“(1) The Care Act 2014 is amended as follows.
(2) In section 15 (cap on care costs), for subsections (2) and (3) substitute—
‘(2) The reference to costs accrued in meeting the adult’s eligible needs is a reference—
(a) in so far as a local authority met the eligible needs, to how much of the cost of meeting those needs at the local authority’s rate the adult was required to pay (as reckoned from the amount that was specified in the local authority’s personal budget in respect of those needs (see section 26(2)(b)));
(b) in so far as a local authority did not meet the eligible needs, to what the cost of meeting those needs would have been at the rate of the responsible local authority (as reckoned from the amount that was specified in the personal budget (see section 26(2A)(a)) or the independent personal budget (see section 28(1)) in respect of those needs).
(3) A reference in subsection (2)(b) to eligible needs does not include any eligible needs during a period when the adult had neither a personal budget nor an independent personal budget, other than eligible needs during the period between the making of a request for an independent personal budget and its preparation.
(3B) For the purposes of this Part an adult’s needs are “eligible needs” if—
(a) the needs meet the eligibility criteria,
(b) the needs are not being met by a carer, and
(c) the adult is ordinarily resident or present in the area of a local authority.
(3C) In this Part, “the responsible local authority” means the local authority in whose area the adult is ordinarily resident or in whose area the adult is present (where the adult is of no settled residence).’
(3) In section 24 (the steps for the local authority to take), for subsection (3) substitute—
‘(3) Where no local authority is going to meet any of an adult’s needs for care and support, the local authority that is for the time being the responsible local authority must prepare an independent personal budget for the adult (see section 28) if—
(a) the adult has any eligible needs, and
(b) the adult has at any time asked a local authority that was, at that time, the responsible local authority, to prepare an independent personal budget.’
(4) In section 26 (personal budget), for subsections (1) and (2) substitute—
‘(1) A personal budget is a statement which specifies, in respect of the adult’s needs which a local authority is required or decides to meet as mentioned in section 24(1)—
(a) the cost of meeting those needs at that local authority’s rate,
(b) how much of that cost the adult must pay, on the basis of the financial assessment, and
(c) the amount which that local authority must pay towards that cost (which is the balance of the cost referred to in paragraph (a)).
(2) If the needs referred to in section 26(1) include eligible needs, the personal budget must also specify—
(a) the cost of meeting those eligible needs at that local authority’s rate,
(b) how much of that cost the adult must pay, on the basis of the financial assessment, and
(c) where the amount referred to in paragraph (a) includes daily living costs, the amount attributable to those daily living costs.
(2A) If the adult also has eligible needs which are not being met by any local authority, the personal budget must specify—
(a) what the cost of meeting those eligible needs would be at the responsible local authority’s rate, and
(b) where the amount referred to in paragraph (a) includes daily living costs, the amount attributable to those daily living costs.
(2B) References in this section to the cost of meeting needs at a local authority’s rate are to the cost that the local authority would incur in meeting those needs, assuming for the purposes of this subsection that the adult is not paying any amount in respect of those needs and has not expressed any preference for particular accommodation.’
(5) In section 28 (independent personal budget)—
(a) for subsection (1) substitute—
‘(1) An independent personal budget is a statement which specifies what the cost of meeting the adult’s eligible needs would be at the responsible local authority’s rate (but the independent personal budget need not specify the cost of meeting those needs at any time when the local authority required to prepare it has ceased to be the responsible local authority).’;
(b) after subsection (2) insert—
‘(2A) References in this section to the cost of meeting needs at a local authority’s rate are to the cost the local authority would incur in meeting those needs, assuming for the purposes of this subsection that the adult is not paying any amount in respect of those needs.’;
(c) omit subsection (3).
(6) In section 29 (care account), in subsection (1), in the words before paragraph (a), for the words from ‘the local authority’ to ‘present’ substitute ‘the responsible local authority’.
(7) In section 31 (adults with capacity to request direct payments), in subsection (1)(a), for ‘needs to which the personal budget relates’ substitute ‘adult’s needs which a local authority is required or decides to meet as mentioned in section 24(1) (see section 26(1)(c)).’
(8) In section 32 (adults without capacity to request direct payments), in subsection (1)(a) for ‘needs to which the personal budget relates’ substitute ‘adult’s needs which a local authority is required or decides to meet as mentioned in section 24(1)(see section 26(1)(c)).’
(9) In section 37 (notification, assessment etc.), in subsection (15), omit paragraph (a).
(10) In section 80 (Part 1: interpretation), in the table in subsection (1), at the appropriate places insert—
|‘Eligible needs||Section 15(3B)’|
|‘The responsible local authority||Section 15(3C)’.”—(Edward Argar.)|
This new clause makes amendments to the Care Act 2014 which would mean that the costs that accrue towards the cap on care costs are the costs incurred by an adult (at the local authority rate) rather than the combined costs incurred by both the adult and the local authority.
Brought up, and read the First time.
With this it will be convenient to discuss the following:
New clause 33—Support provided by the NHS to victims of domestic abuse—
“(1) Each Integrated Care Board must—
(a) assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services;
(b) prepare and publish a strategy for the provision of such support in its area;
(c) monitor and evaluate the effectiveness of the strategy;
(d) designate a domestic abuse and sexual violence lead; and
(2) An Integrated Care Board that publishes a strategy under this section must, in carrying out its functions, give effect to the strategy.
(3) Before publishing a strategy under this section, an Integrated Care Board must consult—
(a) any local authority for an area within the relevant Integrated Care Board’s area;
(b) the domestic abuse local partnership board appointed by the local authority for an area within the relevant clinical commissioning group’s area under section 58 of the Domestic Abuse Act 2021; and
(c) such other persons as the relevant local authority considers appropriate.
(4) For the purposes of subsection (4), ‘local authority’ means—
(a) a county council or district council in England; or
(b) a London borough council.
(5) An Integrated Care Board that publishes a strategy under this section—
(a) must keep the strategy under review;
(b) may alter or replace the strategy; and
(c) must publish any altered or replacement strategy.
(6) The Secretary of State may by regulations make provision about the preparation and publication of strategies under this section.
(7) The power to make regulations under subsection (7) may, in particular, be exercised to make provision about—
(a) the procedure to be followed by an Integrated Care Board in preparing a strategy;
(b) matters to which an Integrated Care Board must have regard in preparing a strategy;
(c) how an Integrated Care Board must publish a strategy;
(d) the date by which an Integrated Care Board must first publish a strategy; and
(e) the frequency with which an Integrated Care Board must review its strategy or any effect of the strategy on the provision of other provision in its area.
(8) Before making regulations under this section, the Secretary of State must consult—
(a) all Integrated Care Boards; and
(b) such other persons as the Secretary of State considers appropriate.”
This new clause would require Integrated Care Boards to publish a strategy for the provision of support for victims of domestic abuse using their services and designate a domestic abuse and sexual violence lead.
New clause 55—Guidance for babies, children and young people—
“(1) The Secretary of State must publish guidance on how integrated care systems should meet the needs of babies, children and young people aged 0-25.
(2) Integrated care systems must act in accordance with the guidance in subsection (1).”
This new clause would require the Secretary of State to publish guidance on how integrated care systems should meet the needs of babies, children and young people aged 0-25 and would require integrated care systems to act in accordance with the guidance.
New clause 57—NHS England’s duty as to reducing inequalities—
“Section 13G of the National Health Service Act (duty as to reducing inequalities), is amended by the addition of the following subsections—
‘(2) NHS England must publish guidance about the collection, analysis, reporting and publication of performance data by relevant NHS bodies with respect to factors or indicators relevant to health inequalities.
(3) Relevant NHS bodies must have regard to guidance published by NHS England under this section.
(4) In this section “relevant NHS bodies” means—
(a) NHS England,
(b) integrated care boards,
(c) integrated care partnerships established under section 116ZA of the Local Government and Public Involvement in Health Act 2007,
(d) NHS trusts established under section 25, and
(e) NHS foundation trusts.’”
Amendment 47, in clause 6, page 4, line 11, at end insert—
“(5) In paragraph 1(a) ‘relevant public body’ means a public authority listed under the title ‘Health, social care and social security’ in Part 1 of Schedule 19 to the Equality Act 2010 or an NHS Trust.”
This amendment provides that NHS England resources for supporting or assisting organisations that are providing or planning to provide health services may only be directed to public sector bodies.
Amendment 58, in clause 12, page 8, line 6, at end insert—
“(2) An integrated care board may not—
(a) delegate that function; and
(b) exercise that function to enter into an integrated care provider contract with any body other than a statutory NHS body.
(3) In paragraph (2)(b) an ‘integrated care provider contract’ has the same meaning as in Schedule 3A of the National Health Service (General Medical Services Contracts) Regulations 2015.”
This amendment is designed to ensure that an organisation carrying out the functions of an ICB on its behalf is a statutory NHS body.
Amendment 59, page 12, line 29 at end insert—
“(3A) Nothing in——
(a) the rules referred to in subsection (1),
(b) this Act, or
(c) any regulations made under this Act
(none) shall entitle any provider of health services to withhold provision of those services from any individual on the basis of the integrated care board to which that individual has been allocated.”
This amendment is to ensure that any providers of health services cannot withhold provision of those services from any individual because of the integrated care board that they have been allocated to.
Amendment 66, in clause 15, page 13, line 44, at end insert—
“(j) palliative care services.”
This amendment adds a requirement for the commissioning of palliative and end of life care services.
Amendment 21, page 14, line 43, at end insert—
“3AA Duty of integrated care boards to commission approved treatments
‘(1) This section applies where—
(a) a treatment has been approved by the National Institute for Health and Care Excellence, and
(b) an integrated care board has not arranged for the provision of that treatment under section 3 or 3A of this Act, and
(c) a clinician has recommended that treatment for a person for whom that integrated care board has responsibility.
(2) The integrated care board referred to in subsection (1) must arrange for the provision of that treatment to the person for whom it has responsibility.
(3) In subsection (1) “clinician” means a medical professional employed by or acting on behalf of an NHS Trust, NHS Foundation Trust or primary care service from whom the integrated care board has arranged for the provision of services.’”
This amendment would require an integrated care board to arrange for the provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area.
Amendment 48, in clause 19, page 16, line 6, leave out “promotes” and insert
“secures the rights set out in”.
This amendment requires ICBs to act to ensure that health services are provided in a way which secures the rights set out in the NHS Constitution.
Amendment 99, page 16, line 34, at end insert—
“(2) In fulfilling their duties under this section, integrated care boards must have particular regard to the need to reduce inequalities between migrant and non-migrant users of health services.”
Amendment 49, page 16, line 37, leave out “promote” and insert “enable”.
This amendment, together with Amendment 50 provides that ICBs enable the involvement of patients, their paid and unpaid carers, and their representatives in decisions relating to the prevention or diagnosis of illness, care or treatment, rather than promoting their involvement.
Amendment 50, page 16, line 37, after “their”, insert “paid and unpaid”.
This amendment, together with the Amendment 49, provides that ICBs enable the involvement of patients, their paid and unpaid carers, and their representatives in decisions relating to the prevention or diagnosis of illness, care or treatment.
Amendment 22, page 17, line 4, at end insert—
“14Z37A Obligation on integrated care boards to ensure appropriate uptake of all NICE approved products according to population need
‘(1) Each integrated care board must promote uptake of all NICE approved medicines and medical devices in accordance with the need of the population it serves.
(2) An integrated care board must, in each financial year, prepare a report on the uptake of all NICE approved medicines and medical devices, including the number of patients that have accessed each product.’”
This amendment would require ICBs to ensure that all NICE approvals are available and promoted to their population, and report on this uptake annually.
Amendment 19, page 17, line 14, at end insert—
“14Z39A Duty to review latest innovations with a view to local commissioning
(1) Integrated care boards must review all new—
(b) medical devices, and
(c) other health care solutions that may benefit the local population.
(2) Integrated care boards must—
(d) appoint a dedicated innovation officer to their board, and
(e) develop and maintain a system to keep up to date with medicines and devices innovation and review suitability for patient usage, including engagement with the relevant—
(i) academic health science network, and
(ii) local pharmaceutical committee.”
This amendment would mandate integrated care boards to monitor and assess innovation for the benefit of the local population.
Amendment 16, page 17, line 19, at end insert—
“(2) Each integrated care board must each year prepare, consult on and adopt a research strategy for patient benefit which—
(a) meets local need;
(b) meets national research undertakings.
(3) In developing a strategy under subsection (2), an integrated care board must engage with—
(b) academic health science networks, and
(c) all other relevant regional and national health research organisations.”
This amendment would require ICBs to establish a research strategy and other connected measures.
Amendment 91, page 18, line 18, after first “the” insert “physical and mental”.
This amendment will require Integrated Care Boards to prioritise both the physical and mental health and well-being of the people of England and to work towards the prevention, diagnosis or treatment of both physical and mental illness replicating the parity of esteem duty as introduced in the Health and Social Care Act 2012.
Amendment 92, page 18, line 23, after first “of” insert “physical and mental”.
This amendment will require Integrated Care Boards to prioritise both the physical and mental health and well-being of the people of England and to work towards the prevention, diagnosis or treatment of both physical and mental illness replicating the parity of esteem duty as introduced in the Health and Social Care Act 2012.
Amendment 68, page 18, line 26, at end insert—
“(d) health inequalities.”
This amendment would modify the triple aim to explicitly require integrated care boards to take account of health inequalities when making decisions.
Amendment 17, page 18, line 38, at end insert—
“14Z43A Duty on integrated care boards to consider requests to engage in clinical trials, and patient participation
(1) An integrated care board must consider any request from the organiser of an authorised clinical trial for the ICB to engage in that trial.
(2) If such a request is accepted, the integrated care board must offer the ability to participate in the trial to any patient within their area who is eligible to take part.”
This amendment would require integrated care boards to consider any requests to engage in clinical trials and offer patients the opportunity to participate.
Amendment 20, page 18, line 38, at end insert—
“14Z43A Duty to update formularies to include all NICE-approved products
(1) Within 28 days of any medicine or device receiving market authorisation from NICE, an integrated care board must update its formulary to include that medicine or device.
(2) On receipt of notice of the market authorisation by NICE of any medicine or device, an integrated care board must immediately instruct providers of health and care services commissioned by the board to update their formularies in such a way that all NICE-approved medicines and devices are available to patients on the recommendation of a healthcare practitioner within 28 days of market authorisation.
(3) An integrated care board must report annually all medicines and devices that have been added and removed from their formulary over the previous year.”
This amendment would mandate integrated care boards and healthcare providers (e.g. hospital trusts) to update their formularies to include all NICE-approved medicines or devices within 28 days of market authorisation to ensure they are available for healthcare practitioners (e.g. physician or prescribing pharmacist) to make available for suitable patients.
Amendment 102, page 21, line 25, at end insert—
“(c) set out any steps that the integrated care board proposes to take to address the particular needs of victims of abuse (including domestic abuse and sexual abuse, whether of children or adults).”
