appointment for cancer. Emergency care is grappling with some of the highest summer demands ever seen. Two hundred and fifty thousand people are waiting for social care. NHS staff are exhausted, facing burnout. We went into this pandemic with 100,000 vacancies across the NHS and a further 112,000 vacancies across social care.
The answer from the Secretary of State is to embark on a top-down reorganisation when we are not even through the pandemic—a reorganisation that will not deliver the integration needed, because reforms to social care are delayed again; a reorganisation that will not deliver more care but in fact, in periods of stretched health funding, could well deliver less care; and a reorganisation that is, in effect, a Trojan horse to hide a power grab by the Secretary of State.
Let us be clear why this reorganisation is taking place. The Government have come forward with this Bill because of the mess of the last reorganisation—the mess that the Secretary of State supported and voted for, and the mess that he spoke out for in this House, saying that it would modernise the NHS and that the
“concept of GP commissioning has been widely supported by politicians from all parties for many years. May I urge my right hon. Friend to keep putting patients first by increasing GP involvement in the NHS?”—[Official Report,
Why, if he believed that then, has he U-turned now? And it was a mess that we warned of. My hon. Friend Liz Kendall, who opposed that Bill in this House, warned the Government that it would increase bureaucracy and increase the fragmentation that the Secretary of State has just complained about from the Dispatch Box.
Ministers said that that reorganisation under Lord Lansley would reduce bureaucracy, and Back Benchers told us that it would reduce bureaucracy, but what ended up happening? Billions were wasted and thousands of NHS staff were made redundant. That was the Government’s priority then, and now they are asking us to clean up their mess today. They also told us that that reorganisation would improve cancer survival rates, and where are we today? We are still lagging behind other countries on cancer survival rates. Perhaps the Secretary of State could have come to the Dispatch Box and apologised for that Lansley reorganisation and 10 wasted years.
The Secretary of State talked about NHS leaders, but the truth is that NHS leaders asked for a simple Bill to get rid of the worst of the Lansley restructuring and instead re-embed a sense of equity, collaboration and social justice in our NHS structures. That is not what this Bill is. Of course, the Secretary of State secretly agrees with me. According to The Times, he wrote to the Prime Minister saying that there were “significant areas of contention” that were yet to be resolved with the Bill, and that he wanted to delay it. The Secretary of State was only back five minutes and already Downing Street was overruling him. When it overrules him on his choice of spin doctors, he walks; when it overrules him on the future of the NHS, he puts his career first and stays in the Cabinet.
I listened carefully to the case made by the Secretary of State. He talked of the need for greater integration between health and social care and the need to provide better co-ordinated care, and he referred to an ageing population.
To be frank, that was a speech that Health Secretaries and their predecessor Social Services Secretaries have been making more or less since 1968, when Richard Crossman proposed the first set of NHS reorganisations. Indeed, there were echoes of the Secretary of State’s speech in that made by his predecessor Keith Joseph, when he came to this House in 1972 to set up the area health authorities, bringing together hospitals and community care and working more closely with local authorities because we needed seamless care. Those authorities were of such a size that, within a year, they were rearranged again into district health authorities. Given the size of some of the integrated care systems that the Secretary of State is proposing, I suspect that the seeds of the next reorganisation are being sown today.
Yesterday, the Secretary of State told the House that his
“three pressing priorities for these critical…months” were
“getting us…out of this pandemic…busting the backlog” of non-covid care, and
“putting social care on a sustainable footing for the future.”—[Official Report,
But absent from his speech was any credible explanation of how this reorganisation will meet his objectives that he outlined to the House yesterday. In fact, in the last 30 years, we have seen around 20 reorganisations of the NHS. Have any of them delivered the outcomes that Health Secretaries have promised from the Dispatch Box? Well, not according to analysis in The BMJ, which observes:
“Past reorganisations have delivered little benefit”.
Why should this one be any different?
The question for me is: how will the 85-year-old with multiple care needs experience better whole-person care as a result of the restructuring that the Secretary of State is embarking upon? How will waiting times for elective surgery for cancer and mental health be improved by this reorganisation? How will health inequalities that have widened and life expectancy advances that have stalled be corrected by this reorganisation? To those questions, the Secretary of State had no answer today: the Bill fails those tests because it is a badly drafted Bill and could in fact even worsen health outcomes.
Let me outline our specific concerns. On the proposed integrated care boards, the Bill collapses the remaining 100 or so clinical commissioning groups into 32 integrated care systems differing in geographical size and with some covering populations up to 3 million or 4 million. In some parts of the country, the ICSs are not based on the NHS agreed boundaries, but currently on centrally drawn-up boundaries for political reasons. We know that Cheshire will be combined with Merseyside. Glossop is cut off from Greater Manchester and allocated to Derbyshire. Frimley is split up, leading the former Prime Minister, Mrs May, to complain in an Adjournment debate recently:
“Do not break up Frimley ICS. Just for once, let common sense prevail.”—[Official Report,
“a worsening of patient care”.
And then, of course, we have the design of the integrated care system, split across two committees—a partnership board containing people from local authorities, the third sector and others, and then an NHS board responsible for spending the money, for commissioning. The Secretary of State has moved away from GP commissioning, of course; he wants the NHS board to commission now. Those two boards will probably have different chairs, but the NHS board only has to have “regard” to the partnership board strategy. Nor is it clear how local authority seats—the one local authority seat—will be decided when they cover more than one council and possibly even councils of different political persuasions, so we will see how a consensus can be built then.
Other important voices are left out. Mental illness accounts for roughly a quarter of the total burden of illness, yet there is no guarantee that mental health providers will get the seats on these boards, when we know that mental health services are under pressure and the Secretary of State tells us that the mental health backlog is one of his personal priorities. The pandemic has also reminded us that the health and wellbeing of our community is not just in the hands of large hospitals or general practice. It is also in the hands of our directors of public health, who have shown exceptional local leadership throughout this crisis, standing on the shoulders of their forebears, who in the past confronted diseases such as cholera, smallpox and diphtheria. Test and Trace would have been far safer in their hands from the outset, by the way, and what is their reward? They are sidelined. Public health, again, should be properly represented on the NHS boards and we will table amendments to that effect.
Does my right hon. Friend agree that it is not just about their being sidelined; it is actually about the budgets for public health, which have been pushed off into the autumn? If the consultation paper that went out last year is anything to go by, County Durham would lose 19% of its budget. How can we effect these changes without its being divorced from what will be provided in terms of cash?
My right hon. Friend is absolutely right. I will come to the financial flows in a few moments. But how on earth can we have a triple aim of trying to improve health outcomes for a population and not even give public health a voice and a seat on the decision-making body that decides health plans for an area?
The Secretary of State talks about integrating health and social care. There is no seat for directors of adult social services on these committees, either. And what about patients? Patients were not mentioned very often by the Secretary of State in his speech. Patients will always come first for the Opposition. They have no mandated institutional representation, either—no guaranteed patient voice—so we have yet another reorganisation of the NHS whereby patients are treated like ghosts in the machine. It is utterly unacceptable. This is fragmentation, not integration, with a continued sidelining of social care.
There is a loss of local accountability as well, because there is no explicit requirement that the boards meet in public or publish their board papers. Although NHS England has stated that that is its preference, it is not required; nor is there any commitment, despite the wide geographical spread of some ICSs, for meetings to be made accessible online. But, of course, the White Paper did indicate that the independent sector could have a seat on an ICS, and the explanatory notes to the Bill state that
“local areas will have the flexibility to determine any further representation.”
The right hon. Gentleman talks about solutions to social care. Will he come on to his own solutions to social care? Will they potentially include the recommendations of the Select Committees about that German-style social care premium—recommendations made by members of his own party who were elected by his party to serve on those Committees? Is that something that he is now willing to explore? He has ruled it out time and again on the Floor of the House.
I have. The hon. Gentleman is a dogged advocate for that proposal for social care, and he is quite right: he always raises it with me. I am unpersuaded but I am more than happy to sit down with the Secretary of State and with my hon. Friend the Member for Leicester West to discuss a solution to social care. We keep being told that there are going to be cross-party talks, but I think I missed the Zoom link, because they have not happened so far.
As I was saying, these committees do permit a seat, if the committees want it, for the independent sector. In Bath, in Somerset, we have seen Virgin Care get a seat on the shadow ICS. The Opposition think that is unacceptable and we shall table amendments to prohibit it.
I welcome the removal of the section 75 competition and procurement rules, finally scraping the remnants of the Lansley competition rules off the boots of the NHS. We did warn him and others that this compulsory competitive tendering would lead to billions going to the private sector, would be wasteful and bureaucratic, and would be distracting—and it even led to the NHS getting sued by Virgin Care when it did not win a contract. But this is not the end of contracting with the private sector. Without clauses to make the NHS the default provider, it would be possible for ICBs to award and extend contracts for healthcare services of unlimited value without advertising, including to private companies. Given the past year, when huge multibillion-pound contracts have been handed out for duff personal protective equipment and testing, we naturally have concerns about that and will seek safeguards in Committee. We are worried about further cronyism.
We are particularly concerned about the Bill because of the power grab clauses for the Secretary of State. He is creating 138 new powers, including seven allowing him in effect to rewrite the law through secondary legislation, to transfer functions between arm’s length bodies without any proper scrutiny. He has not explained why he needs these powers or given any guidance on how he expects to use them. These powers also include a requirement that Ministers be informed of every single service change, every single reconfiguration, and the Secretary of State will then decide whether or not to call them in for ministerial decision. Are you sure you want that power, Secretary of State?
The Government have gone from wanting to liberate the NHS under Lansley to now listening out for the clang of every dropped bedpan echoing through Whitehall. This is not a plan for service modernisation; it is a “Back to the Future” plan and it will mean more inertia. Instead of powers to interfere at every level, resetting the mandate for the NHS within years, we instead would want the duties on the Health Secretary, and therefore on the 42 ICSs to which he delegates those responsibilities, to continue the promotion in England of a comprehensive health service, as per the National Health Service Act 2006, to be fully reinstated and made explicit.
As ever, I have listened carefully to the right hon. Gentleman. If this is the “Back to the Future” Bill, presumably it puts right what once went wrong. Does he support the clauses on foods that are high in fat, salt and sugar, and the watershed proposals for advertising?
Yes, although I am disappointed that they are in this particular Bill. I think they should be part of a stand-alone Bill. In my concluding remarks, I will make a point or two about other public health interventions, which I imagine and hope that the hon. Member, as a great champion of public health, would support.
It is crucial that the Secretary of State’s duty to provide comprehensive healthcare is reinstated, rather than the duty to meddle in the NHS at any time he wants, because there is a lack of clarity about how the funding flows work in this system. The talk is of moving to capitated budgets for an area to provide holistic care to meet the complicated care needs of individual. But when waiting lists are increasing at the current rate, and when cancer waits and mental health referrals are going up, how is an area going to fund the episodic care for each unit of extra care that is needed—often care that is expensive and more complicated because it needs to be done in the acute sector?
We have worries. Clauses 21 to 24 on the financial duties on ICS boards, NHS trusts and NHS foundation trusts are alarming, because they put in place a duty to ensure financial balance across the ICS area, but there is no clarification of how that balance should be achieved and enforced. Local health budgets have been stretched to breaking point after years of underfunding, so what does this duty mean for existing deficits? At the moment, trusts have a combined deficit of £910 million. King’s has a deficit of £111 million. Worcestershire has a deficit of £81 million. University Hospitals of Leicester NHS Trust has a deficit of £80 million. Will the ICBs need to fill this £900 million black hole before they are even up and running How exactly will trust and ICS board deficits be dealt with at the end of each financial year?
This could well be a return to the days that we saw in the ’80s, which some Members in the House may recall, when health authorities would close beds and put off paying bills from January onwards in order to hit financial balance. If health authorities have to hit this financial balance year by year, will it result in a postcode lottery of more rationing and an even longer list of treatments being removed from the NHS through the decisions of ICBs because they have to hit balance, effectively forcing patients either to go private or go without? I hope that the Minister, in summing up, can clarify what the situation will be.
If a set of providers, trusts and an ICB feel that the financial settlement they have been given by NHS England will not allow them to deliver the levels of care to bring down the waiting lists, which the Secretary of State said is one of his top priorities, or to improve mental health outcomes, which he has also said is one of his top priorities, what is their appeal process? How will the arbitration process work on an area’s financial settlement under the current plans to bring together NHS England and NHS Improvement, not split them out?
The Bill is spun as an attempt to integrate health and social care, but there is nothing in it actually to integrate health and social care, because there is nothing in it to fix social care. If it is about integrating health and social care, where is the long-promised Bill to reform social care? The Bill will repeal provisions in the Care Act 2014 that require patients to be assessed for their social care needs before they are discharged from hospital. Without long-term funding in place, that could mean a patient being sent home, left out without support and waiting for an assessment. Will the Secretary of State, or the Minister who responds to the debate, guarantee that that will not be the case? Will they put in place the necessary funding alongside the Bill?
