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“The provision made under sub-paragraph (3) must include provisions for meetings of governing bodies to be open to the public, except where the consortium considers that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting.”

Meetings will therefore be held in public unless the consortium decides on a whim that it is not in the public interest for the public to come to the meeting—that is, for the meeting to be held in public. That is the tone that Ministers have set throughout the Bill. It is misrepresentation. It relies on the fact that there are thousands of words, acres of clauses and endless amendments. Ministers are trying to bore people into failing to look at the details, but I am far too much of an anorak; I will keep reading the Bill, keep looking at the amendments and keep drawing them to the public’s attention.

Helen Jones: Does my hon. Friend agree that experience shows that when bodies are left to determine when it is in the public interest not to know what is going on, they usually do so on the basis of what would be embarrassing to them? Does he not fear that when difficult decisions are to be taken, commissioning groups will shut down public debate by making their meetings not open to the public?

Owen Smith: One needs to look at the top of institutions in this country—at the Government, and the extent to which Governments of all stripes choose what they are going to reveal to the public and what they deem not to be in the public interest. That standard is set and applied throughout public and private bodies in this country and elsewhere.

I have no doubt that there will be many instances when CCGs will determine that it is not in the public interest that the public be admitted to their meetings—in particular, for example, when they are discussing hospital reconfigurations or closures, and changes to public services that people consider to be vital in those areas. CCGs must consider all those crucial issues, but they must do so in a transparent manner, which is what we said in Committee last time round, on the previous iteration of the Bill. We have said it again and the Government still have not answered the point to our satisfaction. I call upon the Minister to amend schedule 2 once more. There is time to do so in the other place and he may well want to give that consideration.

Mr David Ward (Bradford East) (LD): As a shadow Minister, is the hon. Gentleman aware that there is a standard clause in the standing orders or constitution of every public body and every local authority throughout the country? It is for those bodies to justify what is in the public interest. That is standard in public sector organisations across the country. He is trying to make something out of nothing.

Owen Smith: No, I am trying to make a point about what the Minister said at the Dispatch Box not five minutes ago, which was that CCGs must meet in public. I am pointing out that that is not accurate. They do not always have to meet in public; they may choose not to. Whereas that may apply across the board in other public institutions, these are crucial new bodies about which there are grave concerns. We on the Opposition Benches are concerned to ensure that they should be obliged to meet in public on all occasions.

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Paul Burstow: My hon. Friend the Member for Bradford East (Mr Ward) is right. That is why the outrage was expressed as it was. This part of the Bill and the schedule have the same effect as the Public Bodies (Admissions to Meetings) Act 1960. That Act does not say in a blanket way that every meeting must be held in public. It allows local authorities to exercise judgment about confidentiality. We are applying the same principles in that regard in exactly the same way as to PCTs, with the additional provision that for the first time all these arrangements must be published.

Owen Smith: I am grateful to the Minister for that further intervention, just as I assume that he is grateful for the intervention of the civil servants in the Box, who must have passed him a note. Clearly, he was not aware of that earlier. When he said that CCGs must meet in public, he was under the impression that that was the case.

Nicky Morgan (Loughborough) (Con): Will the hon. Gentleman give way?

Owen Smith: No. I shall move on now. We have debated the topic long enough.

Andrew Gwynne (Denton and Reddish) (Lab): My hon. Friend is right to be concerned about the way this part of the Bill is drafted. It is incredibly open-ended for the consortium to decide what is exempt from public knowledge. That is quite different from the situation in local government in England, where the Local Government Act 1972 prescribes what is exempt from the press and the public.

Owen Smith: Indeed. The key difference is that it is for the clinical commissioning groups, in establishing their constitution, to determine what the rationale will be for allowing the public in or not. That is not set down in statute or in direction from the Minister or the Secretary of State. It is for individual CCGs to determine when they should let the public in. I give way to my colleague on the Bill Committee.

Nicky Morgan: I am grateful to the hon. Gentleman. I remember discussing with him whether he was a lawyer, and he was proud to say that by background he was not a lawyer. As he knows, there will be occasions when a clinical commissioning group is considering a matter which is sub judice. It could be an employment law matter; it could be a confidential matter relating to a patient—for example, a mental health patient for whom there has been very sensitive care. There will be times when it is appropriate and in the public interest and that of relatives—[Interruption.] I am making the point to the hon. Gentleman, not to those on the Opposition Back Benches. There will be occasions when it is appropriate for the CCG not to meet in public, as I am sure he will concede as a matter of common sense.