This amendment requires the joint forward plan for an integrated care board and its partners to set out any steps it proposes to take to address the particular needs of victims of abuse (including domestic abuse and sexual abuse, whether of children or adults).
Amendment 51, page 22, line 23, leave out
“in a way that they consider to be significant.”
This amendment requires ICBs and partner NHS Trusts and NHS Foundation Trusts to consult on all revisions to their forward plans.
Amendment 52, page 23, line 42, at end add “on its website”.
This amendment is to require capital resource use plans to be made publicly available on the internet.
Amendment 53, page 24, line 22, leave out
“in a way that they consider to be significant”.
The purpose of this amendment is to require all revisions of capital resource use plans to be published.
Amendment 18, page 25, line 6, at end insert—
“(d) explain what research activity it undertook during the year, including
(i) research to meet local health issues, and
(ii) research to support national research projects.
‘(2A) The annual report prepared by the Secretary of State under section 247D of this Act must include a section which reproduces, and comments on, the sections of the annual reports of each integrated care board prepared under paragraph (1)(d).’”
This amendment would require integrated care boards to publish an account of their research activity, and require the report the Secretary of State must prepare and lay before Parliament under section 247D of the National Health Service Act 2006 to include a section which reproduces, and comments on, the research activity of all ICBs.
Amendment 23, page 25, line 14, at end insert—
“14Z56A Report on assessing and meeting parity of physical and mental health outcomes
(1) An integrated care board must annually set out in a report the steps it has taken to fulfil its obligations to deliver parity of esteem between physical and mental health to its local population.
‘(1) The report must set out—
(a) the number of patients presenting with mental health conditions,
(b) the number of patients presenting with physical health conditions,
(c) the number of mental health patients waiting for initial assessment,
(d) the number of physical health patients waiting for initial assessment,
(e) the number of mental health patients waiting for treatment,
(f) the number of physical health patients waiting for treatment,
(g) the number of mental health patients receiving treatment,
(h) the number of physical health patients receiving treatment,
(i) the number of patients readmitted to mental healthcare settings, and
(j) the number of patients readmitted to physical healthcare settings.
(2) The report must set out performance against nationally set standards in both physical and mental health.
(3) Each year the Secretary of State must lay before Parliament a consolidated report of all the reports made by integrated care boards under this section, and make a statement to each House of Parliament on the report.’”
This amendment would require an ICB to report on assessing and meeting parity of physical and mental health outcomes.
Amendment 15, in clause 20, page 29, line 20, at end insert—
“(2A) The Secretary of State may by regulations make provision about representation of particular health, social care, and local interests, clinical fields, and types of health or care provision in the membership of integrated care partnerships.”
This amendment would enable the Secretary of State to make provision about the membership of integrated care partnerships.
Amendment 100, page 29, line 22, at end insert—
“(4) A member of the Integrated Care Partnership may not work for, be the representative of or hold financial interest in any private company delivering or seeking to deliver health and care services or services supporting the health and care sector or producing or seeking to produce health and care products, with the exception of general practitioners.”
This amendment seeks to ensure that Integrated Care Partnerships are made up wholly of representatives from public sector organisations and that private companies are not represented on them.
Amendment 1, page 29, line 45, at end insert—
“(c) fully integrate the promotion of everyday wellbeing, self-care for minor ailments and the management of long-term conditions into local health systems.”
This amendment would ensure that everyday wellbeing, self-care for minor ailment and management of long term conditions are integrated and promoted into local health systems.
Amendment 2, page 30, line 3, after “services” insert
“including services provided by pharmacists for minor ailments”.
This amendment would ensure that integrated care partnerships include in a strategy its views on how health-related services, including provision for self-treatable conditions, are integrated into health and social care services in that area.
Amendment 69, in clause 23, page 35, line 32, at end insert—
“(5) NHS England must publish guidance on the means by which an integrated care board, NHS trust or NHS foundation trust which believes its capital resource limit or revenue resource limit risks compromising patient safety may object to the limit set.”
Amendment 114, in clause 25, page 37, line 27, at end insert—
“(2A) The priorities set by the Secretary of State under subsection (2)(a) must include priorities relating to leadership, the integration of services and the quality and safety of services.”
The Secretary of State has the function of setting priorities for the Care Quality Commission in carrying out assessments in relation to integrated care systems. This amendment requires the Secretary of State to set priorities relating to certain matters.
Amendment 61, in clause 64, page 59, line 27, leave out from beginning to end of line 28.
This amendment is to ensure that a commissioner cannot also be a provider.
Amendment 62, in clause 69, page 63, line 30, leave out “may” and insert “must”.
This amendment makes it a requirement that regulations make provision in relation to the procurement by relevant authorities of (a) health care services for the purposes of the health service in England, and (b) other goods or services that are procured together with those health care services.
Amendment 63, page 63, line 36, leave out “may” and insert “must”.
This amendment makes it a requirement that regulations make provision in relation to (a) general objectives of procurement, and (b) procurement processes.
Amendment 64, page 63, line 39, leave out “may” and insert “must”.
This amendment along with Amendment 65 makes it a requirement that regulations make provision for the purposes of (a) ensuring transparency and fairness in relation to procurement, and (b) ensuring that compliance can be verified, or managing conflicts of interest.
Amendment 65, page 63, line 41, leave out “or” and insert “and”.
This amendment is to make it a requirement for regulations to make provision to ensure both transparency and fairness in relation to procurement.
Amendment 9, page 64, line 1, at end insert—
“(3A) The regulations must provide that—
(a) there is a presumption—
(i) in favour of contracts being awarded to NHS trusts and NHS foundation trusts, and
(ii) that integrated care provider contracts will not be awarded to a body other than to an NHS trust or an NHS foundation trust, except for under the provisions of paragraph (b);
(b) if an NHS trust or an NHS foundation trust does not consider that it is able, or does not wish, to provide certain services under a contract, it must publish its reasons;
(c) if paragraph (b) applies, the integrated care board must consult the public if it proposes to award any contract for those services to any body other than an NHS trust or NHS foundation trust;
(d) a consultation under paragraph (c) must—
(i) set out the responses of the integrated care provider to the reasons given by the NHS trust or NHS foundation trust under paragraph (b),
(ii) specify the proposed parties to and the full terms and conditions of the proposed contract, and
(iii) specify that the terms and conditions for staff under the proposed contract must be at least equivalent to NHS terms and conditions.”
This amendment would make NHS trusts and foundation trusts the default providers of NHS services.
Amendment 72, page 64, line 1, at end insert—
“(3A) The regulations must make provision in relation to the procurement of the services referred to in paragraph (1)(a) (other than primary medical services, primary dental services and primary ophthalmology services) that before any contract for a service with an annual value in excess of £5m may be awarded to an organisation that is not an NHS trust or NHS foundation trust—
(a) the business case for the award of the contract must be published;
(b) any responses to the proposal in the business case must be considered and published;
(c) the process for awarding the contract must be open and transparent and non-discriminatory at every stage, including (but not limited to)—
(i) procurement strategy and plan,
(ii) invitation to tender,
(iii) responses to invitations,
(iv) evaluation of tenders,
(v) decision to award, and
(vi) contract awarded;
(d) the process for awarding the contract must demonstrate due regard to the principles established in the Public Contracts Regulations 2015 (S.I.2015/102) or any regulations which may supersede them;
(e) in any case where it is claimed that an emergency justifies an award without the process being used then the responsible body must within 14 days publish the business case for the award of the contract and the record of the decision.”
Amendment 101, in schedule 2, page 125, line 26, at end insert—
“(3) Members of an Integrated Care Board may not work for, be the representative of or hold financial interest in any private company delivering or seeking to deliver health and care services or services supporting the health and care sector or producing or seeking to produce health and care products, with the exception of general practitioners.”
This amendment seeks to ensure that ICBs are made up wholly of representatives from public sector organisations and that private companies, their employees and representatives, and those with financial interests in them, are not represented on ICBs.
Government amendments 25 to 28.
Amendment 76, page 126, line 26, at end insert—
“(d) at least one member nominated by the mental health trust or trusts that provide mental health services within the integrated care board’s area;
(e) at least one member nominated by the Directors of Public Health that serve each local authority within the integrated care board’s area;
(f) at least one member nominated jointly by any NHS trust, NHS foundation trust and local authority that provides social care services within the integrated care board’s area;
(g) at least one member nominated by the trade unions representing the health and social care workforce that serves the integrated care board’s area;
(h) at least one member appointed to represent the voice of patients and carers in the integrated care board’s area.”
Amendment 77, page 126, line 26, at end insert—
“(2A) The constitution must prohibit representatives of GP practices with active Alternative Provider Medical Services contracts from becoming members.”
This amendment would mean that the only GPs able to participate in Integrated Care Boards would be those whose practices are on the standard General Medical Services (GMS) contract.
Amendment 78, page 126, line 26, at end insert—
“(2A) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to NHS decision-making boards, integrated care boards, or any place-based committee or sub-committee of the boards.”
Amendment 81, in schedule 2, page 130, line 14, at end insert—
“(7) An integrated care board may enter into an externally financed development agreement in respect of any Local Improvement Finance Trust relevant to the area for which it has responsibility and receive the income related to that agreement.
(8) An integrated care board may enter into an externally financed development agreement in respect of any proposed Local Improvement Finance Trust relevant to the area for which it has responsibility.”
This amendment would enable integrated care boards to participate in existing and future LIFT schemes and to receive the income that would come to the local area from the local investment in such schemes.
Amendment 79, in schedule 3, page 132, line 28, leave out “person” and insert
“general practitioner, GP partnership or social enterprise providing primary medical services”.
This amendment would prevent an integrated care board from entering into or renewing any Alternative Provider Medical Services (APMS) contract.
Amendment 80, page 132, line 32, leave out “person” and insert
“general practitioner, GP partnership or social enterprise providing primary medical services”.
This amendment would prevent NHS England from entering into or renewing any Alternative Provider Medical Services (APMS) contract.
Government amendments 29 and 30.
New clause 49 has attracted a slightly fuller House than my previous speech did. This additional clause relates to the cap on care costs for charging purposes.
Underpinning the reforms set out in the plan is an additional £5.4 billion over the next three years. That funding will end wholly unpredictable care costs and include at least £500 million to support the adult social care workforce. The reforms will make a real difference to the frontline of adult social care, including care users and the dedicated care workforce who have performed heroics throughout the pandemic. A crucial element of the reforms in the plan are the proposals to reform the existing social care charging rules.
I am grateful to the Minister for giving way so early in his speech. I am glad to hear him assert that no one will lose out and most people will win. Will he publish an impact assessment that will allow us to look at the detailed figures? As he will be aware, there is much commentary about the distribution of the possible losses, which seems to me to be an extremely important and sensitive issue for the Government to address.
My right hon. Friend has long taken a close interest in this issue. In a moment, I will come to some of the figures and changes; I hear what he says about giving the House and the other place the information that they need and the aim is to do exactly that.
Currently, one in seven adults over 65 faces care costs of more than £100,000 over their lifetime. We are capping the amount that anyone will be forced to spend on personal care costs in their lifetime at £86,000. That is a seismic and historic change in the way we pay for care in England.
The Government deserve credit for grasping this nettle, which has evaded Governments of both parties for too long, but he must understand that there is a real cause on the Government Benches in respect of the distribution of the relative losses and the worry that those who are less well off will be hit hardest by the Government’s new clause. Will he address that issue?
I understand where my hon. Friend and Members from both sides of the House are coming from. This is the first major step forward in the reform of social care that we have seen in decades and must be seen as part of an overall package of changes.
I would like to make a little progress, if I may.
The reforms will make the existing means test far more generous. We are increasing the upper capital limit from £23,250 to £100,000, which will make masses of people with moderate assets eligible for some state support towards the cost of care earlier, and the lower capital limit will also increase, from £14,250 to £20,000. Below that level, people will contribute only from their income, fully protecting their savings and assets below £20,000.
Over recent days, people have compared our policy proposals to previous, abandoned and never-enacted proposals for reform. I am clear that our proposals will deliver the changes needed where others have failed and see a significant improvement on the system that is in place today.
I am grateful to the Minister. Will he confirm that the amount of tax that is going to be raised in the immediate future, in national insurance and then in a separate tax, will make up a relatively small minority of the total costs of public social care? Will he also confirm that none of these measures addresses the issue of the hotel costs that people need to pay when they go into care homes?
My right hon. Friend is right to highlight that this is talking about personal care costs, so he is right in his point on that.
Did I see Catherine West rise earlier?
While the hon. Lady and I do not always agree on everything, she asks a perfectly a reasoned and measured question. I pay tribute to Andrew Dilnot’s work on his report. I just happen to think that, on this point, we diverged from what he proposed and we believe that what we are proposing is the right way forward. We have always intended for the cap to apply to what people personally contribute, rather than on the combination of their personal contribution and that of the state. It will mean that people with fewer chargeable assets meter towards the cap more slowly, because they are paying much less each week than people who are entirely self-funding. This amendment will make it simpler to understand the amount that will go towards the cap and make it fairer.
On the point the Minister is making about the Dilnot proposals and a comparison, let me tell him that the Alzheimer’s Society said that 15% of people with dementia in the north-west would reach the cap under the Government’s proposals, compared with 34% under Dilnot’s proposals. That is a massive amount, and those are the people, with their families, who are paying hundreds of thousands and pounds. That is the comparison.
To reiterate, as my right hon. Friend, the Prime Minister, said on
Is not the right way to think about this change to consider the proposal in front of us and compare it with the current system? The reason that the Dilnot system, as previously proposed, was never put in place was that there was never a proposal to pay for it, whereas this package is paid for. That is why this Government have been able to deliver a package where no previous Government have been able to do so.
I am grateful to the former Secretary of State. He is absolutely right. We deal in the reality and we should compare the reality of the system that we have in place now with what we have proposed here, which not only moves us forward, but is funded and sustainable.
Can my hon. Friend help me on two short matters? Can he give us an assurance that there will be no adverse impact on local government financing in relation to this, and that he will talk to the Local Government Association, if necessary, in this regard? Secondly, he says that it is part of a package. My right hon. Friend Damian Green referred to the impact assessment. Does he agree that it is only fair that, at the very least, we have an impact assessment before the Bill completes its passage through both Houses?
Yes, of course, as we move through this reform process, it is absolutely right and vital that we work with our partners in the Local Government Association and local authorities of all political complexions. In respect of the impact assessment, I do believe that it is important that we have an impact assessment before this legislation completes its passage through both Houses.
I am extremely grateful to the Minister. He is showing his typical courtesy in giving way. Many across the House are puzzled because we recall this document that the Government placed before the House when they asked the House to endorse the national insurance increase. Indeed, many Members did endorse that national insurance increase, even though they were breaking a manifesto commitment. This document actually says that it will introduce a care cap and
“deliver a core recommendation of the independent Dilnot Commission. It will be implemented using legislation already in place under the 2014 Care Act, which introduces the independent Dilnot Commission’s social care charging reform.”
It goes on to describe that as the “new cap”. Why have the Government moved away from the position of just a few months ago that they published ahead of a vote on increasing national insurance and moved to a policy now that disproportionately benefits those with greater assets, which surely cannot be fair?