A number of royal colleges and health bodies have said today that the biggest challenge facing the NHS is workforce. The Bill proposes a duty on the Secretary of State to report on workforce once every five years. That is simply not good enough. We need a solution to workforce now; we need a solution to recruitment now; staff need a fair pay rise now; we need more investment in training and professional development budgets now; and we need safe staffing legislation now. We will therefore look to amend the Bill, hopefully on a cross-party basis and perhaps working with others who put forward proposals to improve the workforce sections of the Bill.
As my hon. Friend Rachael Maskell asked the Secretary of State, what does the Bill mean for “Agenda for Change”? The Bill suggests that an integrated care system will be able to change “Agenda for Change” terms; we disagree with that.
Finally, on public health, the Bill introduces restrictions on the advertising of less healthy food and drink. We welcome this step—it, too, was in our 2017 manifesto, which the Secretary of State has been reading—but we would go further. Why can we not have more restrictions on the advertising of unhealthy food around schools? Our public health crisis is about not just obesity but smoking and alcohol, so why are there no provisions in the Bill on smoking services and to ensure alcohol calorie labelling? We will table amendments on those issues in Committee.
This is the wrong Bill at the wrong time. Will the person with learning difficulties or the older person who needs social care experience improved care? No. Will social care be brought back in from the wilderness? No. Will the cancer backlog be tackled more effectively? No. Will health inequalities be narrowed? No. Will parity of esteem for mental health be delivered? No.
Instead of this being a simple Bill to end competition and foster local collaboration, NHS staff will be left trying to second-guess where the Secretary of State will interfere next in the safe running of their local NHS with his in-year changing mandate. The rules on funding could result in more rationing and cuts, so we cannot possibly support the Bill. We have championed integrated care for many years, but the Bill does not deliver it and we urge the House to accept our reasoned amendment.
To reorganise the NHS as one of your first acts as Health Secretary is what Sir Humphrey would describe as brave. I support this Bill, because it contains changes that the NHS has asked for. I take the Secretary of State at his word that there is more to come on social care, and he has said that he will pursue the idea of independent safety and quality inspections of the new integrated care systems to make sure that they are outward facing and focused on the needs of patients.
When it comes to the biggest challenge facing the NHS today, which is workforce gaps, the Bill says little or nothing. Independent forecasts say today that we are currently short of 400 psychiatrists; 1,400 anaesthetists; 2,000 radiologists; 2,000 midwives; 2,000 to 2,500 emergency care consultants; and 2,500 GPs. We have more nurses but we are short of learning disability, mental health and community nurses.
It is unquestionable that we have a challenge with the GP workforce. It is about numbers, yes, but does my right hon. Friend agree that constituents have a big challenge with access to general practice? We currently do not have the right balance between telemedicine and in-person medicine.
There is a big issue, and my hon. Friend is aware from his time at the Department of Health that its root cause is capacity in the system. These capacity issues taken together are why the Health Foundation says that, in just over a decade, we risk a workforce gap in the NHS of about half a million people. That is why this is such a big issue. I urge the Secretary of State to think about that during the Bill’s passage.
Does my right hon. Friend agree that that is also the case for the rehabilitation services used by stroke victims? There is a vital link between occupational therapists and physios, but we do not have the proper workforce in place for at-home care after a stroke.
My hon. Friend is absolutely right. These issues are about not just doctors but all associated health professionals, allied health professionals and indeed the social care workforce. It is important to note that they predate the pandemic. That is why, when I was doing the job of my right hon. Friend the Secretary of State, I set up five new medical schools and increased the number of doctor, nurse and midwife training places by a quarter, but we need to go further.
When the number of clinicians we train is decided by haggling between the Department of Health and the Treasury in a spending round, there is always the risk that it will be eclipsed by more short-term considerations. The truth is that we have a short-term emergency with workforce burnout, so I urge my right hon. Friend to look at the simple and sensible solution proposed by the Health Foundation and all the royal colleges in The Times today to legislate for Health Education England to have a statutory responsibility to publish annual independent workforce projections across the health and care system for the next five, 10, 15 and 20 years. That would show how many training places are needed, which would start to tackle this problem and the obscenity of spending £6 billion every year on locum doctors and agency workers. That cannot be the best use of funds.
Frontline health and care workers are exhausted. They know that there is not an instant solution, because they know it takes three years to train a nurse and seven years to train a doctor, but we can at least give them the reassurance that there is a long-term plan in place. That is not in the Bill, but it needs to be. Given the dedication that we have seen from health and care staff over the last year, it is the very least that we owe them.
The Health and Social Care Act 2012 was what got me involved in politics, as I followed the Lansley proposals in sheer disbelief that anyone could think that breaking the NHS in England into pieces and making them compete with each other would somehow improve patient care. So here we are, less than a decade on, and the Government are having to unpick some of the worst aspects of their legislation, which drove competition instead of collaboration and led to the fragmentation of the NHS in England.
Many will be glad to see the back of section 75, which forced services to be put out to tender to commercial companies, but the Government’s covid response does not exactly suggest that they are any less keen on outsourcing. In the last year, we have seen the establishment of parallel systems of laboratories and contact tracing instead of investment in the expansion of NHS labs and public health teams. Health and care services need collaboration and integration with the patient and their family at the centre. That was key to the NHS requests that led to the Bill.
This is obviously a bit of a kitchen sink Bill, with many disparate components. The main aim is meant to be removing some of the barriers to local collaboration, and to some extent it will do that. Achieving integration, however, will still depend on the establishment of a culture of genuine co-operation within integrated care systems and partnerships. They should be statutory public bodies focused on how to provide the best services to their local population, including working with local government to provide social care and tackle the social determinants of health. Instead, private companies can sit on the integrated care partnership boards, as is the case with Virgin Care in Bath, Somerset, and could influence the commissioning of services for which they are hoping to win contracts. It is hard to see how this is anything other than a blatant conflict of interest and suggests that private providers are moving higher up the ladder and could exert influence on a larger scale.
One issue is transparency, as private companies hide behind commercial confidentiality and do not publish accounts of how they have spent public money. Instead of taking the opportunity to return to a publicly funded and delivered health service, as we are lucky enough to have in Scotland, the purchaser-provider split remains and the principle of commissioning and procurement means that financial competition continues. The administrative costs of such transactional systems waste funding that would be better spent on direct clinical care. Unfortunately, the Government are still wedded to the flawed idea that financial competition drives up quality, yet there is no evidence of that. Indeed, financial competition can mean that, when a service starts to struggle, the loss of funding makes its failure become inevitable. It is actually a relentless focus on safety, clinical audit and peer review that can drive improvement in the quality of patient care.
Thanks to devolution, our NHS was spared this destructive experimentation in marketisation, but we inherited a system of competing hospital and primary care trusts, which were then abolished and replaced with statutory public health boards. These are funded to deliver primary, community and hospital care to the population of their geographical area, and work with local authorities on integrated joint boards to deliver public health and social care to the same population.
The long-term Scottish policy of integration was one of three aspects of our healthcare system that was praised in the Nuffield Trust report, “Learning from Scotland’s NHS” that it considered the NHS in England might want to look at. The other two aspects were quality improvement and patient safety. I was honoured to lead the development of the Scottish breast cancer standards in 2000, and, through our yearly audit and peer review, saw outcomes in all units improve in the following years. We now have regular prospective audits of clinical care in 19 of the most common cancers, as well as standards in a broad range of medical conditions and services as diverse as diabetic retinopathy, bowel screening and forensic medical services.
In contrast, many clinical outcome audits have disappeared in England, and publication of the “Getting it Right First Time” audit into breast cancer services has been held back since December 2019. The whole point of such audits is to identify weaknesses and drive clinical improvement. They should not be delayed for political reasons, because they highlight issues that need to be tackled.
With regard to patient safety, I am very glad to see the proposal for the Health Service Safety Investigations Body make it into the Bill after a four-year delay. The agency will take a similar approach to that used in air accident investigations and share the learning from significant healthcare failures to try to prevent similar episodes in the future. Having been on the pre-legislative Committee, it will be interesting to see how that innovative system evolves.
However, I find it surprising that more has not been taken from Scotland’s national Patient Safety Programme, which promotes a whole-team approach to patient safety to try to prevent incidents from happening in the first place. I remember it being introduced to surgical theatres in 2008 and it reduced post-operative mortality by over a third within two years. It has been extended to almost every division of our health service, leading to a significant reduction in standardised hospital mortality and morbidity, such as sepsis or pressure sores. A key principle at the core of both the patient safety and quality improvement programmes has been the involvement of frontline staff and patients in their design and development. I am sure that the Secretary of State or Health Ministers would be made very welcome by me and my colleagues in the Scottish Government should they wish to visit Scotland to see the programmes in action.
Several clauses of the Bill apply to the devolved nations, but although some relate to traditionally reserved issues such as professional regulation, others are less clear. There is growing concern in Scotland and Wales about how this Government are using the United Kingdom Internal Market Act 2020 to undermine devolution and about how the data-gathering or procurement aspects of the Bill might be widened to apply to our health services.
In 2015, NHS England’s five year forward view highlighted the critical dependence of the NHS on a well-functioning and resilient social care sector. That is still the gaping hole in this legislation. With the funding gap in England now between £8 billion and £10 billion a year, a failure to properly fund social care will undermine the whole integration agenda, as providers are unlikely to be willing to share financial risk with a woefully underfunded service.
Not only has the pandemic highlighted the vulnerability of the social care sector, particularly care homes, but it has brought home the important role played by care staff. The Feeley review for the Scottish Government proposes the development of caring as a profession and proposes taking a human rights approach to social care, valuing it as enabling participation in society rather than looking on care support always as a burden. At the 2019 election, the Prime Minister boasted that he had a fully prepared social care plan, but it has yet to see the light of day. It is hard to see how any integration agenda will succeed without it.
Lord Stevens’s plan stressed the importance of preventive public health to reduce the burden on the NHS, but public health budgets in England have been slashed over the past five years. While policies on tackling obesity are welcome, they are quite narrow and there is little recognition of the role that food poverty plays. Healthy foods are often more expensive. Indeed, poverty is the biggest single driver of ill health. With another decade of Tory austerity due to begin with the cuts to universal credit in September, there is little chance of improving health and wellbeing, particularly among the most disadvantaged.
Wellbeing is not about healthcare, and it is more than just an absence of physical or mental illness. Developing a wellbeing economy would require a total change in philosophy from this Government—and there is little sign that they are interested in taking up the challenge.
I want to make three quick points in my short contribution today.
The NHS is a great institution because it has wonderful, dedicated and selfless people working in it. That was recognised by the Department in the people plan, on which clause 33 builds. I had wanted to make other comments about the workforce but, frankly, they have made more ably by my right hon. Friend Jeremy Hunt. I support exactly what he said. I encourage the Minister to listen to his comments about the need for a long-term plan and perhaps for the duty to be shortened in time, as well as about Health Education England. All my right hon. Friend’s comments were admirably sensible, as we have come to expect.
I welcome the new powers of direction, and I want to counter some of the criticism in the House about them. The newly merged NHS England and NHS Improvement have a range of new functions. Despite what the shadow Secretary of State, Jonathan Ashworth, said, it is clear that the powers of direction will apply only if they are in the public interest and if they relate to the functions. Given the new scope and scale of those functions, it seems right that accountability—and possibilities for the accountability needed in the future—be put in place.
Likewise, I encourage the Secretary of State not to listen to criticisms of political expediency and political interference with respect to reconfiguration. All too often, it is not political expediency but political acrimony that trumps political need. All too often, reconfiguration that would benefit our constituents and the health of this nation is held up. Far from meaning that every bedpan in the NHS will be looked at, reconfiguration is a sensible move. Quite rightly, the reconsideration will still be done by the Independent Reconfiguration Panel, and it is right that if the Secretary of State has the chance to look at those reconfigurations earlier, it should too. I strongly encourage my right hon. Friend to ignore the criticism and to proceed with that power.
My third point is on the prevention aspect of the Bill, which I warmly welcome. Obesity is a UK-wide health crisis. More than 60% of adults in the United Kingdom are above a healthy weight. Some of the measures may well be discussed in Committee, and there may well be some changes in Committee, but the thrust of the measures is correct. We in this country need to recognise that health outcomes and inequalities are affected by not tackling prevention. The Bill starts that; I warmly welcome it, and I will be happy to support it.
I find it very worrying that the Government are choosing to reorganise the NHS during the third wave of the pandemic—a time of exhausted staff and huge pressure. The health service has been stretched to its absolute limits and the road back will be long and difficult. The NHS is scrambling to catch up, yet amid the chaos, the Government want to completely restructure it. Although I support the integration of healthcare and social care, that is not what the proposed integrated care boards and partnerships will achieve.