Owen Smith: I will not dispute that there may be occasions when it will be appropriate for the CCG to meet in private, but that is not what the Minister said. My point was to do with the tone and the misrepresentation that has been systematically applied by those on the Government Benches. That is the difference.

Dr Wollaston rose—

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Owen Smith: I shall not give way any more on that issue. [Interruption.] I was enjoying it too, although I would be surprised if the Minister was. I shall move on, if I may, to questions. As I said, there are many questions.

The Minister said today with his usual candour and clarity that the vast bulk of health care will in future be delivered by NHS services. That is a new one on me—“the vast bulk of health care”. That raises two questions. Will he characterise what he means by “the vast bulk”, and what he means by “NHS services”? In a world in which we will have a much more mixed economy, with a much greater mix of public and private providers working under the banner of the NHS, it is far from clear whether those things will be provided through what we have understood traditionally to be a public NHS or through some new hybrid NHS that the Minister is cooking up in the laboratory at the Department of Health.

The Minister said a moment ago that there were many amendments. He is a master of understatement, as ever. There are about 100 amendments in the first group, and a further 100 or so to be debated later today—part of the 1,000 amendments that have, extraordinarily, been tabled at this stage of the Bill, eight months after it first appeared.

3.30 pm

I will consider the amendments in three broad groups. The first group relates to the duties of the Secretary of State. The second group relates to the creation of the national commissioning board and the clinical commissioning groups, and the consequent disaggregation, or break-up, of the hitherto integrated and collaborative national health service, which is what we believe will happen. The third group encompasses the important issues relating to the cost of the envisaged Government actions for NHS staff, for their education and training and for their terms and conditions.

In addressing all those things, as the Minister keeps telling us and as I have repeated, tone is very important. The Opposition have repeatedly been accused of scaremongering and misrepresenting the Bill in a cynical fashion. Is the Minister seriously saying that all the people who have criticised the Government and levelled accusations that this is a damaging Bill are scaremongering, because it is not just the Labour party? [ Interruption. ] The Minister says from a sedentary position that he did not use the word “scaremongering”. His colleague, the Minister of State, Department of Health, the right hon. Member for Chelmsford (Mr Burns), used that word on three separate occasions yesterday, and I have noted the Secretary of State use it on several occasions. I have no doubt that, were I to read the Hansard reports of the Bill Committee’s sittings, I would find that the Minister had used the word, because it has been very popular on the Government side of the House.

The word “scaremongering” is popular, because it is what the Government think we are doing. [ Interruption. ] The Secretary of State says that we are, so perhaps he will get up and tell us whether the British Medical Association, the Royal College of General Practitioners, the Royal College of Nursing, the Royal College of Midwives, the Royal College of Psychiatrists, the Chartered Society of Physiotherapy, the Royal Pharmaceutical Society, the British Association of Occupational Therapists and the Association of Medical Research Charities—the

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alphabet soup of medical organisations that have criticised the Bill—are all scaremongering? Do they all misunderstand the Bill?




He is not just talking about us, because in many instances we are raising the same concerns that those groups have raised both in detail and in broad terms.

I want to start—I have not even got rolling yet—by stating in the strongest possible terms that it is the Government who are being cynical in systematically obscuring the true intentions of the Bill and misrepresenting our profound concerns, because there is nothing hyperbolic or synthetic about them. They are very real concerns. We feel that the NHS, as a national, universal, publicly controlled and publicly financed institution is jeopardised by the Government’s proposed reforms. Not tomorrow maybe, or next year, but eventually and gradually it will be jeopardised by the new laissez-faire, localised, commercially driven and legally contestable version of the NHS. [ Interruption. ] The Minister sighs, but all those things are precisely what the new system is about. The matter will be tested in the courts, and the first things that we will test are the duties of the Secretary of State.

We feel that progressively the national, strategic and equity-driven system that we have had in the past 60 years in this country will be undermined. Worst of all, we feel that wider society, because of the obfuscation carried out by the Minister, will only really spot it when it is too late. We will only really miss the NHS, as we have known it, when it is gone. It is particularly ironic that, at a point when many people in the House and elsewhere are thinking about what binds our society together and what are the things we want to nurture, how we bring about a sense of community, collectivism and mutual support, as well as self-reliance, one of the institutions that is the shining example in our society of all those values is being so profoundly undermined by the Government. Is that scaremongering? I do not think that it is. I do not think that we need to rely on our words or those in the medical profession who have criticised it. We can rely on the words of the Government, because they have been very clear about their intentions. They stated in the White Paper:

“Our aim is to free up provision of healthcare, so that in most sectors of care… effective competition stimulates innovation and… increases productivity within a… market.”