I am grateful to the shadow Secretary of State who, while I do not necessarily agree with what he says, as ever puts it courteously. We hold true to what we put in that “Build Back Better” document. It is necessary for this one particular element to see further primary legislation, hence the amendment today.
Forgive me, but no.
To reiterate, as my right hon. Friend the Prime Minister said on
I want to make a little more progress. I will not give way to one of my hon. Friends or to the hon. Lady at this moment.
This will be done by amending the provisions to clearly describe the information that must be included in a personal budget so that individual contributions count towards the cap at the local authority determined rate, and to ensure that personal budgets and independent personal budgets work as they were originally intended when being used in conjunction with the cap.
Before turning to integrated care boards, let me put it on record that, once again, this must be regarded as part of a package of measures that improves significantly on the current provision in place for those funding care.
I am extremely grateful to my hon. Friend for giving way. Before we leave the subject of the cap, can he just confirm that this proposal includes the costs of domiciliary care, which had not been included under the original Dilnot proposals that are exercising Labour Members?
My right hon. Friend is exactly right. I am grateful to him for giving me an opportunity to highlight that this improves in this respect on the Dilnot proposals. I put on record my tribute to Andrew Dilnot for his work, but we believe that this is a better package, and, as he highlighted, a sustainable package from a financial perspective.
The hon. Lady implores me, saying that after six weeks of having to sit opposite me in Committee, the least I can do is allow her to intervene.
Several times in that Committee, I offered to help the Government in a cross-party way. The Minister has been dealt a bad blow here tonight, having to come here and defend this proposal. In those six weeks—I think 21 sessions—not one iota of this proposal was mentioned or brought forward. We all know about bad legislation, rushed legislation, and legislation that does not have the commitment on something so important. I have commended the Government for starting this conversation, but this is a poor legislation move. I am sure that Members here would support the Minister tonight if he were to withdraw this proposal, go back to the Chancellor and ask him to think again. We would all be behind him if he took that opportunity.
I did wonder whether I would regret that intervention. It was typically courteous, although I have to say that when a Member of the Opposition says that, “We’re here to help you”, I am not always sure. [Interruption.] Of course, when the hon. Lady does it, I know that she is sincere about it. The point I make is that this important change is necessary to deliver on the pledge we have made. It is being introduced on Report. While ICBs and integrated care systems, which we will speak about shortly, are hugely important, I suspect that this matter will dominate the debate in this group on Report. Equally, I suspect that it will be fully debated and scrutinised in the other place.
Does the Minister agree that we have been on a journey? The context of this needs to be considered. We are starting a conversation, but other things will come. There will be bumps in the road, but the context that we need to consider is that this is the first Government to tackle the issue of social care in decades. That is the right way to look at this piece of legislation. It should not be looked at in a short-term way.
I am grateful to my hon. Friend, a member of the Health and Social Care Committee, for his intervention. He makes the point well that this is another step on the journey, but it is a journey that only this Government have actually got round to starting. Previous Governments have failed to make that progress. The previous Labour Government produced two Green Papers, one Royal Commission, and one spending review and nothing was done, so this Government are making significant progress.
I have already given way to the hon. Lady, so I will not do so again.
I thank the hon. Member for Bristol South for her words, but the situation is not as she characterises it with my having been dealt a difficult or challenging hand this evening. I am proud to stand here and defend this Government as the first Government to make changes to tackle the social care challenges that this country faces.
I have given way a number of times and I want to make some progress. I will be winding up the debate, so hon. Members will have the opportunity to come back in then.
Let me turn to integrated care boards and integrated care partnerships. I remind the House of what my right hon. Friend the Secretary of State said on Second Reading. These bodies are critical for delivering the key aims of the legislation: reducing bureaucracy; supporting integration and collaboration; and improving accountability. At the heart of the legislation for these bodies is flexibility—giving systems the scope to shape structures according to their needs. This principle is widely supported across the NHS and local government, and we would not want to imperil that, which is why we will be resisting attempts this evening to constrain more tightly how ICBs and ICPs operate. However, we recognise that there are a number of points of clarification that would be helpful to include, and we have tabled a number of amendments to do just that.
Before we reach the meat of this section, there are a number of minor amendments to deal with. First, minor and technical Government amendment 29 will update a reference in the Health and Social Care (Community Health and Standards) Act 2003 to reflect the changes made to section 99 of the National Health Service Act 2006. Secondly, Government amendment 30 will designate integrated care boards as operators of essential services under the Network and Information Systems Regulations 2018. This will place requirements on ICBs to protect their network and information systems by managing risks to ensure service availability and prevent patient harm.
We expect ICBs to take decisions on IT investment, including on cyber-security, and owning systems—and the associated cyber-risk—that are critical to the provision of healthcare. This includes holding the shared care record. The loss or corruption of data from the shared care record could have clear implications for the delivery of care, and for wider public trust in the digitisation and data-sharing agenda. We must take this risk seriously, and assure ourselves that ICBs are doing so as well.
May I take the Minister back to new clause 49, very briefly? He is right to point out that some measures that he has brought forward are more generous than previously proposed, but there is no doubt that the way that the cap works means that it is less generous for those with more modest assets. Does he not agree? How can that be fair?
I simply take my hon. Friend back to my previous point: when compared to the current system, this is a significant improvement and step forward, particularly when taken in the round with the overall package of measures that see the floors go from £23,250 up to £100,000 and from £14,250 up to £20,000. We have to look at this issue in the round, considering all those aspects rather than purely one element alone.
I would like to move on to ICBs and ICSs, but I suspect that, assuming there is time, my right hon. Friend, who chairs the Treasury Committee, may have the opportunity to intervene during my winding up, or to give a speech during the course of the debate.
Currently, the NIS regulations cover NHS providers in England, rather than commissioners. Government amendment 30 allows us to mitigate cyber-risk in a wider sense, making cyber-security a responsibility for organisations that have duties across the system, and to drive forward a shared and collaborative effort towards reducing the risk to patients. I hope that Government amendments 29 and 30 will be uncontentious and supported on both sides of the House.
Is the Minister absolutely sure about what he said in response to Kevin Hollinrake—that everybody would be better off under new clause 49 than they are now? Is it not the case, as illustrated by the Health Foundation, that people with very modest homes, worth less than £106,000, will never hit the cap and therefore will not be better off under the Government’s proposed system than they are now?
I make the point to the hon. Lady that I made in my opening remarks; I said that no one would be worse off and the majority would be better off. That is the point that I make to her: people would not be worse off. If she looks at Hansard, she will see that those were my original remarks when I opened this debate.
Let me turn to the amendments that the Government are introducing on the membership of integrated care boards. Government amendments 26 to 28 are minor and technical, and simply make it clear that the constitution of an ICB may provide for more than one member to be nominated by NHS trusts and NHS foundation trusts, primary medical service providers or local authorities. The proposed legislation sets out the minimum membership of the integrated care board, which needs to include members nominated by those bodies. However, local areas can go beyond the legislative minimum requirements in order to address their local needs. We want to make it clear that that includes being able to nominate more than one member from those sectors to sit on the board, if that is what is best for the local system.
On ICBs, but not on new clause 49. We have moved on and I need to make some progress, because I know that many Members want to speak.
Local authorities will have a seat on ICBs and on ICPs. The approach set out in the legislation is appropriate. We have sought throughout for it to be permissive, not prescriptive, and that remains the right approach.
May I make a little bit of progress? Depending on time, I may then give way to my right hon. Friend. I am conscious that hon. and right hon. Members want to speak—I suspect, primarily on new clause 49.
I turn to Government amendment 25. In doing so, I thank Justin Madders, whose birthday it is today—I wish him a happy birthday; I am sure that he can think of nothing that he would prefer to be doing—and Alex Norris for their discussions about this issue. I do not know what view they have reached, but I am grateful for the helpful spirit in which they approached those conversations.
Although service provision—I emphasise the word “provision”—by the independent and voluntary sectors has been an important and valuable feature of the system under successive Governments, it was never the intention for independent providers to sit on integrated care boards and it still is not. We were clear that the conflict of interests provisions addressed the issue, despite misleading and inaccurate claims by some campaigners. However, we are happy to put the matter even further beyond doubt.
Government amendment 25 makes it clear that no one may be appointed to an ICB who would undermine the independence of the NHS, either as a result of their interests in the private healthcare sector or otherwise. We expect this to prevent, for example, directors of private healthcare companies, significant stakeholders of private healthcare companies and lobbyists from sitting on the board of an ICB. It would also prevent anyone with an obvious ideological interest that clearly runs counter to the NHS’s independence from sitting on a board of an ICB.
Will the Minister give us a brief comment on the recruitment of chief executives and senior management to the boards? Will we be using people who already have senior NHS jobs, meaning that there will be no redundancy and transfer costs, or will there be quite a redundancy bill because we want to change personnel?
I think my right hon. Friend is talking about executive posts. Yes, there will be processes in place to ensure that employment rights are respected. There will be some roles that are completely new and there will be a competition, but I would expect that those with a significant track record and experience would therefore find themselves in a strong position. I will not prejudge any of those individual decisions.
I am not a right hon. Member, but I am very happy to take the promotion.
I have tabled a number of technical, totemic amendments on parity of esteem that appear on today’s amendment paper and tomorrow’s. They propose taking general references to “health” in the Bill and changing them to “physical and mental health”. I hope that the Minister will receive those amendments with his usual generosity and make the necessary changes over the next two days.
I take my hon. Friend’s amendments in the spirit in which they are of course intended. I recognise the importance and value that those on both sides of this House put on parity of esteem of mental and physical health. I suspect that we may debate the amendments in subsequent groupings and I look forward to responding then.
We have, in the process of drafting this amendment, heard suggestions that we should simply ban private company employees completely from the boards of ICBs. I am afraid that doing so is not so simple, nor would it achieve the desired result in all cases. In fact, our amendment goes further to underline the importance of NHS independence than would an amendment that focused purely on banning employees of private providers. There are clearly some candidates who would be suitable but may have minor interests in private healthcare. GPs, for example, do provide, and have provided, their excellent knowledge and experience of their patients in guiding commissioning decisions, and some may have private practices as well. Excluding them would be to lose their experience from the NHS, and therefore such an involvement with the private sector would clearly not risk undermining the independence of the NHS.
I draw the House’s attention to my declaration in the Register of Members’ Financial Interests as a practising NHS doctor. A number of GPs have, in recent times, sought to group together into confederations of practices, which could create a bloc interest within a local board area. How will that potential conflict of interest in the commissioning and provision of services be addressed by the Government through legislation?
I am grateful to my hon. Friend, who knows of what he speaks in terms of the operation of healthcare services. We would not wish to exclude GPs or groups of GPs from being able to participate in decision making. That expertise, as we have seen with clinical commissioning groups, can be hugely valuable. What we have sought to do, in an amendment that is technically worded, for want of a better way of putting it, is to strike the right balance while also ensuring that the additional measures on the constitutions of the ICBs and ICPs have to be approved by NHS England to avoid any obvious conflict of interest. But we are not seeking to avoid GPs being able to operate in that space and sitting on ICBs.
I would like to make a little progress and then I will give way to the hon. Gentleman, who has been bobbing for some time.
We believe—this may not answer the hon. Gentleman’s point, but I will make a little progress and then if there is time—[Interruption.] Well, we will see. Hope springs eternal. A blanket ban on employees of private companies would also, we fear, be arbitrary. It would not cover the full range of people involved in non-NHS providers, some of whom may not be suitable candidates to sit on ICBs because of their involvement, but not employment, within the private healthcare sector. With the complex corporate structures that providers may have established, a narrow definition in the Bill could be unhelpful and risk not capturing the people we wish to capture.
I support what my hon. Friend is saying. It would be crazy to exclude primary care because it is effectively a private healthcare business, and therefore what he is saying is enormously important. In support of my hon. Friend Sir Charles Walker, I believe it would be absolutely wrong, looking at my own county, if the mental health trust did not have a presence in the governorship of the ICB. I hope that the Minister will ensure a presence not only for the conventional trusts in hospitals and in primary care but for the mental health trusts, because their role is vital and the integration of services is essential to the delivery of good mental health care.
My right hon. Friend makes a point that came out in some of the oral evidence sessions on the Bill. Our aim was to create a minimum membership for the ICBs and ICPs, but it is not prescriptive—it can go beyond that—so there is scope for mental health trusts or other health trusts to have seats on those boards. Indeed, Dame Gill Morgan, who runs the integrated care system in Gloucestershire, said that that is exactly what she has done and that she would be surprised if any ICB did not wish to do it. But we wanted to set a de minimis membership to allow for local flexibility.
We have GP practices that are being privatised now—they are being bought up by private companies, with some foreign interests as well. If the Minister is saying that those companies can have representation on ICBs, we have already seen circumstances where people have tried to redact minutes of meetings, so does this not open up the possibility of private interests being served at these meetings but not being accountable through public scrutiny?
I entirely understand the point the hon. Gentleman is making. I think he was careful, shall we say, given some litigation that may be going on, not to mention anything specific, but I know what he is talking about. We believe that our amendment will prevent private companies—whatever services they were providing for the NHS—with a significant private interest in this, or their lobbyists, from being able to sit on ICBs. Karin Smyth raised the need for transparency in Committee a number of times, and I suspect we may return to that point. We believe that the current transparency requirements on CCGs that will be carried across are sufficient to ensure transparency and public access to the information they need.
I am afraid I am about to conclude. I suspect that the hon. Gentleman will come back in with a speech and I will endeavour to pick up on that in the wind-ups.
There are a number of similar amendments, such as amendment 101 in the names of the hon. Members for Wirral West (Margaret Greenwood) and for Brighton, Pavilion (Caroline Lucas). I hope they might feel, to some degree, reassured by our amendment and the intent behind it, but that is obviously for them to say. We believe that the Government’s amendment puts beyond doubt what we believe was already entirely clear but were determined to put beyond doubt—that ICBs will not and cannot be controlled in any way by the private sector, as NHS-accountable bodies guided by the NHS constitution and with NHS values at their heart. These principles, I believe, irrespective of other debates we may have this evening, command respect from both sides of this place. I therefore commend the amendments to the House.
A wide range of issues that are part of this group of amendments demonstrate the cold reality of this Bill. It is a jumble sale of bits and pieces. Of course a Bill can be wide-ranging, but having breadth is not the same as having coherence, or indeed clarity. Such are the issues within scope in this grouping that I will not comment directly on every new clause and amendment but hope to have time to say at least a few words on those emanating from the Opposition Front-Bench team, as well as on any Government new clauses or amendments that we oppose. Some amendments refer to matters that have been dealt with in Committee where we have expressed our views and put forward amendments that failed to persuade the Government. Sadly, we have insufficient time to go over the same ground again, particularly given the rapid shifting of the goalposts we have seen in the past week.