I am especially concerned that the Bill removes the duty to provide secondary care services, permits the deregulation of all health professions and encourages hospitals to discharge patients prematurely without the assessment of their care needs. In some areas, commissioning responsibilities are up for grabs or even promised to local authorities, which believe they can just use them without the benefit of NHS commissioning experience. There is no doubt that patients and staff will suffer amid the organisational chaos.
I am delighted that this appears to be the end of the disastrous competition of the Lansley Bill, but I doubt we can trust that the end of tendering will mean the end of privatisation. It could actually give rise to privatisation that is unregulated by the tendering process. The private contracts awarded in my constituency have been nothing short of a disaster. To be told that the culprit can have a voice in future decision making is simply unacceptable. How can we allow self-interested, profit-motivated company stakeholders to influence decisions that are supposed to be made with one person in mind—the patient? Remember, it is all about the patient.
I am very concerned about boundaries and the democratic deficit that they will throw up in my constituency. Primary care will be in the Lancashire integrated care system, while acute services will be in the Cheshire-Mersey ICS. My constituents will not be at the table at any point when their hospital services are discussed, as they are not in the Cheshire-Mersey footprint, although their hospitals are—so much for the primacy of place that everybody talks about.
This is a disaster waiting to happen. Many MPs voted for the Lansley Bill with deep and great misgivings. They were right then—the Bill is testimony to that. I implore them not to make the same mistake now.
Health Bills, rightly, do not come around too often, so when they do there needs to be good reason. My conclusion, from the necessary establishment of integrated care systems to the so-called triple aim, the removal of the competition aspect and the new power of direction, is that there is good reason for legislation at this time. This is obviously a vast Bill, but because Health Bills do not come around very often, it is understandable that colleagues and officials will use the opportunity to give legislative cover to things that they have been working on for a long time. The Healthcare Safety Investigation Branch is a very welcome example of that.
I want to focus on workforce and then on primary care, and in doing so I refer the House to my entries in the Register of Members’ Financial Interests. On workforce, I remember publishing the cancer strategy in 2018. The issue then was not our ambition but having the cancer workforce to meet it. Obviously, the chances of surviving cancer have improved significantly in recent years. There are many reasons for that, but detecting 75% of cancers at stage 1 or early stage, which must happen, needs the radiographers in post and demands an endoscopy workforce that can properly execute the FIT screening for the bowel cancer programme, as one example.
The hon. Gentleman is making an excellent point about the necessary workforce in the NHS. Does he agree that if we were perhaps to offer indefinite leave to remain to the many thousands of frontline NHS workers in all departments who are here on visas and have worked hard through this pandemic, we would help to fill the gap that so desperately needs closing?
The hon. Lady makes a sensible point. There is obviously a process in place whereby that can happen, but if she is asking whether I agree with a liberal immigration policy to help our health service, then absolutely, yes I do. Addressing the cancer workforce and the wider NHS staffing picture is not an omission from the Bill—we cannot legislate staff shortages out of existence—but if we do not address that issue and face up to our long-term structural gaps, many of the reforms around tackling the backlog and building back better will not amount to a row of beans.
I congratulate my hon. Friend on the extraordinary work he did when he was a Minister on early diagnosis of cancer. Is he aware that the Health and Social Care Committee has just opened an inquiry—we had our opening session yesterday—into that issue, and into how we can get the right workforce in place to deal with those important matters?
I was aware of that, and I am pleased to hear it. The Select Committee will soon have Cally Palmer before it—she is the national cancer director and one of the best in the business—and I look forward to following what she says. In advance of the comprehensive spending review, the Bill should include a requirement on the Government to publish modelling of the future supply of the entire healthcare workforce.
On primary care, I welcome the formal creation of integrated care systems, but we need them to realise their potential, and to do so fast. If they are going to work, general practice needs to embrace the wider primary care family, which means finally to recognise the potential of community pharmacy, ophthalmology and dental services as vehicles of prevention as much as of treatment.
Finally, if we move upstream of the Bill, what we do must be about prevention. We hear talk this weekend of a waiting list touching 13 million people. Let us tackle that for sure, but let us also get behind the food and drink clauses in part 5, and think about the future and our children as much as about the present. Several years ago I was fortunate to write up the high fat, sugar and/or salt proposals as part of chapter 2 of the child obesity plan, and I am pleased that the 9 pm watershed is legislated for in the Bill. I pay tribute to Jamie Oliver and his Bite Back 2030 campaign, and the young people involved with that, as well as to Cancer Research UK for its support. I realise that not everyone on these Benches, or perhaps outside, supports that move, and I agree that it will have little impact if that is its grand sum. Ministers need to take the tackling obesity strategy that was published last year, implement it all, and then go again.
I welcome the clauses on the fluoridation of water supplies. Let us stop debating whether we do that and —to borrow a phrase—follow the science.
Our NHS is built on the values that Britain holds dear: each of us is equal, and we will be treated on the basis of our need, never on our ability to pay. It is part of our national heritage, so much so that even the Tories have to pretend that they believe in its founding principles. Those are principles of fairness for all, and from each according to their means, to each according to their needs. Those are the values that led to the creation of the Labour party over a century ago. If the Tories hold those values so dear, why have they failed to apply them everywhere else?
This is the Tory Government who left children without food during the school holidays, and who are failing to pay for children to catch up with their education. They are cutting £20 from universal credit for the poorest households in the country. Why did we have 11 years of austerity, when billions were taken from public services, hitting the poorest communities hardest? There was no sign of levelling up there.
In the past 40 years our NHS has come under threat on two occasions: first during the Thatcher years when it was starved of resources to breaking point, and again from 2010 with the Tory austerity years and the Lansley Health and Social Care Act 2012. Now the Tories are at it again. Integrated care systems are nothing short of capitulation to the forces of the market.
This Bill will give the private sector the freedom not only to plan services but to do so in their commercial interests above those of patients and to cover their tracks by hiding the records of meetings where they have intervened. For too long, there have been those within the NHS who believe that it can only be improved if it is exposed to the rigours of the marketplace. The rigours of the NHS are saving lives and healing patients. There is no higher market test for the skills and dedication of health workers and none is needed. Where the private sector is used, it should be to support NHS services, not replace them.
Nye Bevan said:
“The NHS will last as long as there’s folk with faith left to fight for it.”
The Labour party breathed life into the NHS. This Bill is one of those occasions where we have to fight for the NHS again, and the Labour party will lead that fight.
I was almost three when I was lying in a hospital bed and my parents were told that I only had two hours to live and they should start preparing for the worst. It was the brilliant doctors and nurses of the NHS who saved my life. The paediatric surgeon who saved my life still refers to me as his miracle.
Only five weeks ago, I became a father for the first time. Thank God for the amazing doctors and midwives at Warwick Hospital, who displayed the highest degree of professionalism. While I do not want to say that they made the journey as painless as possible, mainly because I was not the one giving birth, they certainly made it a little bit easier. I want to thank the midwives, Sharon Lester, Gemma Fletcher and Nadine Morley, and the doctors, Samir Sadanandappa and Giles Coverdale, for all that they did.
I am a believer in the NHS. I am grateful for it. I want to do everything I can to preserve its status as one of the foremost healthcare services in the world. To do this, we must not shy away from reform. We cannot stop in the journey to make the NHS better, fixing what is broken, revolutionising old practices and evolving into a healthcare system that continues to be free at the point of access but delivers world-leading healthcare.
In this Bill, I am particularly supportive of the integrated care systems approach and putting ICSs on a statutory footing. In Birmingham and Solihull we have an ICS on a non-statutory footing. In my experience, while clinical commissioning groups do many good things, when they do not, there is no clear line of accountability. I believe that the Bill will fix that. When I have not been happy with the CCG, I have found myself getting lost in an opaque quagmire of passing on responsibility and lack of accountability, and ultimately it is my constituents who suffer. I am therefore pleased with the ICSs’ place in the Bill, with clear lines of communication straight to the top and putting patients at the heart of everything we do, as we will then have a more tailored and better healthcare service.
In particular, I am keen for us to move away from a one-size-fits-all approach. What works for the urban part of my constituency does not necessarily work for the rural parts. Will the Minister give consideration to what ICSs can do to provide a much more adaptable approach to different communities and different patient needs?
I am concerned about the impact of the past 16 months on the mental health of our population. One charity I spoke to this week said that one in four people will suffer from a diagnosable mental health problem in the next 12 months. I have spoken to a number of charities that have equally great concern about the situation that we are facing. I would like to hear a bit more from the Minister on what the Bill does in terms of improving mental healthcare provision and hopefully get some clarity on that.
I believe that this Bill will improve the NHS. I am optimistic for its future and for the healthcare of this country, as long as we put patients at the heart of everything we do.
It is a pleasure to follow Saqib Bhatti and to congratulate him on the birth of his child.
First, I am going to vote against giving this Bill a Second Reading. I cannot believe that the Government are going ahead with the Bill at this time. It is irresponsible and without any consideration to those who have worked to save our lives and continue to save our lives. The Secretary of State is going to have to assert himself, because he is only just in the job and he seems to have been bounced into this legislation.
Why is this happening now? We have been through this before. I was on the Health Committee from 2010 to 2015. The right hon. Stephen Dorrell was its Chair. On a cross-party basis, we heard evidence that the Bill introduced in 2012 was not the best solution for the NHS. We managed to pause the Bill but the Government continued to press ahead.
Integrated care is Labour party policy. We have seen it. We visited Torbay, where the fictitious Mrs Smith had a single point of entry and everyone was able to track her all the way through the system—through hospital and out—for all her needs. But the 2012 Act stopped that. It stopped the pooling of resources. Integrated care can work only if there are adequate resources for local authorities. Austerity measures since 2010 have starved local authorities and other public services of funding. That is what is making people angry. But the governance of the integrated care system has no clinicians and no patients. People who use it or work in it do not get a say. All sorts of other people can be added on.
My second point is that we do not trust the Government on contracts. Look what happened during the pandemic: £347 million to Randox, the Tory-linked private healthcare company whose testing kits had to be recalled over the summer because of concerns about contamination. We warned them about section 75 and opening this out to tender. The transaction costs associated with that drain the NHS of resources. There is fragmentation and destabilisation. Just ending section 75 is not sufficient; the NHS must become the first and the default option, and private providers cannot be involved in the ICS or in commissioning decisions. We cannot have a select group of fast-tracked friends.
My third point is about the workforce and it has already been raised. They have been magnificent. They have already had a slap in the face with a 1% pay rise and now they are facing further reorganisation. Workforce planning is key to a smart organisation. Clause 33 says who is responsible, but not what must be delivered. Instead of reporting once every five years, how about laying that before Parliament every year? The modelling will have to be done on the workforce assessment, so why can it not be made transparent and available? As the British Medical Association said, we need independently verified projections of future workforce supply so that local and regional decisions can be made on safe staffing levels. That phrase is not even in the Bill, post Francis.
The Secretary of State should think again, as this is the wrong time. The graphs are going up. The BMA and the royal colleges are against this Bill. The main point about healthcare—the right to healthcare—has not been enshrined in the Bill. It must be stopped now, and people and patients should be put first.
May I thank Neil from Buckinghamshire Healthcare NHS Trust, Buckinghamshire County Council, the local Bucks clinical commissioning group, local GP surgeries, REACH care homes and care workers across South Buckinghamshire, Thames Hospice and Jayne from the Care Campaign for the Vulnerable? They are all already modelling integrated care, which is promised and promoted through this Bill, and I just want to thank them for their tireless service.
I also need to declare an interest: I am now a carer for a very disabled relative, who became disabled through the pandemic and now requires 24-hour care. So I am fully aware of how broken the care pathways are. I want to speak on behalf of disabled adults and their access to care, and the carers who struggle with the demands of finding ways of advocating for their loved one in the current system. I welcome any changes to integrated care because of that. I want to share examples from my personal experience, not because it is important; it just chimes with what I keep hearing from patient advocacy groups, Age Concern, Mencap and other charities. The problem we see is: when a patient is discharged from hospital, who then takes up the duty of care? I have countless examples of my relative being discharged with open bleeding wounds or bed sores, of waiting four days for a nurse to come to attend to them, of being given the wrong medication, of being unable to access—
I just wanted to give the hon. Lady a bit more time. Does she agree that we would want to see more in this Bill on how social care is going to be accounted for? Currently, I feel that is lacking.
I thank the hon. Lady for the point she has raised. I have had reassurances from the Minister that we are going to address the social care issues, but I agree that we need parity of esteem between health and adult social care. We need to see those who are delivering those care pathways—local authorities—given the parity of esteem that the NHS and other care providers now have. I hope that we will look at this further as the Bill progresses.
Parity of esteem is very important because there is a difficulty with collaboration and co-ordination of care, and it is the major driver of health inequality and avoidable deaths for people with learning disabilities. Many people with learning disabilities have very complex health needs that require healthcare professionals to collaborate and to co-ordinate interventions. On top of that, healthcare staff need to work together to deliver the healthcare that those vulnerable patients need, which requires effective communication and understanding, as well as resource. How those funding streams are co-ordinated and improved in future is something that should be looked at.
