My Lords, over the pandemic the NHS has worked wonders. Throughout the greatest challenge that our health and care system has ever faced, the extraordinary dedication, care and skill of the people who work in our communities and hospitals have been unwavering, and I am sure that the whole House would want to put on record our thanks and admiration for staff across the health and care system.
The Government believe that part of that thanks must be in the form of giving the NHS the Bill that it wants, the Bill that it has asked for and the Bill that it needs to take better care of all of us. Some may say that this is the wrong time for this legislation. The Government and, more importantly, the NHS disagree. The Bill builds on the progress that the NHS made during the pandemic. Under crisis conditions, the NHS evolved, finding new reserves of incredible creativity, innovation and collaboration. It rolled out an extraordinarily successful vaccine programme, it drew on our collective strengths to deliver a programme reaching every corner of the United Kingdom and it has continued to deliver.
But the NHS has told us that the current legislation contains barriers to innovation that the Government feel duty-bound to remove. The NHS has asked for more flexibility to enable local leaders to try out new things—not as a free for all but in ways that best suit local needs and ensure that the system can evolve. The NHS has asked us to protect and nurture the innovation and hard-won lessons of the pandemic, as we begin to build back better.
Much of the Bill is not new: it builds on years of work on the ground to integrate care, on the work outlined in the NHS Long Term Plan and on years of experience, effort and learning, and of the system pushing the legislation to its limits to do what is best. It also builds on the Integration and Innovation White Paper that we published in February 2021, and on the many consultations that we have held on different aspects of the Bill. The NHS asked for legislation to make it fit for the future, and we are delivering. The Government believe that this is the right Bill at the right time, with wide support for the principles of embedding integration, cutting bureaucracy and boosting accountability.
I am sure that noble Lords will agree that one of the biggest challenges facing the NHS is the workforce. The Bill proposes a duty on the Secretary of State to report on the workforce “once every five years”. The Government are asking the NHS to develop a 15-year strategic framework for workforce planning, and we are looking to merge NHS England and Health Education England to deliver this. We are on track to deliver on our promise of 50,000 more nurses by March 2024.
The Government believe that this Bill will also help to deliver adult social care reform. In September, we announced plans to invest an additional £5.4 billion to begin a comprehensive programme of reform. Last week, we published our reform White Paper, People at the Heart of Care. This sets out our vision for adult social care and our priorities for investment, with measures including a new £300 million investment in housing and a £500 million investment in the workforce, to bring tangible benefits to people’s lives.
My Lords, I am glad to speak in this Second Reading debate on a Bill that has generated much anticipation and interest; the Minister’s comments today have also created much anticipation and interest. I am grateful to the many parliamentary colleagues, organisations, charities and representative bodies that have given their time to give their invaluable views and expertise to many of us in your Lordships’ House. I also thank the Minister and his team for making themselves available, and for the extensive work that they have already undertaken and will continue to undertake. I look forward to the maiden speech of the noble Lord, Lord Stevens of Birmingham; I wonder how he decided to choose this particular Second Reading in which to make it.
However, I am sorry to say that this is the wrong Bill at the wrong time, as it fails to deal with the real and immediate issues in the health and care system: scandalous social care provision; no workforce planning; no strategy for integration between health and social care; weak and underfunded public health services; and inadequate levels of funding. Regrettably, the Bill does nothing to resolve the democratic deficit around accountability in the NHS, and fails to put patients, their carers and the workforce at the heart of building back a better NHS. It is not about improving well-being or addressing the social determinants of poor health. Nothing in this Bill will make much difference to the long waits for people in pain and distress, or those who experience delays in waiting for an ambulance. As for it being the wrong time, we know that the pandemic is far from over. We still await proposals for social care integration, and the most vital issue—responding to the workforce crisis in the NHS and social care—is not even at the planning stage.
Let us remind ourselves that this Bill began as a legislative response to desperate pleas from the NHS to reverse some of the provisions in the Health and Social Care Act 2012, which made it impossible to develop the NHS Long Term Plan. There were demands to end compulsory competitive tendering for health care services and allow much greater co-operation and joint working between various bodies. Also, it was clear that the informal organisational arrangements that the NHS had developed in the sustainability and transformation partnerships needed to be put on to a statutory basis. These have become the proposed 42 integrated care partnerships.