As the Minister of State put it on TV, “We want a genuine market.” As the Secretary of State put it, “I believe it would be right for us to have price competition.” He has changed his mind about that, just as the Government have been forced to change their mind about a lot of things, but nevertheless I think that it is legitimate for us to point to those as reasons for being deeply concerned about the trajectory of the Bill.

The Minister opened his remarks by talking about the duties of the Secretary of State, which I will move on to now because they are absolutely critical to the debate. We believe that the changes to the Bill, even in its third iteration, will fundamentally diminish the political accountability of the Secretary of State. As with the competition issue, the critical change is one that has been profoundly contested by the Government, but we think it is very clear. With respect to the changes introduced after the pause, we think the Bill still places at one very large step removed from the Secretary of State the fundamental duty to provide or secure the

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provision of health services in England, removing the duty that was placed on the Secretary of State by the National Health Service Act 2006, the National Health Service Act 1977 and all NHS Acts since 1946.

Initially, the Government were not at all coy about that; they were absolutely up-front about wanting to remove political micro-management, as they kept putting it, from the NHS. In the White Paper, they said:

“The Government will liberate the NHS from excessive…political control”.

Paul Burstow: Is it still the Opposition’s policy to seek a division between the role of commissioning or purchasing health services and the provision of those services? Does the hon. Gentleman believe in that split?

Owen Smith: Yes. The current situation is clear: the Secretary of State has a legal duty placed upon him in the legislation to secure and provide—not just to promote—a comprehensive health service in this country, and to issue direction to PCTs and SHAs, such that they so do. Those two crucial aspects of the current legislation are being changed in the Bill, and I intend to discuss them in a moment.

In version 1 of the Bill, the Government were less coy, because it actually excised section 1 of the original 1977 Act. After the deluge of criticism, however, they decided that they needed to put it back in, making it explicit, as they put it, that the Secretary of State will be responsible, as now, for promoting a “comprehensive health service”.

Section 1 of the Act was duly reinstated, as was the duty to promote, but there was a critical change, in clause 1(2) of the new Bill, which diluted the traditional duty to provide and secure. Ultimately, it placed a duty on the Secretary of State only to

“exercise the functions conferred by the Act so as to secure that services are provided”.

I shall come on to the reason why that is significant, but equally significant and allied to it was the retention—against the advice of Opposition Members and many others—of clause 10, which amends section 3 of the 2006 Act, thus keeping commissioning bodies, not the Secretary of State, as the parties with a legal duty to provide health care in England.

The net effect of those changes—despite what the Minister said earlier, and despite what the Secretary of State has said on several occasions, including notably on Second Reading—is no change. The Secretary of State is still, as the Minister put it, washing his hands by divesting himself not of the NHS but of a direct duty to provide a comprehensive health service. That is the distinction which the Minister failed to make today. The Secretary of State is palming off that precious duty, which has been placed upon successive Secretaries of State, and handing it on, via the mandate, to a quango and to unelected commissioning bodies.

The Secretary of State for Health (Mr Andrew Lansley): If the shadow Minister is so concerned about the Secretary of State’s legal ability directly to provide services, will he answer me a question? Does he know the last time the Secretary of State for Health actually directly provided any services? In the Department of Health, we cannot find out when it was.

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Owen Smith: With the greatest respect to the Secretary of State, who I have to confess knows a lot about the NHS and about the health service in this country, I think that that question is completely erroneous—a total red herring. As I said earlier, the practical reality is that the Secretary of State delegates—[ Interruption. ] No, no, no. The Secretary of State delegates to PCTs and SHAs his powers to provide, but, as I am going to tell the Secretary of State, he will know that under the aegis of this new Bill he will not have the power to direct clinical commissioning groups to do what he says, so he will not have a direct personal duty to provide. On the courts, we heard another interesting thing earlier from the Minister of State. He said that it was okay, because the Secretary of State will be able to justify in court when he directs a CCG to act. That is very important, and I am keen to hear the Secretary of State’s response to it, but I do not think that he has one that will convince us.