I turn first to integrated care boards, or ICBs, and, more widely, the issue of governance. The question of governance and accountability remains an important matter to us and needs greater clarity than currently appears in the Bill. For Members who may not be familiar with the detail, the Bill proposes yet another reorganisation of the NHS, creating 42 new integrated care systems where decisions on how NHS and care spending will be made. The decision-making bodies within these systems are the ICBs, replacing the CCGs, which fall away into the annals of history alongside the primary care groups, the primary care trusts and all the other permutations that we have seen.
Our discussions on these matters in Committee showed that our disagreements tended to centre around an intention by Government to limit what is in statute and to leave maximum flexibility at local level, as opposed to our desire to ensure that safeguards and protections were in place for those matters we felt were too important to be left out. It is wholly ironic, therefore, that the Bill proclaims, on the one hand, local freedoms and flexibilities, yet on the other proposes sweeping top-down powers for NHS England and the Secretary of State. Our view remains that some flexibility is fine to allow shaping to local needs, but that some key principles need to be put into the Bill to ensure that there are no misunderstandings or unintended consequences.
We know that the genesis of this Bill has been the realisation that increasingly large parts of the NHS were ignoring the 2012 Lansley Act. Along with changes to procurement and pricing, this grouping deals with the main elements of reversing parts of that Act. We could spend all our time referring to what we said 10 years ago, and how the Health and Social Care Act 2012 has proved to be the disaster that we said it would be, but we will spare the Government the “We told you so” lectures, because even those on the Government Benches are now aware that the 2012 Act has been among the worst policy mistakes in the history of the NHS. Whether that damage was worse than the damage done by a decade of austerity remains to be seen, but repairing the damage done by austerity is not for today, as there is little in the Bill to address the ongoing consequences of a decade of underfunding, particularly the wholly appalling waiting times that we now see across the board.
What became clear in Committee was that the Bill is an NHS reorganisation with little to say on social care. In fact, until last week at least, just two clauses out of 135 related to social care. We get one system of procurement replaced by another that resembles Swiss cheese, and we get nothing at all in the Bill on funding flows and pricing. We were originally told that this was a Bill for integration, but halfway through its consideration, we were told there would be a White Paper along shortly to deal with integration. At least that means there is recognition that the Bill will not deliver the promised land of integration—if, indeed, it is the promised land—but in the meantime, the Government will expect people to crack on with this reorganisation, taking them away from the day job.
On Second Reading, we said that the Bill was
“the wrong Bill at the wrong time.”—[Official Report,
It does not address any of the vital issues facing the NHS. Since then, on every metric, the NHS is performing worse. The challenges have got greater ahead of what is widely expected to be the most difficult winter in the NHS’s history. The NHS does not need yet another reorganisation when the fundamental challenges it faces remain untouched. The explanatory notes and impact assessment for the Bill are both sketchy at best. For example, we do not know what this reorganisation will cost the NHS, and there is certainly nothing in the Bill about social care caps, but we will return to that later.
Then there is the justifiable fear about private sector providers being given a seat on the ICB, although, as the Minister has said, there does appear to be general agreement that something should be done about that, so this debate is more about the how than the why. I appreciate the efforts made by the Minister with amendment 25 in trying to find an accommodation with us, and his birthday wishes. He is absolutely right; there is no place I would rather be than in this Chamber discussing health and care integration. I am afraid we will not be able to support Government amendment 25, because it does not go far enough in our opinion. It adds unnecessary subjectivity into matters and it is not comprehensive in its coverage.
Amendments 76, 77 and 78 deal with the issue and would limit the possibility for influence by vested interests, especially those of the private, for-profit sector. Crucially, they close the door on the possibility, left open by the Government’s amendment, of private providers sitting on sub-committees or place-based bodies of ICBs. Incidentally, that problem is of the Government’s own making by virtue of them leaving the level of direction for place-based Government arrangements deliberately vague in the Bill.
Perhaps my hon. Friend can illuminate me. I was going to ask the Minister who owns the assets of the ICBs. Can the ICBs sell some of those assets and rent them back as a service? What constraints are there to stop people on the board enabling that, because they have some strange link to the people buying the assets?
At the moment, ICBs are not a legal entity, so they do not own anything. When the Bill comes into force, they will effectively take over mainly administrative buildings from the CCGs, and the trust will hold ownership of most of the assets. We hope that there will not be the risks that my hon. Friend outlines, although it is not impossible for ICBs to set up their own trusts at some point in the future.
We do not believe that the question of private providers sitting on the place-based boards can be left open in this way, because this is really about who runs the NHS. There is a complete and utter incompatibility between the aims of private companies and what we say should be the aims of the NHS and the ICBs. I can do no better than refer to the evidence of Dr Chaand Nagpaul from the Bill Committee. He identified the concern perfectly:
“We forget at our peril the added value, the accountability, the loyalty and the good will that the NHS provides. We really do…I am saying that it does matter. Your local acute trust is not there on a 10-year contract, willing to walk away after two years. It is there for your population;
it cannot walk away.”––[Official Report, Health and Care Public Bill Committee,
Those final words sum it up perfectly. Put a company on the board, and its interest lasts as long as the contract, and those interests will of course not be the same as the NHS’s anyway. A company’s primary concern is the shareholders, not the patients. With that clear and unanswerable concern about conflicts of interest, we invite the Government to withdraw their amendment and support ours.
We have already had some discussion of who goes on the ICB. Apparently, the answer is not the most appropriate people chosen by an independent external process or individuals directly accountable to the public; the answer is left to guidance that leaves open the risk that voices we think need to be heard will slip through the net. Our amendment 76 deals with that by setting out the requirements for ICB membership. Allocating scarce NHS resources should be robustly debated and will always be political. Tough choices have to be made, so we need people on the ICB who will be there to cover all the necessary interests for the wider good.
If Members look at what amendment 76 suggests, I hope nobody would argue that those interests do not have to have some voice. The public, patients, staff, social care, public health and mental health—which of those can be safely ignored and which has no part to play? As I have already mentioned, there is a major area of uncertainty because of the complete absence of anything that sets out how the much-vaunted place-based commissioning will work. Who will sit at the place-based table is, I am afraid, still completely opaque.
The next major area covered in the Bill is a further deconstruction of Lansley with the removal of compulsory competitive tendering for clinical services. We have seen the NHS proposals for a provider selection regime to replace the regulations under section 75 of the 2012 Act. That is to be regarded as a work in progress, so our amendment 72 covers the issue and would reintroduce some safeguards into how our money is spent. Since its inception, the NHS has always relied on some non-NHS providers, with the model developed for GPs being an obvious example. However, in recent decades there has been an increase in the use of private providers of acute care, most notably in diagnostics and surgery.
To be clear, we on the Opposition Benches believe that the NHS should be the default provider of clinical services. If it is not the only provider, it should be the predominant provider in geographical and services terms. Where a service cannot be provided by a public body because the capability or capacity is not there, there is still the option to go beyond the NHS itself, but that should be a last resort and never a permanent solution. Amendment 72 therefore sets out a clear framework for how we could achieve that. We hope that extra transparency and extra rigour would mean we avoid buying stuff that is unsuitable and sits in container mountains, stuff that does not meet specifications, and stuff made by companies that have no experience, but are owned by friends and family. In short, we would stop the covid crony gravy train.
The use of private sector capacity in the covid emergency turned out to be a farcical failure. It became very clear, very quickly that it was not there to support the NHS; it was there just to make profits. Use of private providers through dodgy deals during the PPE scandal has highlighted the need for greater transparency and greater capacity in the NHS. We can never allow a repeat of what we have seen there. We need the rigour set out in the amendment to be put into legislation, rather than left to guidance. We need to be able to challenge NHS bodies that do not comply, as well as Ministers who try to flout the rules.
I will now deal with new clause 49, saving the best—or more accurately, the worst—until last. Because of how Report stage works, it has fallen to me to express our opposition to this measure, rather than my expert colleague, my hon. Friend Liz Kendall, who shares my dismay at what has been produced and how it has been presented to us. Starting with the process, it is wholly wrong to bring such a fundamental change forward as a last-minute addition to this Bill. That means it cannot be debated properly today. There is no impact assessment and, as we have already heard, this change was not discussed in Committee at all. In fact, in 22 Committee sessions spanning some 50 hours, we never once heard mention of this amendment coming forward or discussion on the care cap. Indeed, when this Chamber was busy debating the social care levy, we were beavering away in Committee on the Bill, oblivious to the fact this measure was coming down the track. If the Government cannot even get their decision-making processes integrated, what hope is there for integrating health and social care?
As we know, the aim of the new clause is to remove means-tested benefits from the costs that count towards the care cap. As has been pointed out far and wide by Members from all parts of the House, that change adversely impacts some more than others. It is a wholly regressive measure, to say the least, to give support through means-testing, but then to penalise people later for receiving it in the first place. We will vote against this iniquity, and I hope many Conservative Members will vote with us. They should be used to the Prime Minister’s broken promises by now; this is their chance to make the point that he should stand by what he says.
Does my hon. Friend agree that it is Robin Hood in reverse? I encourage Conservative Members who wax lyrical about levelling up, particularly in the north, to do the right thing.
The proposal is grossly unfair. I gave the example earlier that in our region, 15% of people with dementia will reach the cap, whereas 34% would have under the Dilnot proposals. The cap also does not protect working-age adults who are accessing social care, or people with a disability, but Sir Andrew Dilnot’s proposals would have done. It is the second major area in which the proposal is grossly unfair.
Again, my hon. Friend must have read my speech because I will make that point later. The proposal shows that the Bill is not a plan to fix social care but a very thin attempt to change parts of the system. There are many other elements that clearly need dealing with.
In case Conservative Members need reminding, in the Prime Minister’s first speech on taking office, he promised to,
“fix the crisis in social care once and for all, with a clear plan that we have prepared”.
We are still to see that plan. What we have is a new tax and a broken promise.
My hon. Friend and neighbour is making an excellent speech. We should be talking about a plan for social care, but we are actually talking about a tax on the people who have lost out over the past decade and more from the excessive house price growth in the south compared with other parts of the country. This is a tax that doubles down on inequality, rather than addressing it.
I thank my hon. Friend and neighbour—I am getting all my neighbours in tonight. She makes a brilliant point: the proposal exacerbates regional inequalities through an unfair tax and is certainly not a plan to fix social care. Hon. Members should look at what my hon. Friend the Member for Leicester West has said about what needs to be done to tackle the social care crisis in this country; it is an awful lot more than putting in place a cap that benefits only some people in certain parts of the country.
Not only will the proposal not stop people having to sell their home to pay for their costs, but it will bake in unfairness for a generation. It does nothing for working adults with long-term care needs, who seem to have been completely missed out, as my hon. Friend Barbara Keeley said. It is not what was promised, but hon. Members do not have to take my word for it. Let us listen to the experts. Age UK says:
“The change the Government has announced makes the overall scheme a lot less helpful to older people with modest assets than anyone had expected. It waters down Sir Andrew Dilnot’s original proposal to save the Government some money, but at the cost of protecting the finances of older home owners…This feels like completely the wrong policy choice and we are extremely disappointed that the Government has made it”.
The King’s Fund says of people with more modest assets that,
“the Prime Minister’s promise that no one need sell their house to pay for care…doesn’t seem to apply to them.”
Instead, it will only “benefit wealthier people”.
My hon. Friend referenced the Prime Minister’s statement that nobody would have to sell their house to pay for social care. I know that my hon. Friend would never seek to call the Prime Minister a liar in this Chamber, but does he wonder, as many hon. Members do, why the Bill appears to be turning the Prime Minister’s words into a lie?
I thank my hon. Friend for his intervention—I think. What I can say here and what I might say outside are not the same, and I do have to finish my speech, so I will leave it there. I am sure that the public will make up their own minds about the veracity or otherwise of comments made by the Prime Minister.
Sir Andrew Dilnot said that the proposals will create a north-south divide, that those with assets of £106,000 will be hardest hit and that anyone with assets under £186,000 will be worse off than under his proposals. According to the Health Foundation, assuming care costs of about £500 a week, those with assets of £150,000 will take a year and a half longer to reach the cap than they would have under the Dilnot proposals, those with assets of £125,000 will take four and a half years longer, and those with assets of under £106,000 will never reach the care cap. Contrary to what the Minister has said, people with assets of £106,000 or less will not benefit from the proposal at all.
The Dilnot commission specifically said that excluding state contributions from the cap would be unfair for those on lower incomes and would mean that they would contribute the same as the wealthy over a longer period, but that is where we find ourselves today with the new clause. Ordinary people on modest incomes will pay an extra tax that will not stop them having to sell their home to pay for their care costs, but that will mean the mansion-dwelling millionaires can keep theirs.
As my hon. Friend Mike Amesbury said, we have a reverse Robin Hood situation. People on lower incomes will pay into a system that they will see little benefit from, but that will protect 90% of a property worth £1 million. In case hon. Members need help translating that into what it means for their constituents, I have a selection of median house prices in various constituencies across the country: in Hartlepool, the median house price is £128,000; in Bishop Auckland, it is £125,000; in Blackpool South, it is £114,000; in Stoke-on-Trent Central, it is £112,000; in Hyndburn, it is £110,000; and in Burnley, it is £99,000. The owners of such houses would all probably have to sell their homes under these plans.
Those figures are replicated across huge areas of the country, so it is not just a few people in those constituencies who will lose out, but thousands of people, mainly in the midlands and the north of England, who will be forced to sell their home while those in more affluent areas of the country can keep theirs. That is not fairness or fixing social care, but a betrayal. We on this side of the Chamber always thought that levelling up was just a slogan with little substance, but we now know that it is worse than that. It is a con trick—a lie—that will leave many of those whom it was meant to support worse off than they would have been otherwise.
Conservative Members who loyally trooped through the Lobby in September to impose the social care levy, knowing that it would have a disproportionate impact on their less well-off constituents who paid into it, must now—to use a phrase that we have heard many times in the last week—be suffering from buyer’s remorse. It must have dawned on them that they have been sold a pup, that there is no plan to fix social care, that the Bill will not stop people having to sell their home, and that the only people it will help are those who are already comfortably well off.
The only way that Conservative Members can represent their constituents, who voted for them because they believed that the Conservative party had changed and was at last on the side of ordinary people, is by joining us in the Lobby to vote against the Government, and by showing that they will not stand for a Government who break their promises. When the chickens come home to roost, and families in their constituency say to them, “We were promised that we wouldn’t have to sell our home to pay for care costs,” what will they say? Will they tell them that they voted for it even though they knew what would happen? Will they tell them that promises do not really matter? Or will they tell them that when it came to the crunch, they stood up for what is right and what is in the interests of the people they were elected to represent, and said to the Government, “No. Think again”?
Finally, I remind Conservative members of the manifesto on which they stood for election, which said clearly and unambiguously of social care that,
“The prerequisite of any solution will be a guarantee that no one needing care has to sell their home to pay for it.”
If they do not think that the Government new clause gives that guarantee, and if they think that it breaks the promise they made to the electorate, they should join us in the Lobby, take back control and vote against it.