I have seen at first hand, particularly with stroke victims who leave hospital with varying levels of cognitive and physical impairment, the need for critical rehabilitation services to be co-ordinated and put in place the moment people leave hospital, but that is often difficult. Many Members have raised the issue of workforce capability—I echo that. We need to look at how we can work together collaboratively to put patients first and deliver the vital services that many disabled adults need. We have an ageing population, and we face a crisis in adult social care that will eclipse all other things in healthcare. If we work to deliver solutions now—I welcome what is in the Bill—to the hard problems that we face in integrated social care, we can find the solutions that we need for the future.
With the climate crisis and the reality of an ageing population, there has never been a better time for the Government to centre the wellbeing of people and planet and the way in which public services and the economy are run. Sadly but unsurprisingly, the Bill fails in this context, so I will vote against it, because it does not fundamentally deal with the very real issues facing our healthcare system. It does not address the desert of NHS England providing oral and dental healthcare, which has made it impossible for my constituents to get an appointment. It does not guarantee fair pay and conditions for the key workers who have seen us through the pandemic, and it does not deal with the scandalous state of mental health- care. Patients in my constituency are in crisis, are discharged too early, or not admitted at all, while for a decade, Norfolk and Suffolk NHS Foundation Trust has failed to end the practice of sending patients out of area.
What the Bill does do is transfer yet more centralised power to the Executive—rightly described as a power grab by my right hon. Friend Jonathan Ashworth—and, of course, to the private sector. Clause 13, which provides for the establishment of integrated care boards, opens the door to private companies having a say in where funding is allocated and what services are delivered. Clause 3 gives greater political control to the Secretary of State over the NHS England mandate without creating a duty to provide universal, comprehensive and free healthcare to all. Clause 38 empowers the Secretary of State to intervene in the reconfiguration of services, opening the door for politicised interference and gridlocks on decision making.
Where is the democracy, accountability and transparency in the Bill? How will the right of my constituents to healthcare be guaranteed over and above the interests of private companies and the political whims of the Secretary of State? To see what happens when private companies have any role in delivering care, we need only look at the social care crisis. In England, 84% of care home beds are managed by private companies, and three of the five largest care home companies are owned by investment firms whose main priority is economic rent seeking, not the long-term care of our elderly. That model has, unbelievably, led to a cut in the number of care home beds, despite an ageing population, meaning that demand is only growing.
I therefore urge the House to vote against this legislation on what remains of NHS England. It extends the same failed ideology that puts profit before people and which has driven our planet and public services to breakdown.
Today’s Bill will help our healthcare system to become more accountable and less bureaucratic, allowing our brilliant healthcare professionals to focus on their job of providing world-renowned care to patients, rather than filling in unnecessary paperwork. It allows our healthcare system to be flexible, adapting to meet future and local needs.
As my hon. Friend Saqib Bhatti said earlier, a one-size-fits-all approach is rarely the most effective, and today’s Bill will mean local areas can develop practices that best suit their needs.
This is something we are acutely aware of in Delyn, as we have a much higher proportion of over-65s than the national average. Sadly, the Welsh Government’s funding to the north Wales health board is significantly lower per capita than that enjoyed by the health board in south-east Wales, but that is a debate for another time and place.
Sadly, one of the major elements of today’s Bill that should be praised falls a little short for my constituents in Wales. The Bill will lead to greater collaboration and integration between the NHS, local authorities and care providers in England, and ultimately this will deliver more joined-up working and the best outcomes for patients, yet this move towards greater collaboration needs to go further. We need to see collaboration in healthcare across all the constituent parts of the United Kingdom.
The NHS is not limited to one part of our country; it is nationwide. When someone is treated in their local hospital, they are treated by the NHS—not NHS England, or NHS Wales but the national health service. People do not see that there should be a difference and, frankly, they do not care.
Just as we should be united in our response to covid-19, it is now time for our healthcare system to work together across borders for the good of all UK residents. Despite holidaying within the same country, as so many people are doing this year, if a constituent from Delyn holidays in Cornwall and needs NHS treatment, their medical records will not be on file and will be difficult to access. Without immediate access to those medical records, I cannot help but worry that it could affect the outcome and care they receive, demonstrating the need to share records between all four nations. This issue is one of many that could be resolved through greater collaboration between the UK Government and the devolved Administrations on healthcare, just as we saw with the fantastic vaccine roll-out.
I urge the Government to remember that they are the Government of the whole United Kingdom, which should come with an overarching responsibility to care for and look after all their UK citizens, regardless of the nation in which they reside. As this Bill progresses through the House, I hope the Government draw on the lessons they learned from working together on the covid-19 vaccine programme to consider how greater collaboration in healthcare can be achieved between all four constituent parts of the UK to tackle the public health issues that we collectively face.
I previously had a role within the NHS, and I have family members who work in the NHS, of whom I am very proud.
Nine years ago the Conservative party passed the Lansley reforms, and for nine years the NHS has suffered the consequences of that disaster. We have seen creeping privatisation, fragmentation of services and a lack of adequate funding. For patients that has meant disjointed care and soaring waiting lists, made worse by covid. For healthcare professionals, it has meant the NHS is no longer a hospitable place to work.
Before the pandemic, the national health service had a vacancy rate of 8%, which is 100,000 vacancies. I know from discussions with a variety of professional bodies and unions that there are significant skill shortages that will only get worse. Last year, a survey by the BMA found that 45% of doctors across the UK experience depression, anxiety, stress, burnout and other mental health conditions. How is it right that our NHS professionals are so over-represented among those experiencing mental health problems?
The Royal College of Nursing has found that 36% of nurses are thinking of leaving the profession, and YouGov reports that a quarter of NHS workers are more likely to quit their job than they were a year ago, due to low pay and understaffing. While Ministers have clapped for carers on their doorsteps, many of my constituents who have worked in the NHS rightly say that they do not want platitudes. They want to be heard. They want a proper pay rise and an end to top-down reforms that do nothing to address the real needs and their real concerns.
For them, this Bill is more of the same, but it is also an indictment of the Health and Social Care Act 2012. It is the Government admitting that they have failed. Rather than learning the lessons, they have doubled down on the failures. There is nothing on waiting lists, nothing on vacancies and, despite the Prime Minister’s promise of a plan for social care, nothing on fixing the system that the pandemic has shown is not fit for purpose.
Rather than reinstating the duty on the Secretary of State to provide a comprehensive health service, reversing the privatisation of the NHS or reinstating the NHS as the default provider, the Bill allows private providers to sit on the boards that decide how NHS money is spent. It is astounding, but not surprising. After nine years of failure and after a year of handing millions of pounds to Tory cronies for useless PPE and a failed privatised test, trace and track system, the Government are now proposing to increase the influence of private companies in the health service. Unfortunately, on all these issues the Bill has nothing good to say, and even worse, it says all the wrong things.
In opening this debate, the Secretary of State said that the Bill would improve patient safety. One area in which it does not do that is the area of cosmetic surgery. In April 2013, the Government commissioned Sir Bruce Keogh to do a review of this industry following the PIP—Poly Implant Prothèse—implants scandal. He came forward with some very sensible and clear recommendations to improve safety in the cosmetic surgery industry and to make sure that patients were protected. The review highlighted the fact that those buying a ballpoint pen have more protection than people having non-surgical procedures in this sector. These recommendations have sat on the shelf in the Department of Health since then. I have asked numerous times when they are going to be implemented, only to be told tomorrow, but tomorrow never seems to come.
We did see some change with the private Member’s Bill of Laura Trott—the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 —which, for example, limited botox for under-18s, but this business is a wild west when it comes to regulation. There is a missed opportunity in this Bill not only to get proper patient safety, but to implement Sir Bruce Keogh’s recommendations, which the Government say they support but somehow do not want to implement. This is a multibillion-pound industry, and patients are being put at risk. It is mainly women who, in this sector, need protection. I hope that the Government will implement the Keogh recommendations in this Bill, and I put the Minister on warning now that I will be tabling amendments for that. This is important, and I do not yet understand the reason why the Government are not doing it, because the royal colleges support this and a large number of Members of Parliament have backed these reforms. They do need to be implemented, and we are missing an opportunity to do so.
May I touch on one last thing about public health? I agree with my right hon. Friend Jonathan Ashworth that public health, strangely enough, has been forgotten about in this crisis. If we had actually concentrated on putting the main focus on public health and supporting directors, I think we would have had a better outcome. This is not just about this Bill forgetting about public health; it is about the money that goes with it. Under the fair funding formula being touted last year, County Durham would have lost £19 million in public health funding, while Surrey would actually have increased its budget by £14 million a year. That cannot be right. Public health now needs to be at the centre of our healthcare locally, and the Government have to ensure not just that it gets a voice in this Bill, but that local directors of public health get the finance and support they desperately need.
In the short time I have to speak, I would like to comment generally on the Bill and specifically on one part of it. This is a Second Reading debate, and I see much merit in many of the provisions of this Bill, and the general thrust and direction of it. I understand much of the thinking behind it, as it is a real opportunity to improve the overall performance of our health service, remove some of the unnecessary bureaucracy that has grown up around it and rationalise some of the geography through the ICSs—a very relevant issue to Cumbria—as well as to improve the decision-making process through the boards and encourage collaboration within the health service, although we must still be open and transparent. These are all very welcome changes that have broad support, including from the health professionals in my community with whom I have already had discussions. This will be on top of the additional financial commitment to the health service that this Government have already made, and of the commitment to more doctors and nurses, all of which is very welcome.
I would, however, like to focus on an area of the Bill where I have some concerns. Clause 125 and schedule 16 relate to advertising, and they have the potential to adversely affect our food and drink sector. I remind the Minister that that is the largest manufacturing sector in the country. It employs a significant number of people up and down the country, it makes a huge contribution to our economy and our exports and—this is a key point—it is an innovative sector with considerable research and development and investment. It has already done a huge amount of reformulation to take sugar and salt out of our foods and it continues to do much on this.
I fully appreciate that obesity is a major concern for our society, and rightly so. Everybody wants the UK to be a fit and healthy country, but we have to tackle this issue in a sensible and proportionate manner. I am not convinced that schedule 16 in its present form will achieve very much. What it will do is reduce investment, resulting in fewer products coming to the market, including fewer healthy products—and those are what we want to see those. There would be less incentive to innovate and ultimately fewer jobs and less money in our economy, and all for very little gain in many respects. Also, as an aside, we need to remember that our own health and wellbeing are our own responsibility. I shall therefore be supporting the Second Reading of the Bill today, but in Committee and on Report, I and I am sure other hon. Members will seek amendments to schedule 16. That is so we get the right balance between our health agenda, the food sector and our individual freedoms and responsibilities.
I would like to make it clear that the Liberal Democrats have long supported the aim of integration between health and social care, and the far greater involvement of local authorities in the planning, commissioning and delivery of services. We recognise that the pandemic has forced many of these bodies to work closely together in a much more collaborative way, and that is welcome. However, the Bill pays lip service to social care. It is largely a Bill about NHS reform, with yet another acronym-laden reorganisation that seeks to provide the legislative basis to integrate NHS services, currently in crisis mode, with a broken, underfunded and fragmented social care system. It is a massive power grab by the Secretary of State for political interference in operational and local service reconfiguration decisions and in who runs integrated care boards. The Bill is woefully inadequate in ensuring that the plans and resources are in place to ensure that we have sufficient doctors, nurses and other healthcare professionals and carers to deliver care, both now and in the future. This is all against a backdrop of record waiting lists and staff who are burnt out, stressed and struggling to cope with the third wave of the pandemic while dealing with surging A&E visitors and tackling the enormous backlog of care.
Without meaningful social care reform, this Bill cannot realise its aim of providing citizens with better joined-up care. With over 100,000 vacancies in the workforce, 1.5 million people are currently missing out on the care they need, putting additional burdens on the NHS and, importantly, on 9 million unpaid carers. The Government have promised—at the moment I take them at their word, though they have broken it many times—that they will bring forward social care reforms later this year. So why not delay the Bill for a few months and take account of the new model of social care, rather than doing a half-baked job now?
It really beggars belief when we look back over the past 16 months of the pandemic that Matt Hancock, who was the architect of the proposals, seriously thought that granting himself more powers over the day-to-day running of the NHS was a good idea. We only need to look at the PPE fiasco and the failures of test and trace, both of which were run centrally, to see that handing back power to the Secretary of State is the very opposite of what we need. Allowing him or her to meddle in the day-to-day running of our NHS seems to fly in the face of the desire for more local and regional decision making.
I fully support and endorse the proposals of Jeremy Hunt on the health and care workforce independent planning proposals. They need to be properly resourced and annually reported to Parliament. Without a workforce plan, without wholesale reform of social care and while waiting lists are skyrocketing and the Health Secretary is embarking on a power grab that is his predecessor’s vanity project, this Bill will fail in its fundamental aim, shared by most Members of this House and health and care leaders—
I declare my interest and my family’s interests in healthcare service.
