Examination of Witnesses

Healthcare (International Arrangements) Bill – in a Public Bill Committee at 9:27 am on 27th November 2018.

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Mr Alastair Henderson and Raj Jethwa gave evidence.

Photo of Graham Stringer Graham Stringer Labour, Blackley and Broughton 9:29 am, 27th November 2018

Q We will now hear evidence from the Academy of Medical Royal Colleges and the British Medical Association.

I remind hon. Members that questions should be limited to matters within the scope of the Bill, and that we must stick to the timings in the programme motion that the Committee agreed for this session. We have until 10.25 am. I hope, because the Minister has to be on his feet on the Floor of the House immediately after this, to cut a couple of minutes off the session to enable him to carry out his duties.

Are there any relevant interests to declare? No. Will the witnesses introduce themselves?

Mr Henderson:

Thank you. I am Alastair Henderson, the chief executive of the Academy of Medical Royal Colleges, which is the umbrella body for all the different medical royal colleges and faculties in the UK and Ireland. We represent the range of specialties, particularly on training, education and standards matters.

Raj Jethwa:

I am Raj Jethwa, director of policy at the British Medical Association, which is the trade union and professional association for doctors in the UK.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q Good morning, gentlemen. Thank you for coming to give evidence to us this morning. Mr Henderson, in your evidence to the House of Lords European Union Committee, you noted that you want to see the current arrangements preserved. Could you just say how you think the current regulations for reciprocal healthcare work and why they are so satisfactory?

Mr Henderson:

Yes, certainly. I think that the feeling of clinicians and health organisations, and also of patients, is that the current regulations work well because they are simple, well understood, easy to operate and pretty well universal in their coverage. We have a good system at the moment that is effective and easy to operate, and going forward we are looking for something that repeats or replicates that as closely as possible.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q In your evidence to the Lords Select Committee, you stated that pretty clearly as well. The Bill obviously aims to replicate and continue the current arrangements. I assume that, given your support for the regulatory system, you think that this is a sensible way for the Government to proceed.

Mr Henderson:

Yes, I do; we are pleased to see that. I suppose our position is that, overall, the best and easiest thing would probably be for reciprocal healthcare agreements to be covered in an overall agreement. That seems to me to be the best thing. If we are not in the position of having an overall agreement, the Bill, which puts in these complementary arrangements, seems to be exactly the right thing. We are very supportive of it and are pleased to see that there.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q This is my final question to you, Mr Henderson. In your evidence to the Lords Select Committee, you also made the point about costs and administrative burdens. As I understand it, if a new system were needed or if a no-deal scenario unfortunately arose—that is not the Government’s intention—the costs or administrative burden would be a change in coding, rather than any other major administrative burden. Is that your understanding as well, in terms of cost recovery?

Mr Henderson:

In terms of the overall cost, that may well be the position. It is not known what the arrangements for cost recovery would be. Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive. If all people in this country from the European Union or European economic area have to be charged, what would be the implications for NHS organisations and clinicians?

It is important to say that doctors have had a consistent anxiety about becoming involved in being responsible for either immigration rules or charging rules, which would potentially have a quite adverse effect on the doctor-patient relationship. I think it is really important that whatever arrangements come in are as seamless and as simple as possible, so that they do not take people away from clinical duties or get in the way of delivering care.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q Thank you.

Mr Jethwa, good morning. I noticed in your written brief that the BMA stated that the Government should undertake every effort to retain the current model of reciprocal healthcare. My first question is the same as that to Mr Henderson: can you state why you think the current system works so well?

Raj Jethwa:

For exactly the same reasons my colleague sets out: the arrangements are wide-ranging, secure and simple. They give security and clarity and are well established. Our view is that the best possible arrangement is for those arrangements to continue. If they cannot, the arrangements that come in their place should mirror them as far as possible.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q Given that, and given that that is the intention of the Bill, do you think that the Government are taking the right approach to ensuring that they put those arrangements in place and that the legislation has the flexibility to cover both what we hope for, which is an achievable deal, and a no-deal situation?