My Lords, I declare my interest as a vice-president of the Local Government Association. I welcome the noble Lord, Lord Stevens of Birmingham, to his place and look forward to hearing his maiden speech. I also offer my thanks to everyone who has briefed us. We, too, regret that the advisory speaking time is five minutes on a long and complex Bill, with many expert speakers whom I am sure the House will want to hear. We note that this time is advisory.
In principle, we have long argued for true integration of health and social care, and reforms are long overdue. The coalition Government created the better care fund, which has set a standard for integrated care in a number of places such as Torbay, but our social care system has needed reform for decades. The increasing workforce crisis and cuts to publicly funded patients, with private patients having to subsidise them, is scandalous. Covid, including the omicron variant as well as the severe winter crisis already with us, makes it much harder for substantial reforms to be in place for the end of March. I echo the comments of the noble Baroness, Lady Merron, about it being the wrong Bill at the wrong time.
The long-awaited adult social care reform White Paper, People at the Heart of Care, was essential for delivering true integration. Despite the Prime Minister’s promise on the steps of No. 10 Downing Street two and a half years ago, I am afraid that the White Paper is deeply disappointing, not least on how integration will work in practice. Perhaps it is not surprising that Ministers have already announced another social care integration White Paper for next year. We still need to see it before the passage of this Bill. I fear that we will not. We believe that these changes will not work without the reform of workforce planning, and we will seek to strengthen the long-term planning arrangements, especially for social care, where progressive career pathways and proper skilled rates of pay are long overdue.
My Lords, I thank the Minister for the thoughtful way in which he introduced this Bill and draw attention to my own register of interests, in particular the fact that I am chairman of the King’s Fund, King’s Health Partners and the Office for Strategic Coordination of Health Research.
I welcome much of what is proposed in this Bill, because it has a specific purpose— to drive integration. It has long been desired across the National Health Service that greater emphasis be placed on integrated care, including integration between primary and secondary care, between physical and mental healthcare, and between health and social care.
Clause 5 also sets some guiding principles for all NHS organisations, with the triple aim of ensuring better health and well-being, improved quality of services delivered and the most effective and efficient use of resources, applied by the state for the provision of health services. However, it fails in setting a guiding light and principle for the NHS to address the important issue of inequalities, which we have seen exacerbated during the Covid pandemic. Might Her Majesty’s Government consider amendments that address this issue in Committee and ensure that there is a fourth guiding principle for all NHS organisations with a duty to address health inequalities and inequalities in outcomes?
We have heard about other important provisions in this Bill, many of which will be addressed by noble Lords today. Although there is consensus that much has to be achieved, a number of the provisions and the failure to address other issues are somewhat controversial. I hope Her Majesty’s Government will give sufficient time in Committee to ensure that these issues can be properly addressed and that there can be absolute confidence, finally, once this Bill passes through your Lordships’ House.
I will emphasise just three additional areas in the time remaining to me. The first is research. We all recognise that a research environment and culture is critical to the sustainable delivery of health and care in our country—research not only in terms of development of new therapies or devices but into new models of care and how best we can deploy the workforce to achieve effective and efficient delivery of healthcare. Clause 20 makes provision for integrated care boards to have a duty to promote research, but that does not appear to go far enough to ensure that the commissioning environment secures a proper ecosystem for research, driving not only the provision of facilities but a culture in the development of a workforce able to engage in research, which is the lifeblood of the future of the NHS.
3:57 pm
The Lord Bishop of Carlisle
My Lords, this is a health and care Bill. I will address certain specific aspects of that care that deserve further attention.
First, on integrated care, like the noble Lord, Lord Kakkar, I welcome the clear desire for integration, collaboration and local flexibility, and the placing of integrated care systems on a statutory footing. But can the Minister assure us that, in ICBs and ICPs working together to ensure co-ordination in the design and delivery of integrated care, there will be an adequate focus on prevention rather than just cure, especially in mental health needs, not least among young people with learning disabilities?
Secondly, there is pastoral, spiritual and religious care, which, as Covid has reminded us and NICE guidelines recognise, are essential aspects of care, especially at the end of life. In Clause 16, mention is made of commissioning “other services and facilities” in addition to the medical, dental, ophthalmic, obstetric, nursing and ambulance services previously mentioned. It is probably not practicable to list all 14 allied health professions in the Bill, but perhaps it could be made clear that these cover important aspects of care that ICBs should be expected, not just encouraged, to commission. That would certainly provide some reassurance for, for example, healthcare chaplains, who, among so many others, have done such valuable work during the pandemic.