I welcome the Bill. Those concerned about it should realise that it is an evolution, not a revolution, coming from the ground up. Do not take it from me; take it from the evidence to the Health and Social Care Committee from Simon Stevens, who said:
“We have been working so closely for a number of years with colleagues across the health service and our broader partners. Genuinely, I think this is unusual, if not unique, in having come from the NHS as a series of asks to Parliament rather than something that Parliament is perhaps imposing on the NHS.”
That is the leader of the NHS.
Three minutes is a very short time to try to pull this Bill apart, so I am going to use my time to set out some amendments and new ideas that I would like the Minister to consider. Some are practical, some are short and some are much bigger. The first is simple: annual virus drills for care homes. We have fire drills regularly, but, given the pandemic, care homes may well benefit from being further prepared for future pandemics.
I would like mental wellbeing to be seen as a public health issue. Everyone suffers with their mental wellbeing; not everyone has mental ill health, and this House often gets confused between the two. That is really important, because until we label mental wellbeing as such, it becomes very hard to implement education and protective policies. Many Members will know that my particular interest is body image—the labelling of altered images, just as we label calories on food, so that we have parity between physical health and mental health.
My final idea—this is probably the most revolutionary piece I would like to put across—is to have a named person for change on the frontline. We have named bodies for whistleblowers, and we have protected people who are guardians for data, but fundamentally, change has to come from the bottom. All too often in my career, I was told, “You’re too junior” or “This is the way we’ve always done it.” We want to empower the people on the frontline who understand how the system works to make changes, and I think there is a chance to amend the Bill to do exactly that. I am happy to meet the Minister to explain further.
As I have a little more time, I am keen to comment on the reduction of bureaucracy. It is all very well making sure that there is not a problem when we are commissioning, but fundamentally, we need to look at the admin on the health service side—the barriers between primary care and secondary care. About 5% to 10% of a GP’s workload is dealing with chasing admin. That is not time well spent; it takes services away from the clinical frontline, and it is something that could be remedied, possibly even without legislation.
We all know that the last top-down reorganisation of the health service was a disaster for our people and those who work in it, so I was quite excited to hear of the plans to sort it out. I must have been mad. Instead of bringing forward a Bill to deal with their own mess and sort out the health crisis they have created, the Government have introduced a hotchpotch, which will do neither and could make it worse.
The Prime Minister’s response to decades of regional inequality and underfunding of communities such as mine is pathetic. It seems that, instead of introducing robust proposals to reskill our people, invest in our services and tackle their homemade crisis in the NHS, the Government are telling us that an increase in al fresco dining and an extension to the service of takeaway pints are the answers. That sort of trite nonsense is downright insulting to people who live in constituencies such as mine.
“If the UK is to tackle inequalities and make sure no community is left behind…then health must be hardwired into the Government’s ‘levelling up’ agenda.”
If the Government are serious about levelling up for communities such as mine, they will have to take meaningful action to tackle the health inequalities that plague them.
In Stockton North, 7.4% of the population suffer from asthma, higher than the 6.5% who suffer across England. In England, the level of chronic obstructive pulmonary disease among the population is 1.9%; that rises to 3.1% in my constituency. There are other inequalities, too, and we need action now. Will the new Secretary of State come good where others have failed and provide Stockton with the new hospital it desperately needs?
Some 13.2% of adults in Stockton-on-Tees are smokers, and smoking-attributable hospital admissions and deaths are increasing, yet Government action to reduce smoking has generally stagnated. Measures in the Bill to tackle obesity are welcome, but smoking is the leading cause of preventable premature death, and yet there are no proposals to tackle it. The Bill represents an ideal opportunity to introduce a US-style “polluter pays” levy with tobacco control, as recommended by the all-party group on smoking and health, and which the Government promised to consider two years ago in their prevention Green Paper. The all-party group—I declare my interest as the vice-chair—has provided a model for this approach, and I am grateful to Action on Smoking and Health and others for their work. The all- party group published a comprehensive set of recommendations that would help the Government to achieve their ambition of a smoke-free 2030, including further regulatory measures to de-normalise smoking, but nothing has happened.
Cancer Research UK has estimated that, on current trends, we will not make England smoke free until at least 2037, and it will be longer for poorer communities. We need action now. The Government say that we need bold action; they should take it now. That is one step towards tackling inequalities that blight our country.
In the past, successful reorganisations have been centred on patient care. We have seen that with cardio and we have seen that with cancer. The reason why this will be successful now is that the aspect of patient care that will improve, including the outcomes for patients, will be around accountability. There are three ways in which the Bill does that quite successfully, but there are also ways in which it could do more.
First, on the involvement of the Care Quality Commission, having the CQC inspect social care services will be crucial for increasing visibility and transparency in terms of the outcomes for patients. The criteria that the CQC uses when inspecting social care and focusing on patient outcomes will make a difference in terms of the quality of care that patients will get—that is also true for integrated care systems as well. We need to make sure that these services are not measured on bureaucratic targets, but on what they are actually doing for patients.
As a side note, let me say that we have talked a lot about GP surgeries today. The CQC, as we all know, inspects GP surgeries. There is a question as to whether these surgeries are doing enough, especially at the moment, when it comes to the outcomes for patients. I have a lot of very good GP surgeries locally, but the levers by which we as Members of Parliament can get them to improve the quality of services are somewhat lacking in many cases and this is something that could be looked at as part of that admirable proposal to increase the involvement of the CQC as part of the Bill.
The second area I want to touch on is to do with the Healthcare Safety Investigation Branch. We have seen through the Health and Social Care Committee how important it has been in terms of changing the culture within the NHS. What we have also seen, though, is the number of times that the recommendations have not necessarily been followed through. More focus on that within HSIB and a mechanism by which the Department of Health and Social Care can be mandated to follow through on the outcomes could really add to the accountability part of the Bill.
The final point is around the somewhat thorny issue of political control. I happen to think that my constituents have a right to be involved in decisions that are made by the health service on their behalf that are not clinically based. It is absolutely right that we have a health service that has to explain to my constituents why it wants to do a reorganisation in the area. If my constituents do not agree with it, I should have a mechanism by which I can go to the Secretary of State and say, “Do you know what? I do not agree with what you are doing here. This is not right for my constituents.”
I understand the arguments that are being made today, but the fundamental point about accountability is the one that will really shape the future of our health service. It is a very positive thing, and the mechanisms in the Bill will have a positive effect on the outcome of patients within my constituency and nationwide.
During the pandemic, NHS staff, care workers and public health teams have all gone the extra mile, as they always do, in protecting and caring for people. Health professionals have been ably assisted by a number of former colleagues who had retired and by an army of volunteers, and I thank them all.
In government, Labour increased NHS funding by more than 9% a year. Let us compare that with the just 2.5% from the Conservatives before the pandemic, or the £8 billion cut from council social care budgets since 2010. In the Liverpool city region, 50,000 patients are waiting to start routine treatment at Aintree University Hospital alone, of whom a third have waited more than 18 months. Meanwhile, many people find it difficult to get an appointment at their local GP surgery. New facilities, including a new health centre in Maghull in my constituency, would help there.
Alongside dealing with the immediate challenges of the pandemic, Labour’s priorities involve addressing the problems caused by those Conservative cuts which predate the crisis: waiting lists, staff recruitment, social care funding, and yes, the need to give our staff a pay rise. After all, who will look after patients if we do not value our staff? Sadly, the Conservatives have rather different priorities. The pandemic has seen companies without a track record—companies that happened to know the right people—making their fortunes. As the National Audit Office confirmed, companies without political contacts had only a 1% chance of succeeding, while £10 million was handed out in contracts without competition. Then there is Serco Test and Trace: delays in returning test results, dependence on £1,000-a-day consultants, and unused call centre capacity.
All that waste and inefficiency prompts us to ask why Ministers were so committed to outsourcing. The Bill offers some answers. Private companies on new health boards and the centralisation of power point to a potential consolidation of the cronyism and privatisation that have characterised the Conservatives’ approach to the covid crisis. Every day that frontline NHS staff are forced to spend on top-down reorganisation is a day less to tackle waiting lists, address the challenges in social care, and cope with covid. Meanwhile, the reorganisation will take money away from local services, where it is most needed. A prime example is the cut of £253 per patient from Knowsley as a result of the Bill. One of the poorest boroughs in the country will face poorer health outcomes.
That is the reality of this Bill. How can it possibly be right?
I welcome the Bill, particularly its intention to better integrate health and social care in England. As vice-chair of the all-party parliamentary group on obesity, I am pleased to see the introduction of restrictions on the advertising of high fat, salt and sugar products online, and on television before 9 pm. I would, however, emphasise the need for a level playing field between the two. As a member of the Health and Social Care Committee, I endorse the findings of our inquiry into the preceding White Paper, especially its comments on social care provision and workforce planning. I hope that these matters can be addressed as the Bill, and indeed the year, progresses.
The Bill also provides the opportunity to address some of the disparities in healthcare provision across the United Kingdom. Further to my constructive engagement with colleagues at the Department, I hope that the Minister for Health, my hon. Friend Edward Argar, will consider four key proposals.
First, we should mandate the collection of an agreed set of UK-wide directly comparable data on NHS performance and outcomes, for clinical and research purposes. I am already engaging with the Office for National Statistics on how that could work in practice, and believe that the Bill could have an important enabling role to play. Secondly, data interoperability must be improved. It is unacceptable that the health service in Wales often cannot communicate in a fit-for-purpose way with services in England, and vice versa. Thirdly, my direct experience of working in the NHS leads me to feel strongly that inspection, safety and audit mechanisms should be introduced at a national level to ensure a minimum standard of care for all British citizens. Those who are managing inferior services must be able to learn lessons from more effectively run areas and, ultimately, be held to account.
Finally, I hope that the Bill can be used to provide people with equal access to and choice of secondary and tertiary healthcare services across the country, regardless of where in Britain they live. My constituent Ian Kightley was diagnosed with cancer in 2015. As a result of his treatment, he developed problems with his vision and required cataract surgery in both eyes. Like so many in north Wales, when he was advised of a two-year waiting list he was forced to pay for private healthcare, which he was able to do only through fundraising. Only in the last week, while working as a GP, I saw patients who had been advised of two-year waits solely for their first out-patient clinic appointments at Glan Clwyd Hospital.
This Bill provides a vital opportunity for us to level up healthcare and ensure that all our constituents can access the best treatment as soon as possible.
When a Labour Government proposed a national health service after the second world war, promising free universal healthcare for all, it was a radical idea opposed by the Conservative party, which complained—I quote from an amendment tabled at the time—that it
“discourages voluntary…association…and undermines the freedom and independence of the medical profession”.
The Conservatives did not like it that the NHS was centralised, public and free for all. They condemned it as Marxist and voted against it 22 times. Fundamentally, they opposed the NHS for taking healthcare out of the market and for putting public good before private profit, but they saw its popularity and begrudgingly were forced to accept it.
Those fundamentals have not changed. This NHS corporate takeover Bill is another step away from the original truly public healthcare system, free from the corrosive influence of profit. The Conservative party still opposes that idea. Conservatives should not just take my word for it; they should take the words of their own Members. The Prime Minister, when he was a Back Bencher, slammed the NHS as “monolithic” and “monopolistic”, and called for privatisation. Four senior Cabinet members, when they were Back Benchers, wrote a manifesto in which they argued that two thirds of hospitals should be run outside of the NHS, and run privately or not for profit. We also have a new Health Secretary, who in the last year, alongside his role as a Back Bencher, has been on the books of US megabank JP Morgan. He has been making £150,000 a year from a company that—I quote from its literature—
“see the opportunities that lie ahead” for private healthcare. The Health Secretary’s ideological hero, Ayn Rand—whose work he says he rereads every year—was an extreme right-wing libertarian philosopher, who detested socialised healthcare.
It is not just words; it is deeds too. The Government are breaking up the NHS, not all in one go, because they know that the public would not like that, but piece by piece. Privatisation by stealth—that is what they have been doing. Since coming into power in 2010, more than £96 billion has gone to non-public healthcare providers and nearly 20% of healthcare bids now go to private providers. This Bill will not reverse that. It will simply entrench it. It will put private companies on healthcare boards, giving them a say over our care and public funds. It will add steroids to the cronyism on steroids that we have seen in this pandemic, whereby Tory mates and donors have been handed billions of pounds in dodgy covid Government contracts. It will implement a healthcare model that incentivises cuts and closures, and rations funding to health boards.
This dangerous Bill is another step towards privatisation. In its place, we need to reinstate the NHS as a truly public service with a proper pay rise for its workers of 15%, making up for a decade of falling pay.
I draw the House’s attention to my declaration in the Register of Members’ Financial Interests.