Raj Jethwa:

We largely welcome the Bill for exactly the intention behind it, but because the detail in it is limited we have some concerns about exactly the clarity going forward that the Bill allows for. We support the broad intentions behind the Bill, but we would like to see more detail about exactly how the arrangements will operate in practice, particularly the scrutiny arrangements to ensure there is clarity and transparency in what the arrangements negotiated and facilitated through the Bill would look like.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q In terms of the security arrangements, do you mean security of data?

Raj Jethwa:

No, I beg your pardon. We do have concerns about security, but I meant clarity, from the perspective of patients understanding and being secure in themselves about what the arrangements would mean.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Mr Henderson, you said you consider that the system works well at the moment. I think it is pretty universally accepted that the cost recovery element does not work so well. Do you feel that more ought to be done in respect of that, and if so what would you like to see doneQ ?

Mr Henderson:

I do not pretend to be an expert on the cost recovery system. I think our members would be very clear that they believe the primary effectiveness of the current arrangements is about providing effective healthcare for citizens across the EU. As clinicians, that is their primary responsibility.

On the recovery of costs, not just in this area but for other areas where recoverable costs were brought in more recently, there are always questions about the amount of effort and return in the whole system. I am not at all opposed to the idea of recovery of costs, but I am not sure we have yet found a hugely simple and easy way of recovering any costs really. I would happily support that, but it seems to us that this works as a system on its most important requirement, which is providing quick, clear and safe healthcare for people.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Q You say that you have basically the same system for 32 or 33 different countries. If we end up in a situation in which we have to make arrangements with each individual country—potentially significantly different arrangements depending on what is negotiated—what effect do you think that will have on your members, in terms of what they can deliver?

Mr Henderson:

It is not a hugely attractive prospect, is it, 32 different settings, for those presumably trying to agree the arrangements? In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up. What clinicians on the ground want is a clear and simple system—ideally a single system—that will cover all the people they are seeing.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Q May I ask Mr Jethwa some questions? Have you looked at all at the situation as it might affect the island of Ireland?

Raj Jethwa:

We have done some work on that.

Raj Jethwa:

Our concern about the situation there is primarily based on the fact that there are some very effective cross-border agreements which have facilitated healthcare over the last two or three decades, particularly through co-operation and working together as a programme. That is only one aspect of it. Given the population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, there have been some fantastic examples of where clinicians have either co-located services in a particular trust or facility where there is not the demand from the local population to warrant it, or travelled across the border to work on different sites. Those two facets together have meant that there have been some great examples of cross-border co-operation. One of our concerns is that those arrangements remain in place in the future.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Q Do you have any idea what the contingency plans might be if an appropriate deal is not put in place?

Raj Jethwa:

That is something that we can write to the Committee about afterwards. We have been talking to our members about this situation. Our anticipation—our hope—is that an arrangement will remain in place whereby that work can continue.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Q Have you looked at what the possible impact might be of a no-deal scenario on increased demand on services if, for example, pensioners currently living abroad came back?

Raj Jethwa:

We are familiar with the research that the Nuffield Trust has done on this, as most people are. Our members are very cognisant of this. I know the Committee will be familiar with the figure of approximately 190,000 UK pensioners who may require access to healthcare facilities in the future if the S1 arrangements do not remain in place. We have concerns about that. In particular, if the arrangements do not remain in place in the future, those people may need to access healthcare facilities back in the United Kingdom. That would be a concern in terms of doctor and clinician numbers and beds, and the tight financial resources that the NHS has to work under at the moment.

Photo of Julie Cooper Julie Cooper Shadow Minister (Health and Social Care) (Community Health)

Good morning. Mr Henderson, you mentioned the protections around personal data in the Bill. Do you feel that the Bill gives enough protection? Are there enough controls in the BillQ ?