Thirdly, there is palliative care. We need no reminder of the fact that we are an ageing population. A significant proportion of those with palliative care needs already do not receive the care they need. By 2040, the number of people who have such needs will have increased by up to 42%. One of the stated aims of this Bill is to reduce inequalities in the provision of care across the country. Therefore, I find it strange that there is no direct reference to palliative care services or the need for integrated care wards to commission such services in their areas.
Fourthly, there is social care. As the Minister has already reminded us, one of the biggest challenges facing social care, as with the NHS, is workforce planning and supply. We are all aware of the alarming statistics regarding vacancies, as well as morale. I am grateful that the Bill aims to improve this situation but, as almost all the briefings that we have received have emphasised, we need greater accountability, transparency and reporting on this issue. So I was disappointed to learn that a proposed amendment to Clause 34 in the other place was not accepted by Her Majesty’s Government. I am equally disappointed that no mention is made in the Bill of the pay of carers, which is obviously an indication of the extent to which they are valued in our society.
My Lords, over the last two years, we have all had cause to be immensely grateful to the National Health Service. NHS staff have responded heroically to the demands of the pandemic, and the service has shown a capacity to innovate, adapt and collaborate. The noble Lord, Lord Stevens of Birmingham, has been at the heart of that, and so we much look forward to his maiden speech today. But we are not out of these woods. There is an immensity of effort yet required, and the Government are right to allocate unprecedented resources to the National Health Service to support the recovery programme.
This Bill enshrines in law an approach that is markedly different from that which has characterised virtually all health legislation in England since the 1980s. That earlier legislation progressively built an NHS based on key principles: autonomous NHS providers held to account by commissioners, who would pay them for the services they actually delivered; patients’ rights to choose a provider; money following the patient; clinical leadership; and, since 2013, an NHS that is operationally independent of politicians but with a series of checks and balances, including a mandated focus on improving clinical outcomes. In some ways, this Bill turns back the clock. Providers’ freedoms are to be limited; the purchaser/provider split is blurred; the NHS is being centralised; payment systems are being delinked from activity; and political direction is being reimposed. We should use debates on this Bill to ask whether this is really the right direction, particularly given the need now for a responsive, productive National Health Service.
One could argue that this Bill reflects a journey that, in truth, started soon after the 2012 Act was passed—and was never truly implemented. We see the Bill establishing integrated care systems, for example, but they have really been around, in one form or another, for six years already, albeit not in statute. Noble Lords considering this legislation should reflect that, much as we labour on the detail of legislation, as the House did a decade ago on my Bill, we should be aware that the NHS may choose simply to ignore it.
My Lords, in the absence of the noble Baroness, Lady Donaghy, I will speak next. I draw the attention of the House to my relevant interests as a vice-president of the Local Government Association and a member of Kirklees Council. I intend to concentrate on those elements in the Bill that impact on local government.
In West Yorkshire and, I suspect, other parts of England, planning is well advanced for establishing integrated care boards. There is a flavour here of a reorganisation that is already a done deal, yet there are important issues that remain unanswered by the proposals in the Bill. The first of these is that the Government proposed three reform programmes: this Bill; the adult social care White Paper, which was published last week; and the missing one—the care integration White Paper, which has been delayed yet again and will be vital as a part of all these reforms. I do not see how you can do this Bill without the White Paper that is missing. Another missing piece of reform is any detail at all about the delivery of health and care at the level defined as “place”. A further, major missing element is an adequate increase in funding for local government delivery of adult social care. You cannot have one without the other: reform without the funding will simply not work.
The final missing piece is democracy and accountability to local people. An opportunity to bring explicitly elected local voices into the governance of health and care at a local level has been ignored. Robust governance models that reflect the people and places served and allow for transparency and accountability provide the best outcomes in the end. However, the model proposed provides for even greater central powers and even less for the people for whom the service is provided.
I now turn to the issue of who pays what towards the cost of their care. There are a number of anomalies in the current proposals beyond the issue of the cap; this is not about the cap. If you are in residential care, you will need to pay a contribution towards the hotel costs; that has been fixed at £200 per week. This means that, if you are living in an older care home in a part of the country with low property values, your fees might be, say, £800, of which £200 might cover the accommodation costs, as these are lower. However, in a new, modern care home, in an area of high property values, your fees per week might be £1,000, of which £400 are accommodation costs. Bear with me—the maths is coming. Under the new rules, both people would pay £200 towards the hotel costs. This is important because the individual in the modern care home would then count £800 towards the cap on their contributions, whereas the second person, in the older care home, would count only £600 towards the cap, even though the value of the care that they receive is the same. In other words, the current proposals favour people in parts of the country with higher property values. I wonder how this approach reflects the so-called levelling-up agenda.