Order. It will be obvious to Members that a large number of colleagues want to contribute to the debate. I urge brevity, so that others can participate. I call the Chair of the Health and Social Care Committee, Jeremy Hunt.
Madam Deputy Speaker, I think on this occasion I can oblige you, because I will be very brief. I wish to speak to amendment 114, which may seem a rather technical amendment—as is evidenced by the fact that, out of 650 colleagues, only one has actually signed it, and that is me—but it makes up in quality for what it does not have in quantity. It is about making sure that the new integrated care boards focus their energy on the safety and quality of care of patients. That is very important, because the new integrated care boards will have enormous power. In effect, they will be the local governing bodies of our NHS.
Although the statutory structures matter, what the people running those care boards focus their attention on is incredibly important to all our constituents. The amendment will make sure that when care boards consider their priorities, the things that matter to patients—the safety and quality of care—are put at the very top of their list. We know the way the NHS works. It is the fifth-largest bureaucracy in the world, and there is a plethora of internal NHS—
There is a plethora of internal NHS targets, there are operational targets and there are financial targets. They often have an excellent purpose, but, as in the case of Mid Staffs and other cases where things went badly wrong, being under a lot of pressure to meet those targets means corners can be cut, and the quality of care experienced by patients can be really damaged. The amendment would make sure that there was discipline in the system, so that whatever pressure NHS managers were under, they were always focused on safety and quality of care.
Before I come to the Minister, I want to say—and I am very grateful to my right hon. Friend John Redwood, who gave me consistent support on this agenda when I was Health Secretary—that, in the public sector, the one system that has seemed to make sure we focus public bodies on our constituents’ priorities is the Ofsted system in schools. We have rolled that out, I think reasonably successfully, to hospitals, GP surgeries and care homes, and this amendment makes that possible for the new integrated care boards. I want to give the Minister a chance to intervene to tell us his reflections on whether this system could work.
I am happy to do that, because I know my hon. Friend has a great interest in social care issues. I feel conflicted by new clause 49. I think that what we will end up with after this measure will be a whole lot better for people on low incomes than what we had, because the means-test threshold will be raised from £23,000 to £100,000, and that is a very significant improvement. However, I have to be honest and say that it is nothing like as progressive as we had hoped, but it is a step forward. My concern when it comes to social care is that our entire debate is focusing on what does and does not contribute to the cap, when the fundamental problem in social care is the core funding to local authorities; that, though not a matter for this Bill, has a direct impact on the care received by our constituents.
I conclude by thanking the Government for their support for amendment 114. I will move it formally later, but I am not expecting to divide the House on it.
I initially want to touch on new clause 49. Like other members of the Bill Committee, I sat through hours and hours from September to November, and the Government have suddenly pounced on us with this at the last minute. It is such a complicated new clause, but it has not been interrogated.
It is quite clear that the Government’s original spin that no one would pay more than £86,000 for social care and no one would have to sell their house is completely misleading. All the accommodation costs are on top of this. As has been highlighted in the media and by Members in the Chamber, those with assets of about £100,000 will not see any real gain from this policy, while those sitting on assets of £500,000 or more will keep a lot of their wealth. That means it exacerbates the differences, and penalises those in the north of England and areas where house values are not so high. Basically, it is feeding the frenzy down here of people sitting on over-inflated house prices. As has been said, this is not levelling up, just doubling down.
The cap applies only to personal care, which means things like washing and dressing. That has been provided free in Scotland both within the care home and in home care since 2002. It was expanded in 2011 to provide more hours so that people with greater need could stay at home longer, and it was extended to those under 65 with care needs in April 2019. Scotland is the only UK nation that provides free personal care, and we see it as an investment. It is an investment that we spend 43% more per head on social care in Scotland, but it is an investment in people’s independence and their inclusion in society. The problem is that we spend far too much time talking about social care just as a burden, instead of actually seeing it from the point of view of the user.
The Scottish Government have already added an extra penny on taxation for medium and high earners to cover things such as our wellbeing policies, health or social care, but this Government’s plan to increase national insurance contributions will disproportionately hit low-paid workers and young workers. I would say that the biggest weakness of all, as we know from the original debate on the national insurance change, is that the funding is not going to go to social care initially; it is going to go to the NHS, yet it is social care that is in crisis. This is what is causing the pressure in accident and emergency, because people who are ready to be discharged simply cannot be, as the care support is not there. I do not think that this fixes the problem. There will actually be very little money, because a lot of it is going to go on capping the overall payment. I do not see social care benefiting from this at all, yet it is social care that needs investment more than anything else.
Turning to the main substance of the Bill, which is meant to some extent to unpick the damage and fragmentation of the Health and Social Care Act less than a decade on, I wish to express support for amendments 9 and 72. Many in the NHS, including me, will be glad to see the back of section 75 enforced tendering. Others in the Chamber know that it was the Health and Social Care Act that brought me into politics, as I just could not believe anybody thought what they were doing was a good idea. It is still clear from the pandemic that this Government are absolutely wedded to outsourcing services to private companies, and to the flawed notion that financial competition somehow drives up clinical quality. I am sorry, but that simply is not the case. As the Chair of the Health and Social Care Committee has highlighted, we have to focus on safety, on clinical audit, and on peer review if we want to drive up care quality for patients, not just on the money in the system.
The Government appear to have conceded that integrated care boards should be statutory bodies, as health boards have always been in Scotland, but partnership boards can include private providers, such as with Virgin Care in Bath. As the partnership boards will be involved in devising the local strategy for health services, that is likely to lead to a blatant conflict of interest, and I do not see a resolution to that. The NHS simply should be the presumed provider of health services. That is not just, as the shadow Health Minister said, because the NHS is in it for the long term, or for a quick contract, but because the NHS provides the training to nurses and doctors who are the vital workforce of the future. Private providers do not do that; private providers largely live off the NHS. As well as not training staff, where there are major problems or complications, patients inevitably end up in the intensive care unit of an NHS hospital.
In conclusion, for all the size of the Bill, and the scale that the reorganisation will involve for staff in the NHS, who we all know are frankly exhausted, the Government have failed to take the opportunity to repair fully the damage of the Health and Social Care Act 2012, and to recreate in England a unified public health system, such as the one we are lucky enough still to have in Scotland.
I thank the Minister for the time he gave me to consider my amendments, which we discussed in some detail, and I thank Her Majesty’s Opposition who, very kindly, took some of my amendments through Committee, sadly unsuccessfully. Tonight I hope to have the opportunity myself to explain why these amendments are so important. Before the House thinks, “Oh my goodness, how can we possibly deal with that many clauses and amendments?” let me say that I will endeavour to be brief. I rise to speak to new clause 33, and amendments 21, 22, 19, 16, 17, 20, 18 and 23—but I will be brief.
Let me divide my remarks into four topic areas: domestic abuse, mental health, access to medicines, and research. New clause 33 deals with domestic abuse. That is a horrific crime. It is insidious, it is hidden, and it is on the rise, and during the pandemic it has, sadly, grown from strength to strength. I say, pointedly, that this is a hidden crime, and at the moment, all the teeth are with the police. However, the police can deal only with very evident crime.
Where does domestic abuse first appear? It is in a doctor’s surgery, or at accident and emergency. To date, however, there is no obligation on clinical commissioning groups, integrated care boards or hospitals to come up with a strategy to address that horrific ill. New clause 33 would place a new obligation on ICBs to put in place a proactive strategy to properly manage that issue, and to introduce the education and training that GPs and those in hospitals and A&E need. We must ensure that we no longer find, as in the Safelives report, that those experiencing domestic abuse will have experienced it for three years before it is picked up, despite having already been to visit their GPs almost five times. I do not believe that that is acceptable in a civilised society such as the one we have today.
Five and a half per cent. of adults between 16 and 74 experience such abuse, and the Home Office has determined that the cost of that was £66 billion in 2016-17. Of that, £2.3 billion was the cost to the health service. We know that 23% of those who are at risk attend A&E, and yet nothing happens. I am fortunate that in Devon we have a pilot. My CCG is the only one in the country to have a dedicated individual on the board who specifically oversees and sets a dedicated strategy on this issue. The estimate from the pilot so far reckons that if we spent £450,000 a year on our GPs in Devon, we would get a return of £7 million. But this is not about money; this is about what is the right thing to do. Until this measure is on the statute book, and until there is an obligation to put in place a strategy, this will not change, and I cannot sit here and accept that.
Let me turn to mental health. For many years and in many documents, we have seen a commitment to parity of esteem, but I have been through every statute on the book and at no point is there any reference to the words “parity of esteem for mental health”. If parity of esteem for mental health is not on the statute book, how can we say we believe in it? If it is not on the statute book, how can we possibly measure it? Currently, there are very few measures of inputs or outputs—or, worse, of outcomes —for those going through the mental health system. There are some, but they are minuscule compared with what we have for physical health.
Amendment 23 to clause 19 would require each ICB to compare the inputs and outputs on physical health and mental health. Each ICB would be required to set out: the number of patients presenting with physical symptoms and with mental symptoms; the waiting times for initial assessment in physical health and in mental health; the waiting times for treatment in physical health and in mental health; the number of patients actually receiving treatment in physical health and in mental health; and, finally, reports on readmissions. I know that Ministers do not like that level of detail, but how important is this? Without some very specific measures, it will not happen. What gets measured generally gets done.
Amendment 23 would also require the ICBs to report against the very few national standards that there are. At least then we would see what they were; we would shine a bright light on the fact that there are so few for mental health while there are numerous for physical health. The Secretary of State would be required to consolidate those reports into a national report, which would have to be presented to Parliament—to both the Commons and the Lords. What is there for Ministers not to like about that amendment? What is there for those on the Opposition Benches not to like about it?
Then I would like to see you wishing to press it to a vote and putting your vote—and your feet—where your mouth is. [Interruption.] I apologise, Madam Deputy Speaker; it is not your mouth. I was carried away by an overwhelming desire to get my point across, and I apologise most profoundly.
I turn to access to medicines. Most Members believe, do they not, that medicines that have been approved by the National Institute for Health and Care Excellence are available to all our constituents? The reality is that they are not. A medicine may have gone through the Medicines and Healthcare products Regulatory Agency and been proved to be safe, and through NICE and been said to be cost-effective, but each CCG—each ICB, as they will be—and hospital trust, and every other NHS body responsible for prescribing, sets its own formulary, and those formularies do not include all NICE drugs. If a medicine is not on the formulary, then no consultant or GP will be able to get reimbursement, so they will not be allowed to prescribe it.
In my constituency, a number of individuals have come to me because they cannot get access to a particular medicine, yet people in another constituency can. I do not believe that a postcode lottery is right. We all talk about the NHS, and health and care, being free at the point of delivery, and we all assume that we can get access, whether to GPs or to hospitals, but I do not think it occurs to most of us—it had not occurred to me—that we cannot necessarily get access to medicines.
My amendment 21 to clause 15 would effectively oblige every ICB, where any individual patient has the advice of their clinician that they should have a particular medicine and it has been approved by NICE, to make provision to ensure that that medicine is provided—perhaps from a neighbouring ICB, taking advantage of the duty to collaborate across ICBs. That would ensure that even if a medicine was not on the formulary in the area of an individual ICB, it could be obtained from another area. Bear in mind that there is no financial loss in doing that, because all NICE-approved drugs are subject to a voluntary pricing agreement between the pharmaceutical companies and NHS England. Under that agreement, x number of drugs will be provided at an agreed cost. Anything above that will be reimbursed by the drug company, so the Government and the NHS will not be out of pocket. Why would that not be a good clause? To provide belt and braces, under amendments 20 and 22, all NICE treatments would automatically be added to all formularies within 28 days of market authorisation and every ICB would be obligated to report.
My last area—I will be very brief, Madam Deputy Speaker—is research, which is so important, as we discovered during the pandemic. I would like to draw the attention of the House to some of the challenges. Some of the anti-viral solutions to coronavirus were late to market because we could not get the clinical trials. Why? Because we could not get access to the records of the patients who had had covid or been diagnosed with covid so that we then had the appropriate cohort to be able to test the anti-virals. It therefore seems very clear that research must be taken on board across every hospital trust and across every ICB. If every ICB and hospital trust had in place a system to ensure research was part of their DNA—that they had to report on what research they were undertaking and had an obligation, if they were asked and had the appropriate cohort, to recruit the patient base so that particular clinical trials could take place—we would get more medicines faster to market. I think most people would say that that was a win.
I declare an interest in that my partner is a clinical research nurse—working in cardiac research—so I completely appreciate and understand exactly where the hon. Lady is coming from. Does she agree that to find patients for studies, often tens of thousands of pounds is spent on radio and online adverts? If her amendment 17 is successful, it could be revolutionary for research in this country.
I thank the hon. Gentleman. He is absolutely right. If we could have this new system, so there was a research strategy and an obligation to consider clinical trial requests and then report, we would be in a very different place.
Madam Deputy Speaker, you have been incredibly indulgent and so have all hon. Members. On that note, having had my time for my four areas, I thank the House for its indulgence and I look forward to the Minister’s reply.
The Bill opens the NHS up to big business, allowing private companies a say in the care that patients receive. The Government’s amendment to the make-up of integrated care boards is weak and it fails to rule out the possibility of people with an interest in private health sitting on them. For that reason I tabled amendment 101, which seeks to ensure that ICBs are made up wholly of representatives from public sector organisations and that private companies, their employees and representatives, and those with financial interests in them, are not represented on them. Surely, that is what the public expect from a body that will be responsible for spending huge amounts of public money?
However, the influence of private companies is not just an issue with ICBs. The Bill allows for private companies to play parts in other ways, for example at sub-system level via place-based partnerships and provider collaboratives—they are not actually stated in the Bill, but that is what it means. Guidance by NHS England states very clearly that the Health and Care Bill will enable ICBs to delegate functions to providers, including, for example, devolving budgets to provider collaboratives. There is nothing to stop such partnerships from being open to big business, so the Government’s rhetoric around protecting the independence of ICBs is, frankly, quite meaningless. For all their talk of recognising
“that the involvement of the private sector, in all its forms, in ICBs is a matter of significant concern to Members in the House,” they have not taken the action needed to stop private companies from influencing decision making. That is why I have put forward amendment 58, which is designed to ensure that any organisation carrying out the functions of an ICB on its behalf is a statutory NHS body.
Although the Government have made some noise about private membership of integrated care boards, they have said with respect to integrated care partnerships that they
“want local areas to be able to appoint members as they think appropriate.”––[Official Report, Health and Care Public Bill Committee,
That is a matter of great concern. ICPs are required to
“prepare a strategy…setting out how the assessed needs in relation to its area are to be met”.
Integrated care boards must have regard to a strategy drawn up by the ICP, which may well be influenced by private companies that do not have the same objectives as the NHS. I have therefore tabled amendment 100, which would do for ICPs what my amendment 101 would do for ICBs: seek to ensure that they are made up wholly of representatives from public sector organisations, and that private companies are not represented on them.