I want to focus on two main areas of the debate: the role of patients in accountability and transparency; and tariffs—the way in which we pay for procedures and care. I support the Bill, but I hope that we have the means to address the deep-rooted cultural issue of regarding patients’ views as less valuable than those who work in our national health service. Before I was elected, I was often involved in advocacy campaigns. Patient groups would want to challenge NHS England’s commissioning policies or service specifications. These policies govern the technologies and procedures that are used to treat conditions, but the patient groups would find the decision-making processes totally impenetrable, as would the clinicians and health policy experts advising them. What chance do individual patients and relatives have to make their voices heard?
The same impenetrability applies to clinical commissioning groups. Patient access to established procedures and technologies is blocked by local policies, but people have to be dedicated to find these policies on convoluted websites or page 178 of a 256-page document. For example, CCGs regularly restrict patient access to hip and knee procedures for patients with a body mass index of over 30. Extraordinarily, some CCGs allow procedures only for patients who have a BMI of less than 25. I would confidently predict that that would disqualify the vast majority of hon. and right hon. Members, and we should call it out for what it is, which is rationing.
Such rationing was routine before covid created massive backlogs in NHS waiting lists in some CCGs. Transparency and openness is the solution to these problems. A formal role for patients on ICS boards, a formal role for patients in the development of commissioning policies and creating a national appeals board for challenging commissioning decisions are all ideas that I hope Ministers might consider as the Bill progresses.
Finally, on tariffs, national tariffs are not perfect but they do incentivise providers to treat as many patients as they possibly can. The Bill states:
“NHS England must publish…‘the NHS payment scheme’”— a document “containing rules for determining” the prices to be paid in future, including, for example, for hip and knee procedures. Tariffs have led to hip and knee procedures and other procedures being done at volume and at scale, certainly, at least, when commissioners agree to pay for them. High volumes of elective procedures have been a good thing and the current elective backlog is probably the biggest challenge that the NHS faces coming out of the pandemic, so whatever ends up in that document, it needs to be clear, transparent and provide incentives for high-volume procedures to be carried out at pace and at scale.
The Government’s health strategy is clear: while health demand rises, the amount of resources being provided to the NHS is declining, which leaves well-heeled patients with nowhere else to go to avoid ill health except into the so-called independent sector. For example, a constituent told me that his opticians had said that he could wait six years for cataract operations, by which time he would be nearly blind, or he could pay for a cataract operation now in the private sector.
Even before covid, the Government had cut the health budget and spending. In Britain we were spending £2,000 per head of population less than was being spent in Germany. There were cuts to the numbers of staff and to their pay, 100,000 vacancies, 17,000 fewer hospital beds and over 100 fewer A&E facilities, with hospital waiting lists therefore doubling—even before covid arose—since the end of a Labour Government. The Bill continues all that process, as we would expect. It will make the NHS more remote because it is top-down, and it is a Trojan horse for elements of privatisation.
Newly remote administrators will have little sensitivity to local health requirements. Members should think of the differences in the health needs of former coalfield communities such as those I represent in West Yorkshire, the inner city of Bradford and the relative affluence of Harrogate, yet all that is to be covered by a single new board, and the centralisation of clinical services makes them less accessible. Some 20,000 people are living in my constituency with no car to their households’ name and with poor public transport, many of them with chronic health needs. How on earth will they be expected to travel to centralised services in Leeds or elsewhere under those circumstances?
There are two competing views of health provision facing each other. Either health is about an ethos of care or it is about making money. This Bill leads in one direction. The Government do not want to fund the NHS properly, so they are trying to entice more private money into health, often from sources, we note, from the Tory party. Privatisation puts one person’s wealth in front of another person’s health. We should look at the pages of the American health service providers today salivating at the prospect of growing NHS waiting lists, and now, so-called independent providers are to be invited to sit on boards that actually manage the NHS budgets. The idea of profiteering from someone else’s ill health is repulsive to most British people, yet it is intrinsic to this Bill. We can call it only one thing: parasitic capitalism. Along with the Royal College of Nursing, the British Medical Association and many other practitioners, we must resist the creeping destruction of our NHS.
Generally, the Bill is to be welcomed as it seeks to promote collaboration and the integration of local health and care services. It aims to give local people, local clinicians and those running local NHS and care services more control over the way that health and care services are delivered. The King’s Fund highlighted that the Bill will remove “clunky” competition rules and make it simpler for health and care organisations to work together and deliver more joined-up care to more people. That said, it is important to recognise that the last 16 months have been very challenging and very exhausting for those working in health and care, and in many respects, the last thing that they now need is yet another NHS reorganisation. Groups such as the BMA have concerns and I urge the Government to look at those closely in Committee.
I wish briefly to highlight two issues. First, I urge the Government to retain the existing boundaries, with the Waveney area remaining in an ICS with Norfolk. To change the boundaries to make them coterminous with the two counties would be highly disruptive and an unnecessary distraction, and it would demotivate hard-working staff. It would place at risk the health integration that has taken place in the area in recent years. To achieve better collaboration with care services, it is better to build on the existing foundations rather than to dismantle them. In many respects, boundary wars have been going on behind closed doors for the past seven to eight months, though I am grateful to both the Secretary of State and the Minister for listening to my concerns in recent weeks. I urge them to retain the status quo.
Secondly, the health issue that has taken up most of my time in recent weeks is NHS dentistry—or rather the lack of it. Many of my constituents are in agony and local NHS dentists urgently need the funds to see more patients. We are gradually moving towards a short-term solution, but it has taken far too long. In the longer term there needs to be greater accountability; dentists need to have a voice on integrated care boards; dental budgets should be protected; and steps must be taken to tackle the staffing crisis.
In conclusion, the Bill provides a statutory footing to ways of working that are in many respects evolving naturally. However, there are potential pitfalls, particularly —from my perspective—the changing of ICS boundaries, which I urge the Minister to avoid at all costs.
This is the wrong Bill at the wrong time. To introduce a Bill like this when the covid pandemic is far from over and staff are on their knees shows a lack of understanding of what is needed.
I am concerned that this reorganisation of the NHS is being used as an opportunity to extend the involvement of UK and international private healthcare companies. The Bill proposes that private healthcare companies can become members of the integrated care boards, potentially meaning they will be able to procure health services from their own companies. Under the Bill, ICBs will have only a “core responsibility” for a “group of people”, in accordance with enrolment rules made by NHS England. There are concerns that this evokes the US definition of a health maintenance organisation, which provides
“basic and supplemental health services to its members”.
What is included in the core responsibilities?
Why is there no longer a duty but only a power for ICBs to provide hospital services? What does that mean for the thousands waiting for elective surgery? What about those waiting for cancer and other therapies? For those who say, “What does it matter who provides our healthcare as long as it meets the NHS principles of being universal, comprehensive and free at the point of need?” I say that not only is the Bill a clear risk to those founding NHS principles but there is strong evidence that equity in access to healthcare, equity in health outcomes and healthcare quality are all compromised in health systems that are either privatised or marketised, as the NHS has increasingly become.
That brings me to my third area of concern: health inequalities. It is notable that the Bill places the duties for the reduction of health inequalities with ICBs. The 2012 duty on the Secretary of State and NHS England to reduce inequalities is repealed, showing the clear lack of commitment to levelling up and the reduction of the structural inequalities that have been laid bare by this pandemic and contributed to the UK’s high and unequal covid death toll. With this change, the Secretary of State is ignoring not only decades of overwhelming evidence that clearly shows that health inequalities are driven at national policy level, but the Prime Minister’s commitment to implement the recommendations that Professor Sir Michael Marmot made in his covid review last December to tackle inequalities and build back fairer.
My final point is on social care. As chair of the all-party parliamentary group on dementia, I express my profound disappointment that, 19 months since the Prime Minister pledged to fix the broken care system, it still has not been fixed. The Bill is a missed opportunity to set out the framework for social care reform in the context of an integrated health and social care system. For people with dementia and their family carers, who have suffered disproportionately from covid, this is a real blow. They deserve better. For me, the principle of health and social care—
Anything that starts to undo the damage done by the 2012 Act is welcome. Some of the Bill reflects what has been the reality on the ground for some years: our local health services have indeed been ignoring the competition elements. I applaud them for it; they sensibly recognised that the only way the NHS could cope would be to co-operate, not compete.
I put on record my thanks to those leading our health and care system in Cambridgeshire in recent years. They were brave—they should not have had to break the law to deliver the services that our people needed. I also give heartfelt thanks to all the staff, medical and non-medical, who go above and beyond. What they do not need at the moment, on top of everything else, is the uncertainty that now encompasses them.
The reason why those people were in that difficult position is what makes me oppose the Bill: I will never trust the Conservatives not to try to privatise the NHS. That is based on long experience, because Cambridgeshire was the test bed for many of the 2012 reforms, which of course were driven by Lord Lansley, the then MP for South Cambridgeshire. Long before I came to this place, I was working with other campaigners, particularly Unison, Unite and GMB colleagues, to tackle what felt like an endless onslaught.
I remember arguing over the lifting of the private patient cap. The then chief executive of Addenbrooke’s Hospital told me at an annual general meeting that where he came from, people were very relaxed about private healthcare. For years, Addenbrooke’s had land allocated for a private hospital, and the chief executive admitted that the future business model was to seek to bring patients from across the world.
The then chief exec of the Royal Papworth Hospital was on record as wanting to expand private care from 5% to 15%. Nearby Hinchingbrooke hospital was run as a private outfit by Circle Health, until it handed it back because it could not make it work; Circle was then run by Ali Parsa, now CEO of Babylon Health, whose app was so brazenly promoted by the former Health Secretary, Matt Hancock. Then there was the UnitingCare fiasco, which I spoke endlessly about in this House: an £800 million five-year contract under which older people’s services were, effectively, privatised, until it collapsed in a huge waste of time, effort and public money. So there is form, and that is why I will always oppose this legislation.
There are other concerns, but time is limited, so I will cite just a couple. The British Association of Social Workers has highlighted the removal of social work assessment prior to hospital discharges. It is right to do so. The relationship between hospitals and some care homes has long been far too close, in my view—frankly, at times it borders on the corrupt. There is pressure to discharge too quickly, so the last thing we need to do is remove professional assessment. I am also concerned about clause 80 on data sharing, because I do not trust the Government on that either.
We have a wonderful NHS. It needs support, not reorganisation, but all past experience and evidence tells me that the Tories will always want to find a way of making money out of it. We will always try to stop them, because that is not what the NHS is about.
I am pleased to support the Bill. It is the first significant reorganisation of healthcare in recent years, and only the second since the Conservatives came into office following 13 years of Labour Administrations who reorganised the health services nine times, so we should not be taking lessons from the Opposition on the timing or the fact of putting things right.
The Bill is very substantial legislation that learns lessons from the way in which the NHS has had to work during the covid pandemic. In particular, the flow-through of patients discharged out of the acute sector as a result of much closer working with social care and local authorities is an integral part of creating the new integrated care boards. I very much welcome the fact that they are being established on a statutory footing and that there will be representation from local authorities and a role for health and wellbeing boards to provide local oversight. That is an essential step to allow the healthcare economy across our communities to collaborate effectively, and to remove some of the artificial barriers.
I will touch briefly on three other points. On the measures proposed for reconfiguration, we in Shropshire have been at the wrong end of a protracted reconfiguration process for our acute hospitals. Streamlining the process by which decisions are made will benefit patients. In Shropshire, it has taken several years to reach the point at which decisions can be made, and at every stage obstacles are put in place that add to delay and uncertainty. As a consequence of that, it is hard to attract staff to a system not working as well as it should, and the system has gone into special measures. The provisions to streamline difficult decisions are therefore very welcome.
Secondly, as my right hon. Friend Jeremy Hunt, the Chair of the Health and Social Care Committee, said, the Bill is somewhat light on workforce, but it does include key measures to speed up the ability of physicians trained in other systems to be welcomed into the NHS or to return to the NHS and if they have retired. I urge Ministers in Committee to look carefully at what can be done—
This Health and Care Bill has been conceived in bunkers behind screens within echo chambers. It is straight from the US health market, and its architects are immune to objection from the frontline leaders who are expected to deliver a new health and care system. In case the Government had not observed it, those people are in the midst of managing a pandemic, its resurgence and its aftermath. They are holding together a fragile workforce, traumatised by the pressure and sacrifice of the covid war. They are vaccinating a nation while seeing others fall to preventable diseases. They are embracing those with broken minds as they try desperately to hold on to their own.
It is no time to strip out the NHS’s infrastructure and replace it—eager as we are to do so—with something as ill-defined, void of detail and illiterate as the Bill presents. The Bill will shift the blame for an imploding NHS and shattered care system from the impervious Prime Minister to NHS workers. The backlogs will be their fault. They will be to blame for service cuts, and the Government will shrug their shoulders at the postcode lottery and rationing. We have more than 5 million people waiting for hospital appointments. We are unable to see a GP for weeks. We are waiting longer than ever at A&E and, when the care system fleeces people for all they have and fails to restore their dignity in their fading years of life, the Bill scapegoats local health and care teams while the Government wash their hands.