My Lords, I thank noble Lords for the warm and generous welcome. I joined the NHS on its 40th anniversary, in 1988; it is therefore a huge privilege to participate in this important debate more than three decades later.
I know that time is tight so I will cut to the chase and make three brief points. First, the Bill does indeed go with the grain of what patients can see is needed and what people across the NHS have been trying to bring about for some time now. It is not a cure-all—no Act of Parliament ever could be—but it removes legal, bureaucratic barriers to more joined-up care. The fact is that, as we dig our way out of the consequences of the worst pandemic in a century, as your Lordships have just heard in Oral Questions, GPs, hospitals and community services will need to work together in radical and new ways. This Bill will facilitate that. It is also the case that, in an era when, despite fantastic advances in medicine and science, we are seeing growing inequalities and a far higher proportion of patients with long-term conditions, just about every health system in the industrialised world is trying to move towards more integrated and preventive care.
In that respect, I should perhaps depart slightly from the noble Baroness’s comments on fluoridation, if I am permitted to do so in a maiden speech. I welcome this move towards dental decay prevention. I should declare an interest on the part of my teeth, in that I happen to have had the good fortune to have been born in Birmingham just a few years after that great city introduced fluoridation. If the whole country now follows its lead, we have the potential to halve the dental decay of children in the poorest communities.
To get back to the point, my second observation is that a number of the concerns raised about the Bill are perhaps a little wide of the mark. It is hard to sustain the argument—it has not been made this afternoon, at least so far—that the Bill in some way advances the privatisation of the National Health Service when in fact it scraps the EU compulsory competitive tendering regime imposed on it. However, there is a case for the Government to consider potentially strengthening some of the safeguards in Clause 70, which would ensure that, where contracts are being let for the private sector, that is done in an open, transparent and fair way.
4:20 pm
20 of 157 shown
The Government recognise that their amendment to the adult social care charging system was considered controversial. However, it is necessary, fair and responsible. Everybody, no matter where they live in the country, no matter their level of starting wealth, will have the contribution they have to make to the cost of their care capped at £86,000. Those with lower levels of wealth will be far less likely to have to spend this amount, thanks to a far more generous means-testing regime that we will introduce. To be clear, the Government believe that nobody will be worse off in any circumstances than they are in the current system, and many people will be better off.
Furthermore, without this change, two people with the same level of wealth, contributing the same amount towards the cost of their care, could reach the cap at very different times. This is not considered fair. A fairer system is to have the same cap for everybody, and then provide additional means-tested support so that people with less are unlikely ever to spend that amount.
At its heart, this Bill is about integration. It builds on the lessons of the pandemic, when the NHS and local authorities came together as one system and not as individual organisations. New integrated care boards and integrated care partnerships will build on the progress made so far to plan, to join up services and to deliver integrated care. We are grateful for the work done to develop these clauses by both the NHS and the Local Government Association.
We have listened throughout the Bill’s passage in the Commons to concerns that we are enabling privatisation. Nothing could be further from the truth. To put this beyond doubt, we amended the Bill in the other place to make it clear that 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.
Many noble Lords will be aware of the integration White Paper announced in September and currently in development. I can assure the House that this will build on the integration measures in the Bill, to go further and faster and to deliver person-centred care. We expect to publish it in early 2022.
As I have mentioned, a key aspect of this Bill is removing bureaucracy where it gets in the way. While bureaucracy often ensures that there are processes and procedures in place, we all know how excessive bureaucracy can make sensible decision-making harder. We believe that health and care staff are able to deliver better when they are trusted and given space to innovate, with barriers removed. Every NHS reform has claimed to reduce bureaucracy, with varied degrees of success, but such reforms have often been top-down. These reforms come not from the top down but from the bottom up, giving the NHS what it has asked for. This includes introducing a new, more flexible provider selection regime that balances transparency, reducing bureaucracy and fair and open decision-making.
It is right that the day-to-day decisions about how the NHS is run, both locally and nationally, are free from political interference. However, it is also right that there is democratic oversight and strong accountability in a national health system that receives £140 billion of taxpayers’ money every year. The public deserve to know how their local health system is being run. Integrated care boards will hold meetings publicly and transparently, and the Care Quality Commission will have a role in reviewing integrated care systems.