The Bill will break up the NHS into 42 integrated care systems. My amendment 59 would ensure that any provider of health services could not withhold provision of those services from any individual because of the integrated care board to which they were allocated. In other words, wherever in England someone falls ill, they could get treated. There have been alarming recent reports of people in need of urgent care being turned away from A&E because they did not present at the A&E centre closest to where they live. That is extraordinary—it is not what we expect of the national health service. One recent report told of a woman who suffered burns and attended A&E, only to be told that the hospital did not treat people from Rochdale. There is nothing in the Bill to ensure that people in the country can go to any A&E in the country if they need to. My amendment is designed to address that shortcoming.
As we know, the Bill is also about enabling privatisation—and when we look at the procurement reforms in it, we can see why. They will enable the removal of the current procurement rules that apply to NHS and public health service commissioners arranging clinical healthcare services. The Bill will provide a power to create a separate procurement regime for those services, including removing
“the procurement…of…health care services for the purposes of the health service” from the scope of the Public Contracts Regulations 2015.
Does my hon. Friend agree that the Bill has the sense of being an NHS corporate takeover Bill? We have already seen £5 billion in contracts being awarded to private companies through the VIP lane. The Bill opens the door to private corporations sitting on 42 local health boards. That is wrong.
I thank my right hon. Friend for putting the case so clearly. She hits the nail absolutely on the head: as a result of the Bill, contracts could be handed out to the private sector without the stringent arrangements that one would expect in the awarding of public money. That is a recipe for the kind of cronyism that has become all too familiar, as she says.
I turn to the cap on care costs. I was proud to stand on a manifesto in 2019 that pledged to
“build a comprehensive National Care Service for England”,
“free personal care, beginning with investments to ensure that older people have their personal care needs met, with the ambition to extend this provision to all working-age adults.”
The Conservative manifesto in 2019 did not go that far, but it at least made the guarantee that
“nobody needing care should be forced to sell their home to pay for it.”
We now know that that was a sham—another broken promise by this Government.
Last week, Ministers sneaked out changes to social care plans that would mean that poorer pensioners will not after all be able to count means-tested payments by the state for their care towards a total cap of £86,000 for any individual. The Chair of the Health and Social Care Committee, Jeremy Hunt, described it as “deeply disappointing” that the new plans were “not as progressive” as those put forward by Andrew Dilnot, the economist who drew up the original plans for a cap on individual contributions. Mr Dilnot has said that the Government’s plan is
“a big change that…finds savings exclusively from the less well-off group.”
“to adopt a different approach”,
“it will be poorer pensioners who have relatively modest assets that will be most affected by these changes.”
I hope that Members on the Government Benches are listening to those points from Government as well as Opposition Members and will do the right thing. Elderly people deserve better. All Members, including Government Members, have a responsibility to vote these measures down.
When the Prime Minister was discharged from hospital in April 2020, having spent seven nights there, of which three were in intensive care, he said that
“the NHS has saved my life, no question.”
Now he and his Government should save the NHS by withdrawing the Bill. The national health service is this country’s greatest social achievement. It is devastating that this Conservative Government are intent on taking it off us.
I support new clause 49 because I support the action that is needed to make reforms to social care that are long overdue. I have listened carefully to the debate, and it is vital that we understand that the new clause would deliver one part, but not the whole, of the package that was set out by the Government in September. There is no doubt whatever that that package, as a whole, improves the provision of social care, makes the way it is paid for fairer, and removes some injustices that have existed in the system for far too long.
First, the proposal that has been put forward—and I think it is the right proposal—is for a cap on the costs that individuals face in paying for their care. The contributions from the state, even if they are from another part of the state such as local government, are not individuals’ care costs, and it is therefore wrong that they should be contributions towards the cap. The cap has the stated goal of being a cap on the cost of care to an individual, not a cap on the cost that accrues to both the individual and a local authority.
Let us look at what would happen if the new clause were not passed. The provision of care by local authorities is different in different areas, largely according to how well off those local authorities are. A richer council that pays more costs than the statutory minimum as set out in the Care Act 2014 would help local residents to meet the cap sooner than a poorer council that pays only the statutory minimum of care costs, and therefore people who live in poorer areas would take longer to reach the cap, so we would end up, in effect, with a postcode lottery cap meaning that people from poorer areas would tend to have to contribute more. That is wrong, and I am very glad that it is put right by the proposals that are before us today.
Secondly, for those with lower asset values, the rise in the floor in the means test is more important. It is the rise in that floor that makes this system fair. When the shadow Minister, Justin Madders, read out a long list of places with low asset values on average—places where house prices tend to be lower—he listed exactly the areas that will benefit most from the rise in the floor. [Interruption.] We can see what Labour Members are doing. [Interruption.] They are taking a narrow area, and they are taking a specific detail, and they are ignoring all the parts of the package that benefit the people who will benefit from this package as a whole. [Interruption.]
Order. We will not get anywhere if people shout. This is supposed to be a reasonable discussion.
Thank you, Madam Deputy Speaker.
A further point that is being ignored by those who are trying to make a meal of this new clause is that the cutting of the daily cost offset is much more valuable to those on low incomes than any change in the cap, because the cap, by its nature, is there to protect assets, and those who do not have many assets gain far more benefit from the cut in the daily cost that would otherwise clock up their contributions to the cap much more slowly.
Taken together, these elements make up a package that is beneficial to those on low incomes. It helps to make the system fairer.
My final point on new clause 49 is this. For years and years—including the years when I was Secretary of State, and including the entire 13 years when Labour was in power—nobody fixed the problem of social care. This Government have come forward with a package, and if we pull apart one part of the package, there is a risk to the package as a whole. As Sir Andrew Dilnot said on the radio this morning,
“the whole package is a significant step forward”.
It is always easy in politics, and in life, to say, “I just accept the bits of the package that I like”—and, in the case of the Labour party, to say, “I accept the bits that are very expensive for taxpayers.” Instead, we must look at the package as a whole, which is funded, and which can be delivered, for the first time in several decades, because it hangs together. The Government have presented a whole package, and it is the best possible option in the fiscally constrained times in which we live.
I am sorry to be unhelpful to my right hon. Friend, but if this element is so integral to the overall package, why was it not brought forward right at the beginning?
This part of the package was described in September, because it was made clear in September that the £86,000 cap was a cap on individual costs. It did not say then that that included the costs that local government may make on someone’s behalf. I think it is a strong Conservative principle that, when we say we are capping the costs that an individual pays, we do not include the costs that another part of the state should pay. I think that that was clear, and more details have now been set out. Most importantly, this is a package that takes things forward in a way that has not been achieved for decades.
I do not think anyone across the House would argue that the measures that have been put forward are a significant step forward from where we are. However, as my hon. Friend Kevin Hollinrake and my right hon. Friend Jeremy Hunt mentioned earlier, they are not necessarily what we might have been led to expect. Would my right hon. Friend like to comment on that?
I will happily comment on that. In the debate over the past few days, many people have been comparing the package put forward by the Government with the proposals from Sir Andrew Dilnot in 2014-15, but there is a reason those proposals were never enacted and never came into force. It is because they had a huge price tag, and there was no successful debate on how to pay for them. It has been easy to ask for social care reform for the past three decades, but until this Government did it, nobody had come forward with a plan for how to pay for it. We simply cannot magic things out of thin air. If we are a grown-up Government, we have to come forward with a grown-up package, which includes saying how it will be paid for. That is what has happened, and that is why this package hangs together. We should support this new clause, because it is part of that overall funded package.
I want to turn briefly to the measures on integrated care systems. The purpose of the ICSs is to have a more preventive, more flexible and less siloed approach than we have under the current clinical commissioning groups, without removing the grit in the oyster that is the purchaser-provider split and without upsetting the 1948 settlement involving local authorities doing social care and having a national NHS. Amendment 76 in particular contains a lot of suggestions that might seem tempting. There are people who have an important voice in the debate. The problem, as we have seen with existing legislation, is that if we put too much into statute, it is far harder to deliver high-quality services that are integrated on the ground. That is why the Government are right to resist putting too much detail into legislation. However, I do support the change proposed by the Government, which makes it clear that the purpose of ICSs is not to have private providers on the board. I can confirm that, as the Minister said, it never was. Mischievous rumours were put about, some of which have been repeated today, that that was the intention, and I am glad that the Government’s amendment puts that matter beyond doubt.
I am attracted to amendments 89 and 90 and, in another group, amendments 91 to 98 and amendment 23, tabled by my hon. Friend Sir Charles Walker. I was going to say this before I knew that I would be sitting next to him in the debate today, and I hope that the Government will look on these amendments kindly. The parity of esteem between mental and physical health is incredibly important, and I commend the amendments to the House.
Order. It will be obvious to the House that a lot of people wish to speak and that there are a lot of amendments still to be spoken to. We have only an hour left, so I am going to impose a time limit of four minutes immediately. I apologise to Peter Dowd for not giving him notice that he would have only four minutes, but I am sure that he will manage.
My amendments 1 and 2 primarily relate to self-care. I acknowledge that self-care is recognised by care professionals as part of the healthcare process, but, like prevention, it should not be an afterthought—a concept that we think invaluable but that we never get around to fully including in our health ecosystem in the way we ought to.
Amendment 1 would ensure that
“everyday wellbeing, self-care for minor ailments and the management of long-term conditions” are promoted and integrated into local health systems. As we learned during the first waves of the pandemic, those with minor ailments are best off seeking care within their local community, for example, by practising self-care or seeking advice from their local pharmacist to support them in their illness. There is nothing wrong with promoting self-care, but it must be as part of a wider, more comprehensive health system, where it is needed.
The health system has promoted self-care forever. It has always done so as part of the process. As integrated care systems become statutory organisations, primary care networks will continue to be an important conduit for improving self-care in the community. They provide an opportunity for the community pharmacy to be fully integrated into local primary care and improve communication across all primary healthcare providers. Promoting and integrating self-care across the self-care continuum, from everyday wellbeing to self-care for minor ailments and the management of long-term conditions, will help to empower people to know when and how to self-care, and in turn support more sustainable local health systems.
Amendment 2 focuses on how community pharmacists are well placed to drive a holistic approach to self-care. They can advise people on the most effective over-the-counter treatments, as well as on self-care techniques, for example, via the community pharmacist consultation service, which has been an important initial step in ensuring that the system is designed to support self-care for treatable conditions. The amendment would ensure that the strategies developed by integrated care partnerships take account of the benefits that services offered by pharmacists for minor ailments can provide, in turn helping to integrate these services into local care pathways.
During covid, many people decided not to go to GPs, and many continue to say they will not go to GPs, but will try to get support outside the GP system as part of that self-care process, as a couple of surveys have indicated. One of the questions they were asked was how they felt about getting advice online or from a pharmacist.
I reaffirm, if it were needed, that self-care is not about self-isolation from health care services. It is not about reducing the strain on the NHS by a sort of self-imposed rationing. It is about not diverting people away from healthcare, but rather providing another route into it. These amendments, at the very least, ask the Government to think on the need for a more structured approach to self-care that is there to help and benefit patients.
The question is whether this Bill, in the round, achieves a reboot of self-care in the light of covid. I am not sure it does, but I ask the Minister to consider carefully the process of self-care in a much more formalised way.
I rise to speak on new clause 49. For 40 years, successive Governments have tried desperately to address this issue, and successive Governments have put it in the “too difficult” pile. It is incredibly expensive, it is hellishly complicated and, to put it simply, there is no silver bullet to address all the concerns surrounding it. That is why I am so proud that this Government have made an attempt to grip this issue.
The fact is that what happens to us in old age is entirely random, and whether we incur catastrophic care costs that wipe out everything we have worked for in our lives is often down to luck. The current system is complex, it is unfair, many people simply do not understand it, and that has been compounded by the fact that successive Governments—nobody is blameless—have used unhelpful language such as “death tax” and “dementia tax”, which have made people terrified of the issue and blown any Government’s attempts to try to solve it out of the water.
Such language strikes fear into people’s hearts about what will happen to us when we are elderly, when we are vulnerable, when we cannot look after ourselves any more. As humans, this is something we do not want to talk about. We do not want to consider it or think about it happening to us; not for us the slow decay, the hellishly expensive degeneration, which affects perhaps four in 10, with the catastrophic amounts of money involved affecting perhaps one in seven. That is why insurance models have never really worked.
The new clause looks to amend the cap on care, basically, where the local authority costs should contribute to the metering towards the cap. I have to be honest: I thought really hard about whether I could support this. Many people, including the brilliant Andrew Dilnot, have pointed out the financial inequalities and some of the geographical inequalities of removing the local authority contribution. As local authority contributions differ by area already—they are much higher in better-off areas—there is already a postcode lottery of care depending on where someone lives. We have to address that. The key thing here is not the cap, but the floor. Those with lower property values will be protected by the floor, not the cap. The reforms increase the threshold above which people must meet the full cost of their care from £23,000 to £100,000—more than four times the limit. The daily living costs limit of £200 per week means that more people will keep more of their income and assets and the package includes domiciliary care, which many others have not done. It is not perfect—it is far from perfect—but everyone who is contributing towards their social care today, and those of us who face the uncertainty of this possible spectre in our future, will be better off than they are now. That is why we have to move forward in a way that is deliverable and that we can finally, for once, get over the finishing line, after 40 years of trying.
There are details that need to be fleshed out. The White Paper just cannot come soon enough and I wish to mention two burning issues in particular. The first is how we support working-age adults, who make up more than half of those who need adult social care. Some people need that care throughout their lives; for others it happens to them unexpectedly. How do we support the people of working age for whom care costs are not paid out of a nest egg, which they might have been able to build up over decades of work? Finally, the biggest issue facing adult social care is the workforce. This job is significantly undervalued. It is too often described as “unskilled”. That drives me mad. These people have unbelievable skills. They have experience and passion, and we entrust our most valuable and precious family members into their care and their hands. Frequently, they just make more money in hospitality or retail. How do the Government create a society that values these heroes for what they are? I look forward to reading the White Paper and seeing how the Government will tackle some of these thorny issues, the most intransigent challenges facing our adult social care system, because for those money alone will not be enough.
I would like to start by talking about social care. The Liberal Democrats have long called for reform to properly integrate health and social care services, but this Bill does not do that. As others have mentioned, it seeks to reorganise parts of the NHS, but it pays lip service only to social care. That is why the Lib Dems think that the Bill should be put on hold until the proper social care reforms are brought forward.
As others have mentioned, it has been months since the Prime Minister announced his plan to fix social care. It is unforgivable that this new clause was sneaked out during the sleaze row last week, in a move that changed the goalposts. The Minister would do well to listen to the unease among his Back Benchers as well as among Opposition Members.
Struggling families now face being hammered by a double whammy of unfair tax rises and the prospect of losing their homes to fund care costs. Matt Hancock is no longer in his place, but I noted that he selectively quoted Andrew Dilnot. He did not quote Andrew Dilnot’s comments on new clause 49. Andrew Dilnot said that that proposal was not welcome. He said that he was very disappointed and that this represented “a big change” that
“finds savings exclusively from the less well-off”.
That is two promises from this Tory Government now broken.