We are in this mess because, in 2012, the Government—and, let us not forget, their Lib Dem chums—messed with our NHS, ignored clinicians and seeded the failures that we have witnessed throughout the pandemic. History repeats itself. The market-driven system enabled Ministers to sign away billions of pounds on crony contracts while frontline staff were wrapped in bin bags—and some, tragically, in body bags. The Bill lets the Government off the hook. When things go wrong, they will simply blame others as they avoid shame. But, worse, private companies are already sitting round the tables of the shadow integrated care systems to profit further. Nothing has changed. If the Bill changes nothing, we do not need it to further destroy the remnants of Labour’s precious NHS. At the one time we need certainty, there is none.
The Bill fails to provide the vital stability, funding, accountability or transparency that is needed. It fails on prevention and the advances that patients need. It has more private commissioning, not less, no workforce planning or vital staff pay and, crucially, no social care, yet the NHS will integrate with it. Labour believes that people deserve better. We must have integrated health and social care, free to all in need, wholly delivered in our public sector by fairly rewarded staff and accountable to this Parliament and to the people. Now is not the time and this is not the Bill. I will vote against it.
I welcome the Bill, and I particularly welcome its aims and objectives to provide the best possible health and care to everyone in this country. However, to achieve that, things must change in the legislation. It must have explicit provisions for mental health, not just physical health. It must also include provisions for children’s social care, not just adult social care, and provide for the commissioning of not just medical services, doctors, nurses, infrastructure and hospitals but medicines and devices, which we know have been crucial in the fight with covid.
How are we going to do that? First, we need to include parity of esteem clauses—one for mental health and one for social care. We need to define what we mean by parity of esteem, which will be a first: what are we going to put in? Not just money; what processes will we promise to deliver? What healthcare outcomes are we looking to deliver? We need the same for mental health and social care—both are deserved.
As others have said, we need a proper workforce plan, but it must cover not just health but social care, and it must look specifically at how we will deal with recruitment. How will we deal with the career path in future? How will we look at training and retention for the future? There should be an integrated plan, not one for health and one for care. Our nurses, for example, work across both systems.
We need to provide for the commissioning of medicines and devices. Currently, it is a postcode lottery. The previous legislation on medicines and devices covered licensing, but not commissioning. Patient choice depends upon forming that system so that everyone gets access to the medicines approved by the National Institute for Health and Care Excellence. Currently, that is not the case.
We must positively review the big-picture strategy. What do we need? What are the skills we need for health and care? We must look broadly, not narrowly. We must look at what greater role our pharmacists can play. How can we improve our training so that people have more general skills that we can use in a pandemic such as this, so that everyone in the health system can be used? To support that, we will need to rework the membership provisions for the ICBs and the ICPs. We will need to amend the data regulations to ensure that they can go beyond the boundary of the NHS, and we will need to look at our medicines directory—the sister of the devices registry—to ensure that it includes information from research through to patient experience. There is much to do; it can be done. Where there is a will, there is a way.
The NHS was established to provide equal rights to healthcare, free at the point of delivery, irrespective of income or personal health. Yet as we emerge from the pandemic in praise of the NHS, this Bill is yet another step towards dismantling and privatising the system.
With the highest vaccination rates, thanks to the NHS, England also has the highest infection rate of the delta variant, thanks to the Government going into lockdown too late and coming out too soon. With 128,000 people dead, 695,000 currently have the covid variant and there are record waiting lists. The Government should be investing in more capacity now—in the workforce and in beds. They should be reinstating the 12,000 empty beds. Instead, the Government are putting £10 billion into the private sector over four years, with the framework contract, when the private sector has only 8,000 beds in total. Doctors will have to leave NHS hospitals to go to private hospitals, further disrupting NHS services.
Coming out of the pandemic, we need a healthcare Bill that re-energises the NHS and rewards our nurses and doctors who saved the country from calamity. Instead, this Bill allows private health companies to sit on boards, deciding where the NHS funding is spent. It allows further outsourcing, opening the door to more taxpayers’ money being siphoned off to the profits of private contractors. The NHS is being fragmented. Talk of patient choice is disingenuous, as funds must be transferred in the internal market, so it is a postcode lottery. There has not been patient choice in England since the internal market was introduced.
In contrast, in Wales, the Labour Government continues with a planned system that has delivered the highest vaccination rate in the world and a 90% effective test, track and isolate system, wholly delivered by the public sector through councils and health authorities. Wales has a lower death rate over a five-year average—13% in Wales vs. 20% in England, despite Wales’s older population. There is public procurement in place of crony contracts to Tory donors.
Wales has shown that public money is used most effectively in the NHS by public sector delivery, so more people are treated equally, irrespective of income and personal health, true to Aneurin Bevan’s founding principles. Instead, the Bill is a back door for United States companies, via trade deals, to further break up our system, on the road to health insurance, which hits the poorest and sickest hardest.
This is a rotten Bill. It is bad for Britain’s health, bad for our wealth and bad for our most treasured achievement —our NHS.
I confess that I am wary of NHS reorganisations, but as Sir Simon Stevens told the Health Committee, this one is almost unique in being primarily a response to a series of requests from the NHS to Parliament. In delivering a more integrated health and social care system, the Bill will implement a number of proposals in the NHS’s own long-term plan and crucially, as other hon. Members have said, the Bill is accompanied by the commitment to raise NHS funding by £33 billion—the largest cash increase in its 73-year history.
I would hope that, in putting the integrated care systems on a statutory footing, Ministers will give them a strong mandate to conduct and fund research. The pandemic has shown the vital importance of research. Not only did the Oxford University scientists deliver a world-leading vaccine in record time, but their recovery trial established dexamethasone as the first effective treatment for covid, saving thousands of lives.
The report that I co-authored for the Taskforce on Innovation, Growth and Regulatory Reform sets out a blueprint for a new regulatory architecture for clinical trials to replace the EU clinical trials directive. The Bill could be an opportunity to take those reforms forward, along with our ideas on a more modern approach to health data. These plans would improve the chances of discovering better treatments for life-threatening diseases and could unlock huge economic opportunities, capitalising on the abilities of our world-leading scientists and universities.
As many have said, the Bill must be used to improve workforce planning. As demands grow on the NHS, we must continue to expand capacity, and we cannot do that unless we are training and recruiting the people we need. In particular, we must have more GPs so that our constituents can get the care that they need when they want it. GPs are currently under unprecedented demand pressure. I urge the Minister to ensure that the Bill gives GPs a strong voice in the new structures to ensure that local input is given to those new structures.
Supporting the NHS will always be a key part of the work that I do as MP for Chipping Barnet, because I know how important it is to my constituents. Knowing that the NHS is there when we need it is one of the greatest advantages of living in our United Kingdom. The covid emergency has reinforced that a thousand times over, and I take the opportunity to pay tribute to the staff of our NHS and thank them for their courage, dedication and professionalism.
This month we marked the 73rd birthday of the NHS, and instead of celebrating it and giving it the homage that it deserves—the NHS, one of the very best things about our country—the Government have introduced a Bill that looks set to ramp up their long-standing attempts to continue to privatise it. I was proud to add my name to the reasoned amendment in the name of my hon. Friend Zarah Sultana because we do not need private healthcare companies to sit on boards deciding how NHS funding is spent, further outsourcing of contracts without proper scrutiny, transparency and accountability, or the introduction of a model of healthcare that incentivises cuts and the closure of services.
Forcing NHS staff to implement yet another top-down Conservative reorganisation would take people away from the task of tackling growing treatment lists and coping with rapidly rising covid cases. We need to fill our 84,000 vacancies, and we need a 15% pay rise across the board for our NHS staff. It is hard to see how ordering a reorganisation such as this while ignoring calls for increased funding and a plan for social care could be anything other than disastrous.
This corporate takeover Bill—which is exactly what it is—will put private companies at the heart of the NHS and pave the way to sell off our confidential health data to multinational corporations. Nobody wants that. It will normalise the corrupt contracting that we have seen during the pandemic. The money that we spend on our healthcare should go to the services that we need, not to the pockets of Conservative party donors or corporate shareholders. Over the path of the pandemic, we have seen what this outsourcing and privatisation has meant in practice. Contract after contract awarded without competitive process. People being failed. Failing contracts. Delivery failed on again and again. Now the Government want to open up new ways for that to happen, just as they have done throughout the pandemic.
Let us consider what happened with Track and Trace, which was a complete disaster in the hands of Serco. The system has been so ineffective that, recently, MPs concluded that it had ”no clear impact”—a £37 billion system with no clear impact. After a decade of cuts, it was our NHS and its staff and volunteers who led the vaccination roll-out. That was a success, but it was their success, not the Government’s success. That is a lesson that we can learn about exactly what happens when we give the NHS the funding it needs, but the Bill does nothing to do that. We do not need more overpaid consultants involved the NHS; we need to value the staff we already have, and put in the investment that made the vaccination programme a massive success. We must be clear—
I strongly support the Bill. However, although it contains strong measures to combat obesity, there is none to tackle smoking, which is the leading cause of preventable premature death, including cancer. I declare an interest as chairman of the all-party group on smoking and health. The report we proposed suggested that we implement the “polluter pays” levy that the Government promised to consider two years ago. The Bill is the ideal opportunity to introduce such a levy. Analysis by Cancer Research UK shows that we will not achieve the Government’s aim of a smoke-free England until 2035—the Government target is 2030, so years later—in our poorest communities, so there is no time to waste. We must get on with the job.
In the Government’s recent paper on public health, they accepted that they have a responsibility not only to help people improve their own health, but to go further when it comes to industries that are based on addictions such as smoking. The Bill is the ideal opportunity, and I urge the Government to consider the recommendations laid out by the all-party group and table them as amendments in Committee, so that we tackle the most deadly addiction in our society.
We need to combat not only smoking rates but the long-standing, unacceptable health inequalities that exist across the country. The plan needs to be comprehensive, but it will not be effective without sufficient additional and sustainable funding. A smoke-free 2030 fund, using the industry to pay for it, but without industry interference, could pay for the comprehensive measures that we need to reach that ambitious target across all socioeconomic groups.
On the plan to combat obesity, there is a measure that will be harmful to many of our media companies, but it will not hit some of the social media and online companies. That runs the risk of having a two-stage process. Perhaps we could consider having limits at weekends to limit the impact of junk food advertising on TV when our young people are watching.
Overall, however, this is a good Bill. We should support it, and we should support our national health service that has brought it before us today.
I pay tribute to everyone working in health and social care and to unpaid family carers. All of them have gone above and beyond in their caring roles during the pandemic. The Government’s response to that could have been to give NHS staff a proper pay rise, to publish plans to put social care on a sustainable financial footing, or to recognise fully the tremendous contribution made by unpaid carers. Instead we have this Bill, and a top-down reorganisation of the NHS that will concentrate power in the hands of the Secretary of State, offering no guarantees of better outcomes for patients and removing rights from carers.
It is welcome that the Bill brings an end to every NHS contract having to be put out to tender and that some changes in the Bill reference unpaid carers, but further changes are needed. Change is needed to put a duty on the NHS to have regard to carers and to promote their health and wellbeing.
It is welcome that the Bill includes a duty on both NHS England and the integrated care boards to consult carers, but rather than just involve and consult them in relation to patients, the duty that is needed is for the NHS to consider carers in their own right, as proposed by the Health and Social Care Committee in its report.
It is worrying that the Bill undermines carers’ rights in relation to hospital discharge. Clause 78 removes carers’ fundamental rights by removing the need to assess a patient at the point of hospital discharge. The way that is done removes carers’ fundamental right to have an assessment to ensure services are provided to make sure the patient is safe to discharge into their care. This is an issue, as Carers UK quotes research showing that only 26% of carers were consulted about discharge and that a third were consulted only at the last minute.
The Bill proposes to extend the Care Quality Commission’s remit to cover the delivery of social care services. However, that excludes social care provided through NHS continuing healthcare. The Parliamentary and Health Service Ombudsman found last year that people continue to be seriously let down by failings in how continuing healthcare is delivered. I ask the Minister to agree with the Continuing Healthcare Alliance that there should be an additional duty on the CQC to assess integrated care systems’ delivery of their continuing healthcare duties and to hold them to account where these duties are not being met.
The Care Quality Commission will have a remit to rate local authorities’ delivery of social care, but when £9 billion has been taken out of social care budgets and long-term reform is consistently delayed, the Government should recognise that inadequate social care services are a problem of their own making.
Finally, I question the timing of the Bill. Staff are exhausted and are facing another wave of covid infections over the summer. I urge the Secretary of State to recognise that and adjust the timeframes for implementing these reforms so that they do not end up distracting from the NHS’s real job of caring for patients.
I welcome this Bill, and I pay tribute to my NHS managers and social care managers in Cornwall. They have been straining at the bit for a long time to integrate more effectively and more successfully, and the Bill will help them to formalise that integration and do a good job of it.