The Bill also ensures greater accountability from healthcare services to government, to Parliament and, ultimately, to the public. Through new powers of direction, the Government will be able to hold NHS England to account for its performance and take action to ensure that the public receive high-quality services and value for taxpayer money. Equally, we must ensure that there are safeguards and transparency mechanisms in place. That is why the Bill is clear that the new power of direction cannot be used to intervene in individual clinical decisions or appointments. The public also expect Ministers to ensure that the system conducts reconfiguration processes effectively and in the interests of the NHS and, where necessary, to intervene. In such instances, the Bill provides a mechanism for the Secretary of State to intervene, subject to the advice of the independent reconfiguration panel.
As we all know, the health challenges that we face are not static, so the NHS must continue to be dynamic. As the noble Lord, Lord Darzi, once said:
“To believe in the NHS is to believe in its reform”.—[Official Report, 11/10/11; col. 1492.]
The Government believe that this Bill allows the NHS to meet the challenges of today and adapt to those of tomorrow. With this Bill, we can look beyond treating disease and focus on prevention with measures to promote good health, such as tackling obesity and stopping the advertising of less healthy products to children. This Bill includes a range of important additional measures, including the establishment of the Health Services Safety Investigations Body, or HSSIB—a world-leading innovation in patient safety—and legislation to ban virginity testing to fulfil the Government’s commitment to the most vulnerable.
The Government believe that the founding principles of the NHS—taxpayer-funded healthcare available to all, cradle to grave and free at the point of delivery—remain as relevant now as they were in 1948. To protect these values, we must back those who make them a reality every day of their lives by building and constantly renewing a culture of co-operation and collaboration. I commend this Bill to the House.
So, a Bill that was expected in 2017 is now with us in 2021 with the addition of extensive new powers for the Secretary of State, which give rise to deep concern. These extend to direct involvement in service reconfigurations, which could be as purely operational as moving a clinic a few yards down the road. They refer to the transfer and delegation of various functions in relation to arm’s-length bodies, the regulation of healthcare and associated professions, and reporting on workforce needs. After Committee in the other place, out of the blue, the Government added a highly contentious new clause concerning the social care costs cap, which will doubtlessly stimulate many hours of debate in your Lordships’ House.
We acknowledge the proposals around information standards and information sharing; setting up, at long last, the Health Services Safety Investigations Body; the introduction of Care Quality Commission powers to investigate adult social care; the reference to medical examiners; food advertising to combat obesity; fluoridation; and the banning of virginity testing.
From these Benches, we broadly support those parts of the Bill that remove the worst of the 2012 Act, but will look to add key safeguards to ensure proper governance and accountability and prevent new arrangements being open to abuse around contracting, particularly with the private sector. However, as I mentioned earlier, we do not support most of the proposed new powers for the Secretary of State in the absence of a proper case being made for them. Of course, the Delegated Powers and Regulatory Reform Committee has reported on these issues; we will be looking very closely at its report.
It is a matter for regret, as I have said, that the Government did not bring forward legislation in 2017 to solve these problems with a far simpler Bill. Having missed the opportunity to act decisively at the right time, we now have to rush through a far more complicated Bill at a more complex time.
Part 1 mostly sets out yet another NHS reorganisation of commissioning on the back of many previous attempts to do likewise. Commissioning will still be conducted on many levels and be difficult to understand and manage. What the public will make of all this is unknown—but then, perhaps nobody actually asked them.
We know that, in Committee in the other place, the Government made a virtue of the flexibility of the Bill. This extends to changes to procurement and pricing, although no details are available. There is a similar lack of detail about what will happen at place, or indeed how “place” is to be defined, or how the two headed integrated care systems will function and how the money will flow.
The Part 1 new powers of the Secretary of State that are spread through the Bill were not what the NHS asked for. Ironically, one relative success from 2012 was the separation of NHS operational accountability from Ministers; the reasons for reversing this are hard to fathom. As any former Minister, including myself, will understand, it is mystifying as to why Ministers should seek such powers.
We will seek to include amendments that will strengthen the governance of integrated care systems by requiring stronger public, patient, carer and staff involvement as a right. We will seek to ensure that the best people are elected or appointed into key roles with due regard to diversity, fairness and transparency. We will seek to prevent the potentially undue influence of private sector organisations in commissioning, and ensure that contracts are awarded with a proper and transparent process that is as good as the Public Contracts Regulations that will be disapplied. Moreover, the Part 1 clause about discharging patients before they have had their social care needs assessed needs fundamental safeguards to ensure that we do not hear once again of an elderly person being returned in the early hours to a cold and empty home. This has to stop.