There is also no mention in this Bill of the millions of people who are unpaid carers in the UK, even though we know that carers are twice as likely to experience ill health as a result of caring. That is why I have tabled new clause 63 for debate tomorrow. It is supported by Carers UK and it calls for the NHS to ensure that the health and wellbeing of unpaid carers is taken into account when decisions are made concerning the health and care of the person for whom they care. I hope the Government will support it. I know it is grouped for debate tomorrow, but I reference it now to highlight again the fact that the Bill does not present a comprehensive plan to reform social care.
The Bill also represents a massive and unnecessary power grab by the Secretary of State. It is simply wrong for the Government to have the power to abolish arm’s length bodies and approve or reject the chairs of integrated care systems. The public have been rightly outraged at political meddling in covid contracts, and the Government should learn their lesson. We should all be seeking to protect the independence of the NHS.
Vacancies in the NHS and social care are utterly staggering. We know the numbers: 100,000 vacancies in the NHS and more than 120,000 in social care; and 1.5 million people missing out on the care they need. We simply cannot go on like this, with the Government setting their own sporadic targets and constantly missing them. NHS waiting lists are at a record high. Ambulance services received a record number of calls in October. Major A&Es treated more than 1.4 million people in October—the third highest monthly figure on record.
The Bill will do nothing to get those waiting lists down, nothing to recruit the workforce we need, nothing to help people get seen faster and nothing for the millions of unpaid carers. The Government should delay the Bill for a few months and look properly at reforming social care, rather than doing a half-baked job now. But I do not think they will, and that is why the Lib Dems will vote against it.
I listened carefully to my hon. Friend the Minister for Health earlier as he introduced new clause 49 because the funding of social care has been a huge concern for too many years. The people we represent deserve far more certainty about how their old age will be funded if they require social care.
We have a pension system and a system to support disabled people, but the funding of social care is a real uncertainty. I pay tribute to the Minister for bringing forward these costed proposals to provide some certainty for the future for more people. He is to be commended for being clear that no one will lose out under the proposals and that the majority will be better off because of the issues that we have already gone through—particularly because the means-test threshold is being significantly raised. He can say that with some force because of the more than £5 billion extra being put forward by the Government to fund social care in a sustainable way for the future.
However, there is still clearly some concern, as the Minister can hear from the debate. As my hon. Friend Caroline Dinenage said, no solution will be perfect, so I was particularly pleased to hear of the Minister’s plans to publish an impact assessment, which will clearly set out the impact of these measures across the board. That is important.
Finally, I want to speak in support of my amendment 102. We all know that the quality of support that we give victims of domestic and sexual abuse is a marker for the health of our society, and it is not just a matter for the NHS. However, the NHS plays a vital part in that support. Amendment 102 requires the joint forward plan for integrated care boards and their partners to properly set out the steps they propose to take to address the needs of victims of domestic abuse—whether domestic violence or sexual abuse, and whether it involves children or adults.
Amendment 102 does not limit the plan to addressing only the victims of domestic abuse; many other types of abuse are equally devastating, and it is permissive enough to allow innovation and improved ways of working to be developed in guidance. I hope that it can be used as a basis for guidance to integrated care boards as part of their general powers.
Amendment 102 is just part of the greater whole. The Police, Crime, Sentencing and Courts Bill in particular will require action across Government, but the amendment will help to ensure that every part of the state is pulling in the same direction when it comes to issues of domestic and sexual abuse. My amendment is similar to new clause 33, which my hon. Friend Anne Marie Morris outlined earlier, but my amendment is more permissive and less prescriptive, so I hope the Government will find it acceptable.
I am grateful to my right hon. Friend for the case she is making. I should also put on the record my gratitude for the work that my hon. Friend Anne Marie Morris has done in this policy space and for her proposal. Her Majesty’s Government are happy to accept my right hon. Friend’s amendment 102 on support for victims of domestic abuse.
I rise to speak against the Bill overall but in favour of new clauses 56 and 57, tabled in my name, and those amendments and new clauses tabled by any Member who has sought to change the pernicious outcomes of the Bill.
Our NHS is really one of the best things about this country, but the Bill is the biggest threat to it yet. It rolls out the red carpet for private companies, ramps up the Government’s long-standing attempts to privatise the NHS, and makes easier what we have witnessed over the past 18 months: the awarding of contract after contract without a competitive process, and the rewarding of failing companies with new contracts again and again.
The Bill will be the destruction of our NHS as we know it, and will widen the inequalities that the pandemic has exacerbated. We now have more than 5.7 million people on NHS waiting lists. Of course, that is not solely because of the pandemic—far from it. After the Government won the 2010 election, around 500,000 to 750,000 people were on NHS waiting lists, and the number rose every year before the pandemic, so the waiting lists are the long-term effect of the Conservative policies of underfunding and privatisation.
Waiting lists have now doubled, and our NHS is in danger of toppling over. All the while, health inequality is rising. That is why, with the support of the Health Foundation, I tabled new clause 57, which would compel the NHS to set out data-collection guidelines on health inequalities. We know that health inequalities exist and have seen them play out with the worst consequences, from postcode lotteries to racial disparities, and it is time that we accepted that, collected the proper data—it is a farce that we do not already do so—and set out to make real change.
Since 2010, improvements in life expectancy in England have slowed more than in any other country in Europe, and the gap between rich and poor in respect of the number of years people can expect to live in good health has widened even further. During the pandemic, that was shown by the higher death rates among people who live in more deprived areas and among certain populations, most notably disabled people and people from black, Asian and minority ethnic communities. Among people younger than 65, the covid-19 mortality rate was almost four times higher for the 10% living in the most-deprived areas than for those living in the least-deprived areas. This is nothing new; the Marmot reviews have covered that many times.
Earlier this year, the King’s Fund found for the NHS Race and Health Observatory that any success we have in tackling health inequalities is always drowned out by other strains, such as waiting times and other clinical priorities. Put quite simply, we cannot tackle inequalities because this Government have never put equality at the front and centre of their policy making. That makes their so-called levelling-up agenda meaningless.
The Bill will enshrine in law the new so-called triple aim to promote various different factors, but the Government are so short-sighted that they have declined to incorporate health inequalities into the triple aim. What a complete missed opportunity that is—or a clear indication that the Government really could not care less. Before anybody says any different, and that the NHS has other means of doing that, we need to look at the state of the outcomes, because what is happening is clearly not working.
The Government continuously and repeatedly fail to accept examples of institutional discrimination, let alone meet their duties under equalities law. We recently heard about how the issues in respect of oximeters and dark skin will have contributed to worse outcomes. The Secretary of State for Health and Social Care has called for a review of gender and race bias in medical equipment; quite frankly, that is groundbreaking—all we seem to do is have reviews. We would already have these types of policies had we just heeded past Government reviews and looked at the equality impact assessments. There is no excuse for the Government to keep ignoring the requirement that is already set out in law for them to meet their equalities duties to people right across this country.
I caught your eye half a minute ago, Madam Deputy Speaker, and you indicated to me with that look that I was next. My heart rate quickened. I am always nervous when I speak in this place because we do really important stuff here—all of us do—and this is an important Bill.
Before the Health and Social Care Bill became an Act in 2012, it was amended by the Conservative Government. It was amended in pursuit of parity of esteem. The Coalition Government changed general references to health to “physical health and mental health”, which was not a courageous thing to do—it was entirely the right thing to do.
I have tabled a series of amendments—10, if I have counted them correctly—for debate over the next two days. They ask the Government to change all general references to health to “mental health and physical health”. It is a call to arms. These changes are not just totemic, but hugely important. Over the next few years, we need to recruit 9,000 more mental health nurses to look after our constituents and more than 800 new psychiatrists, and we need to give all organisations charged with delivering healthcare that nudge, that push, that call to arms that they need to make these important things happen. We also need to send another message from this place—on top of all the other messages that we have sent over the past nine years—that we believe that there is no physical health without good mental health, and that good mental health means good physical health.
I am looking at the Minister because he has made a couple of staggering interventions on colleagues tonight. Colleagues in full flow, prostrating themselves at the feet of Government, have suddenly been rewarded with his stylish, charming intervention of, “The Government have heard your cries, and they shall act on them.” I looked at the joy that spread across the face of my right hon. Friend Mrs Miller, and across the face of my right hon. Friend Jeremy Hunt, the former Secretary of State, who spoke before me. I look at the support I have from my right hon. Friend Matt Hancock, the most recent former Secretary of State—there are a few of them—and from a former Prime Minister. May I ask the Minister to make one of those generous interventions on me this evening? I am still here. I want to sit down, but if he is not going to make that generous intervention right now, I shall be back tomorrow. I shall also be travelling up to the other place and knocking on its door to make sure that these amendments are tabled there, so that, eventually, we get our way.
I came to this place largely on the back of the disastrous Lansley Act, and I am pleased to see it banished to the dustbin of history, which is what this Bill essentially does. It also banishes to the academic shelves that example of how not to make policy. Lansley took a sledgehammer to our work in primary care trusts, to partnerships, to morale, and to our capacity to forward-plan. Along with the austerity funding that came with it, the Act directly led to the poor state in which we entered the pandemic, and that must be front and centre of any review of the pandemic.
This Bill is a seminal point in the history of the NHS, because it banishes again to the history books experimental competition as an organising principle and a driver of efficiency. The key issue is what replaces it. Now we have in its place local cartels dominated by hospital trusts, and the supreme power of the Secretary of State to interfere in all local decisions. There is no power here for local elected representatives, no power for primary care or community care or mental health, no voice for patients, no voice for the public, and no voice for the taxpayer, who is asked to pay ever more. As we move to an ever more costly health service, accountability and transparency of our NHS in this role has to be at front and centre in order to bring people with us on that journey of paying more.
I have tabled two amendments to this part of the Bill. One is on the need for the local boards to be cognisant of palliative and end-of-life care. The other is on local improvement finance trusts, the local public private sector bodies introduced under the last Labour Government that are instrumental in providing good primary and community care estate—something that this Government are allowing to wither on the vine. My own South Bristol Community Hospital needs more support through these trusts in order to thrive, so that people have decent, good-quality estate from which to receive their care.
I also draw hon. Members’ attention to my new clause 23 on a good governance commission, which will be discussed tomorrow. I genuinely offer it as a helpful way forward. If it were enacted by the Government, it would avoid the cronyism that we have become used to, and would ensure that local bodies are more democratically accountable to their populations and more cognisant of the needs of their local populations. It would ensure that the people leading the local bodies are fit and proper, meet basic criteria regarding what is expected of them and have crucial accountability to local populations. It is akin to the Appointments Commission, which was abolished in the abolition of the quangos; that was a huge mistake. If the Government took notice of it, the new clause would really help us to get around some of the real concerns about how our local health services are governed.
Let me finally address new clause 49 on social care. It is a disappointment and unexpected. We had six weeks in Committee. In that time, we could have looked carefully at the proposal and shone a bit of light on it. Matt Hancock, who is no longer in his place, clearly tried to say what this provision is really about, in that one part of the state should not be subsidising another part of the state. He started to say that that was a true Conservative principle and he was absolutely right. This provision will remind people who are in receipt of benefits that they are in receipt of those benefits, and that anything they may have built up should not be counted towards their future. It is a punitive property tax. I am old enough to remember what happened to the last Conservative Government who introduced a regressive property tax; this Government really ought to think again.
I draw the attention of the House to my entry in the Register of Members’ Financial Interests in that I am married to an NHS doctor, who is employed by a hospital trust that serves my constituency.
Let me turn first to new clause 49. Those of us who have been in the world of local government for a long time will have seen the attempts by Governments of various parties to address the financial settlement around social care. I chaired a social services committee that pushed through the charging policies introduced by the last Labour Government in an attempt to address these costs. I also chaired a social services committee that had to balance the demands of the fair access criteria, and saw the last Labour Government drive a coach and horses through a lot of local provision.
I recognise that we should all seek to ask questions of Governments about how we address in particular the impact on working-age adults. In response to the people asking whether we are proud of what we are here to do tonight, I would say that we should be proud of the fact that we are willing to take what are sometimes difficult decisions to ensure that we balance the books and have a sustainable financial settlement that supports social care for our constituents. It is too late for my two grandparents, who went through the process and saw very modest assets consumed by the cost of long-term care, but I welcome the fact that my constituents, and people up and down the country, will benefit from what this Government are seeking to achieve.
I will move on, briefly, to new clause 55, which addresses the responsibilities for ICSs regarding the provision of services and planning for services for our youngest children. My right hon. Friend Jeremy Hunt made a helpful intervention, in which he pointed out the effectiveness of Ofsted-style regulation in ensuring the quality of provision at a local level.
We had an excellent debate in the Chamber just a few weeks ago, discussing the work done by my right hon. Friend Dame Andrea Leadsom, which was reflected in the budgetary decisions that were brought forward previously. Having had that debate, it seems clear to me that in tabling an amendment supported by more than 70 organisations in the field of children’s care, we have an opportunity—one which was debated and touched on through various assurances from Ministers in Committee. It is an opportunity to ensure the right level of rigour and accountability in what we ask of ICSs, so that we can make sure that our youngest children, babies, neonatal care, and indeed young people up to the age of 25 who are already covered by statutory provisions in respect of special educational needs and care leaving, are appropriately covered.
I am going to reduce the time limit to three minutes in the hope that as many people as possible can get in.
The Health and Care Bill is deeply problematic. I want to focus on two issues that, when combined, mean that it is a complete disaster. It not only makes it easier for private health giants to profit from the national health service; it also makes a charter for corruption because it opens the door to even greater private sector involvement in our NHS. That is why this Bill should really be called the NHS corporate takeover Bill. For example, it allows private corporations to sit on health boards, which make critical decisions about NHS budgets and services, and the Government’s amendment 25 does not go nearly far enough.
Even before this Bill, an unbelievable £100 billion has gone to non-NHS providers of healthcare over the past decade alone, and earlier this year half a million patients have had their GP services quietly passed into the hands of a US health insurance giant. This Bill would lock in yet more privatisation in future, with even less scrutiny, because it means less transparency. It means private health giants getting an even bigger slice of the action with less scrutiny.
I draw the House’s attention to my declaration in the Register of Members’ Financial Interests as a practising NHS doctor. On the issue of private healthcare provision, the hon. Gentleman will recognise that GPs are in fact small businesses in their own right, and some of them quite large businesses. How does he equate the role of the GP as a small business in the context of his concerns about private healthcare?
We are not seeking to wage war on GPs; we want to support GPs and properly resource them. We see so many GPs retiring and not being replaced. It is this Government who are waging war on our NHS with this further Americanisation of our NHS. It is a dangerous cocktail where the dodgy contracts we have seen throughout covid risk becoming the norm. The billions squandered on test and trace should serve as a warning of what the Government could do to the whole of our NHS.
There is a sleight of hand going on with this Bill. It is true that under the Bill NHS bodies will no longer have to put services out to competitive tender to the private sector. Such tendering to the private sector was made a requirement under section 75 of the coalition Government’s Health and Social Care Act 2012. It was a shameful Act and its scrapping has long been demanded by those opposed to privatisation of our national health service. However, the change in this Bill does not reverse privatisation, because without making the NHS the default provider, that simply means that contracts can not only still go to private healthcare corporations but can do so without other bids having to have been considered.