In the short time I have, I want to talk about the patient’s perspective. We know that diabetes, for example, costs the NHS and social care a colossal amount of money, and we also know that across the UK we have pretty much all the tools, treatment, care, support and devices so that someone with diabetes can manage their condition and live, as much as possible, a full and good life. We also know that, because of the current situation, that care is not joined up and is not universal across the country. I hope the Bill delivers, for diabetes, a joined-up, clear pathway from diagnosis—I welcome the emphasis on prevention, too—through their lifetime, as they manage this lifelong condition. The Bill enables them to get every bit of support and care and every device they need to live full lives, to manage their care and to take an active part in society as a whole.
I am talking about people with diabetes because I chair the all-party parliamentary group on diabetes, which I should have declared, but the Bill also provides a blueprint for all sorts of lifelong conditions that enables people to live their lives successfully in their community.
In today’s debate we have heard from 37 hon. and right hon. Members, as well as Rob Roberts, and another 29 hon. Members registered an interest to speak but were not called. A huge range of topics has been covered, some of which I hope to address briefly. I hope Members will forgive me if I cannot mention each contribution individually.
Many Members have talked about the particular geographic configuration of their ICS, and it is clear that there is lots of unhappiness about that in certain parts of the country. That is hardly surprising, given that has been done without any parliamentary oversight so far. It seems that, under the Bill, Parliament will not even get to approve where the boundaries lie.
There has been no attempt at public consultation or discussion about where these boundaries sit, and that is a theme throughout the Bill. Decisions, money and power move further away from the public and closer to the Secretary of State. He is certainly taking back control but, at the same time, he is silencing the patient voice.
In the Bill, the Secretary of State has a veto on who leads the integrated care systems, and he can stop foundation trusts borrowing money that they desperately need to tackle the £9 billion maintenance backlog. He even has the power to decide whether to instigate the closure of local services.
By contrast, when the 2012 Act was going through Parliament, Lord Lansley, who was then Secretary of State, told the Chamber:
“We want clinicians and their patients to lead the NHS, but they cannot do this while they sit under a vast hierarchy of regional and local organisations, all reporting to Whitehall. Everyone agrees that top-down command and control gets in the way of clinicians doing their job”.—[Official Report,
The Bill supercharges command and control, so it is little wonder that even the British Medical Association has come out against it. It creates a vast web of new organisations, but very few of them will make decisions. It is pretty clear that the integrated care partnerships in particular will be little more than bystanders when it comes to the crunch, and that the boards will have all the power. That is a huge democratic deficit that must not be allowed to go unchallenged. When we hear about companies such as Virgin already having a seat on one of the ICS boards in the south-west we know that the power lies in totally the wrong place. The Bill needs to make it crystal clear that private companies should be a million miles from making decisions about how the NHS is run.
At the same time, the Bill does not legislate for boards to include a representative from a mental health organisation, for example. How will that encourage integration, let alone parity of esteem? There are plenty of others who are not guaranteed a seat at the table but who ought to be in the vanguard of integration: directors of adult social care, directors of public health, carers and, most of all, patients, who seem to have been completely forgotten in all this. How will decisions be made by the boards? Will there be transparency about where the money is spent in those areas which, we should not forget, are much larger than clinical commissioning groups. How can we be sure that the money will go to those parts of the ICS with the most need, and how can that be challenged if it does not?
We have seen the blatant abuse of the levelling-up fund, and party political considerations seep into every decision made by the Government. Will it now be patients who pay the price for that? How will the combined trust deficits of £910 million be met? The danger is that the Bill will force ICSs to close small local services to bail out the bigger trusts.
While we welcome an end to section 75 provision, I wonder exactly how much money has been wasted in convoluted procurement processes and legal challenges. Is it £3 billion, £4 billion or £5 billion? Whatever the final figure, there is no doubt that that money could be better spent on frontline services. While moving away from that monumental mistake is a good thing, it seems as if we are going from one extreme to the other, with the removal of any safeguards at all on who contracts can be awarded to. The Government are legislating for cronyism. I am sure that pub landlords and pest control companies will be delighted, but we cannot give the Secretary of State the blank cheque that the Bill allows.
There is a huge blank sheet of paper where the plan to tackle the workforce crisis ought to be. The Secretary of State will produce a report once every five years, but that is not a serious commitment to the workforce. Indeed, it is not a serious commitment to Parliament either, and the social care workforce is not even mentioned. Let us not forget that we have 122,000 vacancies in that workforce. The Select Committee has set out the kind of people whom we really ought to aim to employ, with annual, independently audited reports that cover the NHS and social care. In the words of the Select Committee:
“The way that the NHS does workforce planning is at best opaque and at worst responsible for the unacceptable pressure on the current workforce which existed even before the pandemic.”
The Bill will only reinforce that position, rather than reverse it.
In the introduction that the Secretary of State gave to the Bill today, it sounded very much as if he thought that it was the panacea that we have all been waiting for, but many more experienced Members could be forgiven for having a sense of déjà vu. Let us remind ourselves of what Lord Lansley told the House about the 2012 reforms:
“Previous changes have tinkered with one piece of the NHS or another, when what was needed was comprehensive modernisation to create an NHS fit for the demands of the 21st century. That is precisely what this Health and Social Care Bill will deliver.”—[Official Report,
The Health and Social Care Bill provided for the constitution and structure of the NHS to work for the long term. How has that worked out? There are record waiting lists and staff vacancies; billions diverted into the private sector away from the NHS; life expectancy has stalled; and A&E targets have been missed five years in a row. The NHS was trying to unpick the last disastrous reorganisation before the ink was even dry on the Royal Assent, so why is this set of reforms going to be any more successful than the last? How is one line of this Bill going to tackle the operation backlog? Is not the truth that without a proper sustained funding settlement to meet the demand in both health and social care, this latest set of reforms is merely another rearrangement of the deckchairs? Why, oh why, is so much time and resource being focused on a wasteful, top-down reorganisation, in the middle of the pandemic? Even the Prime Minister told us on Monday that we are not out of it yet. Only today, planned operations have been cancelled in Newcastle because of a surge in covid cases. Is it not the case that every meeting called, every document written, every minute spent on this top-down reorganisation is less time spent on fighting the increase in covid cases we currently see, bringing down waiting lists, tackling the increase in mental health conditions, solving the workforce crisis and actually delivering the reform to social care that the Prime Minister promised nearly two years ago?
This Bill is the equivalent of someone reorganising the whole interior of their house, spending fortunes on new furniture and decorations, but finding it is all ruined within months because they forgot to put a roof over their head; we cannot fix the NHS if we do not fix social care. We know that, everybody knows that. The Government say they have a plan, but we still do not know what it is. Crucially, for the purposes of today’s debate, we do not know whether it will fit in with what is in this Bill. So are we going to have yet another reorganisation next year because there was no forward thinking? What about learning the lessons from covid? The inquiry is not even going to start until next year, so are we going to see yet another reorganisation when we have learned the lessons from that? The only thing guaranteed from this reorganisation is that another one will surely follow shortly afterwards. So let us reject this Bill, go back to the drawing board and come up with a plan that actually deals with the challenges that we have to face.
Before winding up this important debate, I would like to put on the record, as I always do and as I know the shadow Minister does, our gratitude to all the staff in the NHS, social care and local government, and other key workers, for everything they have done in recent months. This Bill is evolution, not revolution. It supports improvements already under way in our NHS and it builds on the recommendations of the NHS’s own long-term plan, laying the foundations for our recovery from this pandemic. This Bill is backed by not only the NHS, but so many others working across health and care. A joint statement from the NHS Confederation, NHS Providers and the Local Government Association reads:
“we believe that the direction of travel set by the bill is the right one.”
It notes that working in partnership at a local level is “the only way” we can address the challenges of our time. The chief executive of Age UK has said that ICSs are to be embraced and made as effective and inclusive as they can be, and the King’s Fund is calling for us to press ahead. The list goes on; the NHS wants us to press ahead, and in the words of Lord Stevens, “The overwhelming majority of these proposals are changes the health service have asked for.” So it is vital that we in this House do right by them and by patients at this critical juncture. It is the right time for this Bill. We legislate, Opposition Members obfuscate. I remind the shadow Secretary of State of his 2017 manifesto, which stated:
“We will reinstate the powers of the Secretary of State for Health to have overall responsibility for the NHS.”
With this Bill, we put increased accountability for the Secretary of State at the heart of this, yet now the shadow Secretary of State no longer seems to agree with himself and characterises his own proposals as “meddling”. I know that he is dextrous in his politics and in his policy position, which is probably why he has survived under multiple Leaders of the Opposition, but this is stretching it a bit.
We have sought, in getting to this point, to work on a collaborative basis at every stage, and hon. Members can be reassured that we will continue to adopt that approach in the weeks ahead as we proceed with this Bill, when we hope it goes into Committee. My right hon. Friend the Secretary of State set out in his opening remarks his willingness to listen. In particular, he highlighted that in the case of ICS boundaries no decision has yet been made. As he set out, we are determined to embrace innovative potential wherever we find it. That is quite different from many of the accusations we have heard here today. I know it is tempting for some—even when they know better, and they do—to claim that it is the beginning of the end for public provision. It is not and they know it. They know it is scaremongering rather than reality. They know that there has always been an element of private provision in healthcare services in this country, and they should know that because, as the Nuffield Trust said in 2019:
“The…evidence suggests the increase” in private provision
“originally began under Labour governments before 2010”.
The shadow Secretary of State should certainly know that because he was a special adviser in the Treasury and in No. 10 at that time.
With regard to the implementation of the Bill, the NHS itself wants, subject to legislation, to move at pace to implement statutory arrangements for ICSs by April 2022. That is why NHS England is beginning preparatory work, including publishing an ICS design framework. Further work, including on integrated care board design and consideration of appointments and staff from CCGs will take place, after Second Reading, of course; this is all subject to the passage of the Bill.
Let me turn to some of the specific points raised by hon. and right hon. Members. Rachael Maskell asked about “Agenda for Change”. I can reassure her that it is not the intention that ICBs depart from “Agenda for Change”. The Bill’s drafting and wording is in line with existing arrangements for other NHS bodies with regard to “Agenda for Change” and translates it into this context. However, I am always happy to discuss that with her further if she wishes. Her suggestion that this was conceived, as she put it, in a bunker is quite simply not the case. Indeed, all the stakeholders, including the NHS, have said that this is one of the most collaborative pieces of legislation development they have seen.
Turning to the workforce, as my hon. Friend Steve Brine said, we cannot legislate to address workforce challenges but we can and we will look very carefully at the recommendations of the Select Committee and of my right hon. Friend Jeremy Hunt.
While we do not always agree on everything, Munira Wilson made sensible points, although I would slightly tease her that she argued against the principle of the Secretary of State taking powers in reconfiguration and shortly afterwards her hon. Friend, Tim Farron, intervened on him asking him to do exactly that.
In response to Dr Whitford, I am again grateful for her comments and happy to accept her kind invitation to join her on a visit to Scotland.
Mr Jones made a very important point. In doing so, he rightly paid tribute to the work in this space done by my hon. Friend Laura Trott with her recent private Member’s Bill. As the Secretary of State said, either he, I or the relevant Minister will be happy to meet him to discuss it further. My hon. Friend Saqib Bhatti was right to talk about the need for local flexibility. That is what we are seeking to do.
Clive Efford asked more broadly about public spending constraints after 2010. He is brave, perhaps, to mention that. I recall the legacy of the previous Labour Government, which Liam Byrne summed up pretty effectively in saying,
“I’m afraid there is no money.”
On social care, which a number of hon. and right hon. Members mentioned, we will take no lessons from Labour. In 13 years, after two Green Papers, a royal commission and apparently making it a priority at the spending review of 2007, the net result was absolutely nothing—inaction throughout. We are committed to bringing forward proposals this year. Labour talks; we will act.
The NHS is the finest health service in the world. We knew that before the pandemic, and the last year and a half have only reinforced that. It is our collective duty to strengthen our health and care system for our times. I was shocked, although probably not surprised, that the Opposition recklessly and opportunistically intend to oppose the Bill—a Bill, as we have heard, that the NHS has asked for—once again putting political point scoring ahead of NHS and patient needs. For our part, we are determined to support our NHS, as this Bill does, to create an NHS that is fit for the future and to renew the gift left by generations before us and pass it on stronger to future generations. We are the party of the NHS and we are determined to give it what it needs, what it has asked for and what it deserves. I encourage hon. Members to reject the Opposition amendment, and I commend the Bill to the House.
I apologise to the 30 Members who did not get to speak in this important debate, some of whom are currently in the Chamber.
Question put, That the amendment be made.
The House divided: Ayes 218, Noes 359.
Question accordingly negatived.
The list of Members currently certified as eligible for a proxy vote, and of the Members nominated as their proxy, is published at the end of today’s debates.
Question put forthwith (