Let me turn to what is perhaps the most challenging clause, the one relating to workplace planning. If there is one thing about which there is universal agreement, it is the inadequacy of this clause. Having the right workforce across the health and social care sector is the issue of the day, and the response thus far is wanting. We need to see a more resolute approach that properly plans ahead across the NHS, social care and public health. This is not just about doctors and nurses but about the entire team, including cleaners, care assistants, lab technicians and catering staff. Last but not least, there is the last-minute new clause on the rules for calculating the cap on care costs, which will be robustly scrutinised and opposed by these Benches and by many others.
Of particular interest to me as a former Health Minister are a range of other welcome provisions dealing with virginity testing, fluoridation and hospital food, to name but three of the public health measures on which I used to work. However, it is disappointing to see a dearth of proposals on dealing with the increasing and unacceptable level of health inequalities that have been exacerbated by the pandemic and well highlighted by Professor Marmot over many years.
As was experienced in the other place, we know that there will be many more proposals for new clauses to cover other matters. This is surely a Christmas tree Bill, and decorations will surely abound. We will be glad to support the three new clauses proposed in the other place dealing with duties on reducing inequality, attention to waiting times and restricting the use of the term “nurse”.
Before I conclude, I wish to come back to the important matter of patient safety and the health services safety investigations body. We strongly supported the original Bill and were very disappointed when it suddenly fell off the Government’s radar. Despite efforts from across the House, Ministers were unable to explain where it had gone and why it was not being vigorously pursued in the light of the urgent imperative to embed the “lessons learned” culture into the NHS.
The aim of this body is of course to improve the quality of locally conducted investigations and to reduce the incidence of future harm to patients. The benefits cannot be quantified, but the expectation and the hope are that they will far outweigh the costs incurred by the investigations, avoid costs associated with correcting or compensating for harmful incidents, and encourage health improvement. I hope this will be a major contribution to patient safety.
In conclusion, I regret to say that, however this Bill is presented, it is in effect yet another NHS reorganisation. In the last 30 years, we have seen around 20 reorganisations of the NHS, and the British Medical Journal has observed that
“Past reorganisations have delivered little benefit.”
So the questions for the Minister are many. Why will this Bill be any different? How will the 85-year-old with multiple needs get better care based on them perhaps being treated as a whole person as a result of this restructuring? How will waiting times for elective surgery for cancer and mental health support be improved by this reorganisation? How will health inequalities, which have widened, and life expectancy advances, which have stalled, be corrected by this Bill? A real test for this Bill is: will it makes things better and, if so, for whom?
This Bill can do some good, but its timing is unfortunate at best and an opportunity missed at worst. The question remains as to whether this is the right Bill or the right time. However, if the Bill is to be implemented from 1 April, it has to be the best that we can collectively craft. We look forward to making a positive contribution to making it so.
We too regret the powers being given to the Secretary of State. The reforms under the coalition Government by the then Secretary of State, the noble Lord, Lord Lansley, to remove them from operational decisions was the right one. Despite some of Ministers’ words in briefings, we need to be convinced that this is the right move. Ministers tampering with reconfigurations, capital grants or even contracts have already led the Johnson Government into serious difficulties. Worse, giving powers to the Secretary of State to transfer or delegate powers or functions without a clear rubric about how sparsely this must be used, and in what circumstances, is also dangerous. Through some of these provisions, Parliament is once again excluded from scrutinising Ministers’ actions.
We are concerned about the membership of ICBs. With the increased commissioning duties on local authorities, it is important that they have a voice at the table. More than one local authority in an ICB area gives us a problem. The same is true for NGOs, charities and local enterprises that are involved in the delivery of local social care. Much of the reforms, for both ICPs and the levy, are based on older people’s social care. We think it is wrong that disabled younger adults and children who need social care have been squeezed into inappropriate arrangements once again. Unpaid carers are still evidently meant to pick up much of the burden of care, especially with the new emphasis on getting people home from hospital, sometimes before assessment. It is time that the Government truly recognised the commitment and the cost of these unpaid carers and rewarded them.