To prevent all this, I tabled amendment 9, which I want to put to a vote—unless of course the Government accept it—because it establishes the NHS as the default option. [Interruption.] Conservative Members groan, but the only reason for people not to support my amendment is if they do not believe in the NHS not moving to a privatised insurance model. Why else would people object to the NHS being the default provider of healthcare? The British Medical Association supports it, so the Tory groans are groans against the position of the British Medical Association. Unison supports it, so the Tory groans are groans against the voices of those who work in the NHS—for most of whom, if they need to have more than one job, it is because they do not get paid enough, not because they are trying to get their own snouts in the trough. I will be voting against the whole Bill, but if the Government refuse to accept amendment 9 to make the NHS the default provider, that shows what the Government of the party that objected to the foundation of the NHS in the first place are really up to, despite all the warm words.
I rise to speak to new clause 49. In doing so, and whatever its merits or otherwise, it is worth reflecting on the comments made by the Minister that we are at least here this evening looking at a part of a process that will lead to some progress in meeting social care costs going forward and removing the catastrophic risk that has hung above the heads of all our constituents up and down the country: that their healthcare costs may end up costing them all of their assets. We are also here having taken the tough decisions around having raised taxes to fund those arrangements.
I have problems with new clause 49. It seems to me that to make good law in this place, first, we need time to consider the matters put before us and secondly, we need the appropriate information upon which to take those decisions. On both those points, I have real concerns about how new clause 49 has been brought forward. The first we heard of it was not in Committee or in September when the general measures were put forward, including the taxation measures on which we all divided and voted, but on Wednesday evening, when the amendment was tabled.
It was fortuitous that the Treasury Committee happened to have Sir Andrew Dilnot before us the very next day. We were able to discuss many of the issues inherent in new clause 49. A number of issues were raised, to which only the Government have the answers. One of them has been put forward powerfully by speaker after speaker tonight, which is: what are the impact assessments associated with these measures? I wrote to the Chancellor immediately after that session and asked him for some impact assessments, including geographical impact assessments, of which we have had none.
It seems that the only information we have had was released by the Department of Health and Social Care on Friday night, in a document called “Adult social care charging reform: analysis”. I am very short of time, which is a shame, but there is, for example, a chart of a 10-year care journey that looks at individuals with different asset levels. While it is true, as my hon. Friend the Minister said, that these arrangements, even with new clause 49, are better for almost every level of wealth than under the status quo, it is not the case that everybody is better off compared with the measures brought forward in September.
The right hon. Gentleman gets to the heart of the matter, which is what people will get, compared with what they were promised. Is that not the heart of this matter?
I think the heart of the matter is that we have to be clear and wide-eyed about what this change will do. Yes, it is true that it will leave us in a better position than the status quo, but it is not the case that it will leave those who are less well-off in a better position than if new clause 49 were not passed by the House. For those with assets of about £106,000, by my read of this graph, about 59% of their assets would be lost on average under the original proposals. Under the amended proposals, that figure would rise to 70%. When it comes to those who would be better off as a consequence of new clause 49, many are the better off, because they benefit from the changes being made to daily living costs, to which my hon. Friend the Minister referred.
I am out of time, but I believe that these measures should have been better ventilated in this House—certainly in Committee, if not earlier. We would then have had better information and more time in which to make these important judgments.
I want to speak briefly to amendment 15, which focuses on the membership of integrated care partnerships—the bodies that will be responsible for developing plans to address the health and care needs of local populations. The amendment would enable the Secretary of State to make specific provisions ensuring the representation of particular areas of healthcare on ICPs via secondary legislation.
In particular, I am concerned about having a strong voice for women’s health in ICPs. I also mention in passing the need for other groups to be represented, such as carers, in an ICP area. As co-chair of the all-party parliamentary group on sexual and reproductive health, I have seen how the experience of women in relation to their healthcare is often an afterthought in a fragmented health system, as in the case of the vaginal mesh scandal; the recent debate about pain during the insertion of intrauterine devices, a form of contraception; maternity provision; and cuts to contraceptive services.
The amendment would ensure that the issue of representation was considered by the Government. It has strong support from the medical bodies in this area, including the Faculty of Sexual and Reproductive Healthcare and the Royal College of Obstetricians and Gynaecologists, as well as in other areas of healthcare, such as childhood cancer, and, as previously mentioned, carers groups.
It is important to protect the independence of ICPs and ensure that they can set a strategy that effectively meets local needs, but there is also a need to ensure that women’s voices are not left behind in the decision making. Without this amendment, it cannot be assumed that those voices will be heard on all ICPs. I hope that the Government will consider the purpose of the amendment, which is to strengthen the Bill.
There is much to be positive about in relation to the recent history of the national health service. NHS England research indicates that the outcomes for most major conditions are significantly better than they were 10 years ago, and the NHS is seeing more patients and delivering more tests, treatments and operations than at any time in its 73-year history—millions more than 10 years ago when the Conservatives returned to power.
To reassure those concerned by some of the campaigns around the Bill, I emphasise that this Conservative Government are committed to NHS values. We are delivering the biggest ever cash increase in NHS funding. It is just plain wrong to accuse the Government of trying to privatise the NHS. In fact, it was the last Labour Government who pushed competition and private sector involvement, including many private finance initiative contracts that proved to be unwise and massively expensive. If anything, the Bill takes the NHS in the other direction by reducing the role for competition and increasing the scope for co-operation.
At the Bill’s core are the integrated care systems considered by this group of amendments. Its provisions on ICSs enjoy considerable support from within the NHS and build on the NHS’s own proposals for reform to make it less bureaucratic and more accountable and to enable it to be more integrated with other local service providers, such as councils.
I will not be backing the amendments in this group except those tabled by the Government. I welcome Government amendment 25 for the clarity that it provides to ensure that appointments to ICBs will not in any way jeopardise their independence. By dismantling elements of the complex system for compulsory tendering of services, we will free up time and resources in the NHS and remove barriers to local co-operation so that we can improve patient care.
We all recognise that ever-increasing healthcare needs place great pressure on the NHS, which will rise in years to come as more of us become frail and need extra care. I ask the Minister, in his response, to emphasise how we will train, recruit and retain the professionals we need to deliver NHS services. Record numbers of doctors and nurses are working in our NHS, and I pay tribute to each and every one, but it is crucial to step up the numbers, especially of GPs. GPs in my constituency are overstretched and we need more of them. That needs to be a priority for the Government.
Members will appreciate that I have had to give precedence to people who have amendments in their names on the Order Paper, so not everyone else will have a chance to speak this evening.
The Government often talk the talk on health inequalities but fail to walk the walk. New clause 57 sets out a requirement that NHS England must publish guidance in relation to health inequalities, which I wholeheartedly support. My amendment 99 seeks to put in provisions to reduce inequalities between non-migrant and migrant users of health services. Campaigners and experts have argued that the pandemic has shown more tangible action is needed to tackle health inequalities. The increased risks of those on lower incomes and black, Asian and minority ethnic communities catching and dying from covid-19 have been well documented, yet the provisions outlined in the Bill will likely make the situation much worse.
I tabled amendment 99 in particular after seeing evidence that people are being denied access to healthcare, or are facing high charges for doing so because of their immigration status. As part of the hostile environment, the Government have increasingly been restricting access to the NHS for certain migrants by introducing upfront charging for those unable to prove their entitlement to care, by charging migrants for the cost of treatment and by sharing NHS patient data with the Home Office for the purposes of immigration control.
Surely, in any civilised society, migrants should have automatic access to services without fear of detention or deportation, and without facing barriers that deny them their rights. Everyone being entitled to treatment goes to the core of what the NHS is, and why it is valued and beloved. Access to high-quality healthcare is possible for all, and this can be done best when healthcare provision is publicly run, publicly accessible and publicly accountable. My constituents deserve nothing less, and I will never stop pursuing this goal until it becomes a reality.
This Bill can really help support giving every baby the best start for life.
First, new clause 55, in the name of my hon. Friend David Simmonds, would require the Secretary of State to publish guidance on how integrated care systems should meet the needs specifically of babies. “The Best Start for Life” report, published in March, calls for every local area to publish a seamless start for life offer for every new family. That must include midwifery, health visiting, mental health support and targeted services such as couple counselling, debt advice and smoking cessation. Each of these services is currently provided from silos within the public, private and civic sectors, so properly integrating them is no small task. I urge my hon. Friend the Minister to ensure there is very clear guidance to every local area on how it should co-ordinate its support for babies.
I also want to support amendments 91 and 92, in the name of my hon. Friend Sir Charles Walker, which call for parity of esteem between mental and physical health. Mental health support for families who are struggling in that critical early period is vital. The London School of Economics has assessed that perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK. Prevention is not only kinder but so much cheaper than cure.
Finally, I would like to support amendment 102, from my right hon. Friend Mrs Miller, which calls for integrated care boards to provide clarity about their plans to tackle domestic violence. I am delighted that the Minister has already agreed to accept it. Analysis by the WAVE Trust indicates that up to 30% of domestic violence begins during pregnancy. The WAVE Trust highlights the crucial nature of experiences in the period of conception to the age of three in the formation of seriously violent personalities, largely because of the sensitive nature of the infant brain in those formative years. Domestic violence within a family is incredibly damaging to the emotional development of a baby, and I encourage my hon. Friend the Minister to ensure that plans for tackling domestic violence cover not just relations between partners, but reducing the impact on babies.
Madam Deputy Speaker, you may have heard me speak in this place before about giving every baby the best start for life, and I keep doing so because I am convinced that, if we invest in the 1,001 critical days, we really will transform our society for the better. It is in the period from conception to the age of two that the building blocks for lifelong physical and emotional health are laid down.
I was not expecting to be called, Madam Deputy Speaker, but here we are. I want to tell a little story about my dad. My dad often rings me and tells me the things I should say in Parliament—I am not entirely sure any of you are quite ready for it, but I want to tell a story about my dad. He was born in the war, and they were given a council house by the Attlee Government—my dad could lecture us on it for weeks! He was given a council house, which his very Conservative parents bought in the 1980s. My granny, unbelievably—a lovely, generous woman—was a massive Thatcherite. She bought her council house in the 1980s, and that council house stands in my constituency. It is worth around £120,000.
My dad went on to get an education—a free education—and he moved into an area of Birmingham that was not very trendy at the time. He stayed there, I was born there, and my brothers lived there. All through our lives we watched that area get a little bit trendier, and the price of my dad’s house, which he bought for £30,000, went up and up and up. He didn’t particularly do much work—he likes to woodwork in his garage, but he has not done much. His house is probably worth around £700,000 now, and it was £30,000 when he bought it.
If my dad were here today, what he would say to hon. Members, and what he will almost certainly say to me, because he watches it all, lurking on Twitter, is that he does not deserve to keep his wealth for his children at any greater rate than the people who live in the council house that his parents bought on Frodesley Road in Sheldon. Yet today, the people who live in my constituency and the council house that my granny bought, to try to get a better life, will subsidise the care of my father, who has a £700,000 house that I do not need to inherit. I’m all right. I’ve got quite a good job. It is totally unacceptable that that is the situation we are putting almost all my constituents in, compared with constituents in Chipping Norton, for example, or the constituents of other hon. Members who have stood up and spoken. My constituents will largely be left with nothing. They will not be grateful.
I am conscious of time, Madam Deputy Speaker, so I will try to cover some of the main themes that have emerged from today’s debate. I am grateful for the debate we have had today. The vast majority of what is contained in the Bill is exactly what the NHS said that it wanted and needed, and it is the right legislation being brought forward at the right time, to drive forward those priorities highlighted by the NHS in its 2019 consultation. The Bill drives forward integration not only within the local NHS within a region, but also greater integration with a local authority. It provides the foundations on which we can continue to build, as we move forward with greater integration of health and social care services that are designed to work around the individual, rather than in institutional silos.
Despite misleading claims by campaigners—and, indeed, by some Opposition Members—the Bill does not privatise the NHS. The NHS will always be free at the point of delivery. It has been in the hands of the Conservative party longer than it has been in the hands of any other party, and the Conservative party has put in place record investment in terms of resources in our NHS. What we propose in the Bill continues to build on that. Government Amendment 25 on ICBs is clear: ICBs are NHS bodies. They have always been NHS bodies in our proposals, and we have put in place provisions regarding conflicts of interest. Just to make sure, and given the misleading claims about private involvement, new clause 25 puts beyond doubt that ICBs are NHS bodies and must act in the best interests of the NHS. It is an amendment that is much stronger and much more effectively drafted than the alternatives put forward by the Opposition, because we believe in putting this question beyond doubt.
On the ICBs and ICPs, we have sought to be permissive rather than prescriptive, giving those local systems, within a national framework, the flexibility to deliver what they need to deliver for their local areas, which they know best.
I have been happy to accept amendments 102 and 114. I will continue to reflect on the points made by my hon. Friend Sir Charles Walker; in the nicest possible way, I suspect that—rightly—he will not go away. The former Secretary of State, my right hon. Friend Jeremy Hunt, set out very clearly the case for his amendment 114, which I was happy to accept, and the importance it places on patient safety.
My right hon. Friend Dame Andrea Leadsom has done a huge amount of work in this space—I pay tribute to her—and she is right: we will look very carefully in the statutory guidance at how we can emphasise that. I fear that my hon. Friend Anne Marie Morris was not in her seat when I paid tribute to the work that she had done previously, but I put that on the record too.
On new clause 49, my hon. Friend Caroline Dinenage, a distinguished former Care Minister, made the point extremely well that this is a significant improvement and step forward on where we currently are in respect of tackling the social care challenge.
I am afraid I will not, because I have only a couple of minutes in which to try to address these points, and I did give way a dozen or so times in my opening remarks.
Equally, I recognise, as always in this House, the strength and genuine sincerity of the views and the points put by hon. Members on both sides, genuinely highlighting and wishing to explore certain aspects of new clause 49 to understand exactly what it does and how it works. I have complete respect for the strength of those views.
I believe that, as my right hon. Friend Matt Hancock set out very clearly, this is a significant step forward. It will make a huge difference, and it must be treated as part of a package of measures rather than in isolation. As he quite rightly highlighted, we must look at the floors as well as the cap, at the support that is available, and at the increases in those floors from £14,250 to £20,000 and up to £100,000.
I am afraid I will not, because I literally have only one minute, and I did give way multiple times in my opening remarks.
I believe that the measures in this Bill, which we have debated with these amendments today, give the NHS what it needs to further integrate to deliver the local services it needs and, crucially, move us a huge step forward in tackling the challenge posed by social care for future generations.
Question put, That the clause be read a Second time.
The House divided: Ayes 272, Noes 246.
Question accordingly agreed to.
New clause 49 read a Second time, and added to the Bill.
Proceedings interrupted (Programme Order, this day).
The Deputy Speaker put forthwith the Questions necessary for the disposal of the business to be concluded at that time (