Mr Henderson:

As Raj says, this is an enabling Bill, so it is slightly hard to say whether there is sufficient protection there or not. Clearly, it is a hugely important issue that needs to be fully addressed. Equally, we would say very strongly that, while individual patients’ data must be protected, the free flow of data and exchange of information are absolutely crucial. We should never forget that side of the equation: properly and safely sharing anonymised data for research purposes, clinical trials and so on is crucial. While it is absolutely essential that we ensure that personal data is protected, I would put more emphasis on that other side, which is ensuring that we continue to share and benefit from the exchange of anonymised data for purposes that benefit the health service and research.

Photo of Julie Cooper Julie Cooper Shadow Minister (Health and Social Care) (Community Health)

Q Thank you. Mr Jethwa, would you like to comment on the same issue?

Raj Jethwa:

It is important that an agreement can allow a seamless operation, but there are some well-established ethical principles and safeguards in relation to this. First, it has to be relevant data and it has to be accessed on a need-to-know basis, and only when it is in line with patients’ expectations. Data sharing has to be transparent. We would be absolutely concerned that any safeguards meet those criteria and principles. I do not think the details in the Bill make that clear at the moment. We would like to see more clarity and detail about that in future.

Photo of Maggie Throup Maggie Throup Conservative, Erewash

Mr Jethwa, when you look at the current regulations, do you think the powers in the proposed legislation are proportionateQ ?

Raj Jethwa:

We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward. There are some negative procedures—I think that is the term. Given the weight of the issue and the number of people that could be affected by it—I have mentioned the 190,000 UK pensioners who live abroad at the moment, but there are close to 3 million people from the European Union who access healthcare in this country, and there are many more than that who travel across the European Union at the moment—there probably needs to be greater scrutiny of any arrangements going forward.

Photo of Matt Western Matt Western Labour, Warwick and Leamington

Mr Henderson, I think you described the existing arrangements as pretty well universal. Could you explain a little more what the gaps areQ ?

Mr Henderson:

I am not actually sure I have all the detail. My understanding is that the European health insurance card and such arrangements work for all emergency situations, certainly, and most normal circumstances. I think, and Raj may know better than I, that there are some areas that are not covered particularly, but as I understand it, it is fairly universal. I am not an absolute expert in that, I am afraid.

Raj Jethwa:

We can write to the Committee. My opinion is that it is pretty universal. There are probably niche areas that may not be covered. We can look into that and get back to the Committee if that would be helpful.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour)

Q I have one more question to both of you—I am not sure if either of you will know the answer. Some of the reciprocal arrangements we have at the moment are based on the actual cost expended and some are based on an average—Estonia, Denmark, Finland, Hungary, Malta and Norway. I am not clear why that is the case. Is there some sort of historical issue? If either of you can shed any light on that, that would be extremely helpful. One of you is shaking your head.

Raj Jethwa:

I do not know that, but again we are happy to look into that and to come back to you if we find out that somebody back home does know the answer. I am not sure that I know.

Mr Henderson:

It is probably lost in the mists of various previous agreements.

Photo of Stephen Hammond Stephen Hammond Minister of State (Department of Health and Social Care)

Q Can I come back on the data point that you both commented on? Clause 4 deals directly with that and provides the usual protections in terms of data. I heard Mr Henderson’s point, and it is important that there needs to be a flow of data, although that needs to be secure. Are you happy that the protections in the Bill at the moment are the normal and adequate protections?

Raj Jethwa:

One of the concerns we have is the reference to the authorised person and who could fit into that category. Without seeing more detail about what the arrangements will look like in the future, we do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly what process will be used to, for example, recoup the money or make payments, it is hard to know exactly what those arrangements would look like and on what basis information would be shared. We do have concerns about the authorised person aspect of the Bill, and we need to ensure that we have greater understanding about exactly who would be an authorised person, beyond that list of specific bodies and individuals who are named in the Bill at the moment.

Photo of Graham Stringer Graham Stringer Labour, Blackley and Broughton

Does the Committee have any more questions? No. I thank the witnesses for helping the Committee with its deliberations, and call the next witness.