Part 2 sets out the new information and data requirements for health and social care, especially the latter. We seek assurances that patient and client data will not only be protected and anonymised but cannot be sold on to commercial parties. We are concerned about the power of the Secretary of State to decide what is and is not commercially confidential. We believe that the Health Services Safety Investigations Body is long overdue, but we will seek confirmation that it is to be truly independent from Ministers. In Part 5, we welcome the proposed ban on virginity testing but also seek a ban on hymenoplasty.
International healthcare arrangements in Part 6 must protect the NHS from this Government’s former aims to give countries the right to bid for NHS contracts as part of economic treaties in the Healthcare (International Arrangements) Bill of 2019. We will seek to ensure that nothing like this creeps in again.
A few weeks ago, the Government rushed the Health and Social Care Levy Act 2021 through Parliament in just a few days. It was clear to us then that the creation of a new tax mechanism deserved careful scrutiny, but this was denied to Parliament, not least because of the lack of detail in how it would work. The Minister said that the new cap arrangements are fair; they are not. They let down exactly the group of people that this Government claim they want to help: those who live outside the greater south-east, with property worth over £100,000.
There is irony in the Government saying in their document:
“It is important that the new reforms are clear and reduce complexity”
before setting out a complex structure of disregards and benefits and the bombshell that neither local authority contributions nor personal care, nor what are sometimes known as hotel costs will count towards the cap. We will oppose this.
My colleagues will cover the clauses on food and drink and the fluoridation of water supplies. We also regret the limited public health reforms to tackle inequalities.
We have argued for years that we need a comprehensive integrated health and social care system, alongside a modernised and effective NHS, managed by its leaders without ministerial interference. Our broken care system, where staff and providers have battled valiantly against all the odds, desperately needs real reform.
This Bill has some of the right ideas, but it is already clear that there are many worrying elements which will not deliver the reform or funding needed. Health and social care providers, all the wonderful staff across both sectors and the public who use and rely on our NHS and social care systems, need that reform. From these Benches, we will aim to persuade the Government to improve this Bill.
There is also considerable concern about Clauses 25 and 142 regarding the change in the regulatory environment. It seems counterintuitive to provide a new system-wide regulatory obligation for the CQC, as mentioned by the Minister in his opening remarks, yet retain the very specific provision for the CQC to regulate individual institutions. Regulation drives culture and behaviour in the NHS, and those two objectives might be in tension with each other, driving unintended consequences and undermining the capacity to achieve true integration.
Finally, there is the question of the workforce. This is critical. Your Lordships’ committee on the long-term sustainability of health and care, chaired by my noble friend Lord Patel, identified this as the key issue critical to the sustainability of the NHS and the care system in our country. The provisions proposed in the Bill are welcome, but they do not go far enough. Your Lordships’ committee suggested the creation of an office for the sustainability of health and care, which would have responsibility to look at demand over an extended period—some 20 years—and, from that, understand what workforce decisions and planning measures should be taken to ensure a sustainable workforce, in terms of not only numbers but its capacity to deliver over time. Those measures are addressed in Clause 35. I hope we will be to explore some of these issues in Committee.
Finally, my right reverend friend the Bishop of St Albans much regrets that he is unfortunately unable to speak in this debate. He has therefore asked me to pass on his congratulations to the Government on bringing forward this important legislation, and to ask the Minister whether the aspiration to reduce inequalities between patients in respect of their ability to access healthcare includes inequalities between rural and urban areas.
The Bill in fact goes beyond the NHS’s own long-term plan. The powers of direction and intervention put in the Bill by the former Secretary of State in Clauses 39 and 40 are not welcome—including to the National Health Service—are a potential political own goal and should be taken out.
Although I see the presentational appeal of repealing Section 75 of the 2012 Act, relating to procurement, virtually the same provisions are contained in Clause 70 of this Bill—highlighting the folly of trying to fix problems in secondary legislation through primary legislation. The slogan is “Collaboration not competition” —ironically, precisely the words that JP Morgan and Rockefeller used when creating vast monopolies.
My legislation was criticised for making the NHS too complex. This Bill takes complexity to a whole new level. We have ICS boards and ICS partnership boards—the latter sitting on top of health and well-being boards. Each ICS is large, so the workaround is to have places within them which map to local authority boundaries. That is just on the commissioner side. On the provider side, we have new provider collaboratives which, in fairness, is where the power in the NHS will lie. The Bill makes no provision for them in terms of transparency, openness or accountability.
The partnership with local government needs to be strengthened. Integration of NHS and social care demands joint planning, so why are the integrated care partnerships and health and well-being boards not made to be the same organisation? We must look also at Clause 54; I do not think hospital foundation trusts should lose their independence.
NHS staff will rightly say that none of this is any good without a clinical workforce, but Health Education England produced the first NHS workforce plan in 2017, and my noble friend referred to the People Plan in 2019. Why, at that time, was Health Education England’s budget cut when the NHS budget was not?
Finally, the Government put Clause 140 in at the last minute, which will mean that if someone has limited assets and must meet heavy care costs, they may end up losing virtually all of their lifetime assets before the cap is applied, but the well-off person would lose only a fraction of their assets. That is not the design of the scheme Andrew Dilnot’s commission recommended to me. I believe many Members in another place want to reconsider this. We should enable them to do so by leaving Clause 140 out of the Bill when we send it back.
As ever, it is our job to revise constructively. I hope that, in doing so, we shall sustain both the independence and accountability of the NHS.
Finally, I refer to the clause related to adding fluoride to the water supply. This is obviously in order to combat tooth decay, which is caused by an excess of sugary foods. However, prevention is better than cure, and substantially reducing sugar intake is surely a better way forward—besides which, adding fluoride to the water supply is not as straightforward as it may first appear because water can be, and is, piped from one water company to another and from one part of the country to another.
I now look forward, with immense expectation, to the maiden speech of the noble Lord, Lord Stevens of Birmingham.
The Bill does not fragment the NHS. It brings together local funding for GP services, hospitals and community services. It removes the role of the Competition and Markets Authority, enabling hospitals to work together, as the pandemic has shown to be so necessary. It brings together the triple-headed Cerberus of Monitor, the Trust Development Authority and the Commissioning Board to create a unified and accountable NHS England.
The Bill puts on a statutory, transparent and accountable basis the informal local partnerships that have arisen between the NHS and local councils out of necessity. It rightly allows them local flexibility because, in a country as large and diverse as ours, one size does not fit all. To suggest that the mere existence of these local bodies somehow constitutes the fragmentation or destruction of a National Health Service makes sense only if you think that every decision in the NHS can be taken nationally. That has never been the case and would never work. As one commentator on the NHS said, in the event of a nuclear war, only two things will survive: cockroaches and the regional tier of the National Health Service.
My third and final point is that, notwithstanding its many merits, just like the NHS, the Bill is not yet perfect. There is an opportunity to strengthen the provisions in respect of social care and mental health. As a number of noble Lords have set out, just about everybody can agree that, in principle, the major challenge facing health and social care is the strength and resilience of the workforce. It is therefore ironic that, for many years now, we have been promised a detailed, funded and properly thought-through workforce plan for education and training, stretching out over five, 10 or 15 years, yet, on each occasion when that detailed plan is about to be produced, it is muzzled. Jeremy Hunt’s Commons amendment sought to remove the muzzle; I hope that your Lordships will consider something similar in this House.
Finally, in respect of the Secretary of State’s powers, care is needed to ensure that this does not end up inadvertently centralising a number of decisions on service configurations that are best made locally. I remember, early on in my NHS career, attending a public meeting at which the proposed closure of a small maternity unit in town was being discussed. It was a very well-attended public meeting; large numbers of people showed up. The director of public health tried to set out the case that there just were not enough births in this midwife-led unit. A voice came from the back of the hall: “How many do we need, then?” There was a bit of head-scratching and a puzzled look, then he spluttered an answer. The voice at the back of the hall came back: “In that case, give us 18 months”. I can tell your Lordships that, in 18 months, that town did produce the requisite number of babies and the maternity unit is still open. That is not a decision that should have been taken in Whitehall. Yet, lurking near the back of the Bill, in Schedule 6 on page 197, are provisions that essentially do that. Nye Bevan may have said that he would like the sound of the dropped bedpan to reverberate around Whitehall, but not even he suggested that each hospital should write to him personally for permission to move the cupboard in which the bedpans are stored.
To conclude, despite all I have just said, there is considerable merit in the Bill. I believe that it is pragmatic, modest and evolutionary. It builds on many of the changes that people across the health service have looked to put in place over the past decade. Nye Bevan, the patron saint of the NHS, said that
“legislation in this country … starts off by voluntary effort … by empirical experiment … by improvisation. It then establishes itself by merit, and ultimately at some stage or other the State steps in and makes what was started by voluntary action … a universal service.”