Mr Lansley: The hon. Gentleman has admitted that for decades the Secretary of State has not directly provided services, and I know that that is true. The issue is about having a legal duty, not to provide services but to secure the provision of services. He admits that that is done through delegation, which is in the structure of the Bill through the delegation of that responsibility to the national health service commissioning board and the CCGs. The mandate, which my hon. Friend the Minister has clearly explained, is much more transparent and accountable to Parliament for the manner in which the Secretary of State secures the discharge of those duties.

Owen Smith: With respect, there is not a legal duty on the Secretary of State to provide, as there has been in successive health Bills. When Bevan talked about hearing the bedpan dropped on the ward in Tredegar, he did not mean that he wanted to pick it up. [Interruption.] I do not know whether the Secretary of State wants to listen. Bevan did not mean that it needed to be picked up by the Secretary of State, but he certainly meant that he would like to be able to direct those responsible operationally for picking it up so to do.

The critical difference in this Bill is that the Secretary of State will divest himself of not only the duty to provide that service, but the power to direct the operational parts of the NHS, save for—[Interruption.] The Minister is waving his head, nodding or something; I know what he is going to say. Under the Bill, save for in cases of crisis or emergency, the Secretary of State will not have responsibility for running the day-to-day operations of the NHS.

Paul Burstow: The hon. Gentleman is wrong again. Unlike the previous Government, who were happy to have directions that did not have any parliamentary accountability, this Government are putting in place the ability, through regulations, to set the standing rules for the NHS, which, as set out clearly in clause 17, include all the issues that the hon. Gentleman is concerned about and show that the Government are committed to ensuring that there is a comprehensive health service.

Owen Smith: As the Minister has just confirmed by omission, there will be no power to direct and therefore no power to deliver absolutely a comprehensive, universal health service as we have come to expect and understand it. Those are the key differences. [Interruption.] The

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Minister can shake his head, but that is an accurate interpretation of what has happened.

Rosie Cooper: My hon. Friend has been talking about mandates. Will he explain under what mandate and how the Secretary of State is implementing all these structural changes? The House has not voted on them and the process started before the Bill came to the House. You are making structural changes, damaging the health service and making it impossible—

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. I am sure that the hon. Lady will not be using “you”.

Rosie Cooper: Forgive me. I am for ever doing that, and I must stop. In essence, I am saying that the Secretary of State and Ministers keep talking about mandates and what they will and will not do, yet they are disregarding everything because they are implementing the Bill before it has been sanctioned by the House or the other place.

Owen Smith: I am grateful to my hon. Friend for that intervention. As she will know, the Government have no mandate for any of these things—they were not in the manifesto, the election or the coalition agreement. There is a mandate, but not one to effect these sorts of changes. That is another disgrace given how large the changes are.

I am going to move off this issue, but I will conclude by reading back to the Government their own words, which make it absolutely clear what they are doing in getting rid of direction. Paragraph 66 of the explanatory notes states:

“Currently, the Secretary of State is directly responsible for providing or securing the provision of all health services as set out in the NHS Act, a function which is largely delegated to Strategic Health Authorities and Primary Care Trusts…However, the new commissioning structure proposed by the Bill means that this would no longer be the case.”

The explanatory notes also state that

“functions in relation to the health service are conferred directly on the organisations responsible for exercising them”.

Effectively, the Secretary of State will move on and his focus will shift to public health.

Paul Burstow: I want to be absolutely clear about this. The hon. Gentleman is happy with an arrangement that allows the Secretary of State to make directions to the NHS that do not require him to come to this House to account for his actions—is that correct?

3.45 pm

Owen Smith: I am happy—we are happy—with the Secretary of State being properly, publicly accountable through this House and having a legal duty placed on him to secure and provide politically accountable health services in this country. We are deeply concerned that the changes envisaged in the Bill, which radically alter the nature of the NHS, will not be able to be held to account through the Secretary of State in future Parliaments. That is our profound concern about the line of direct political accountability that so many of the Minister’s hon. Friends share, which is why they have tabled amendments to that effect and why they have repeatedly raised these

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concerns in the Bill Committee and elsewhere. The Minister does not have those concerns, but many other Liberal Democrats do.

Andrew George: I have to say that I entirely respect my hon. Friend the Minister. The hon. Gentleman’s point echoes what I said earlier in contradicting the Department of Health’s claim that the original 1946 Act did not have a requirement to provide or secure services. My quote provided evidence that that requirement has always been there. The Department also claims that because of the changes it is no longer legally acceptable for the Secretary of State to have that responsibility, but that issue has not been properly addressed. Would the hon. Gentleman care to deal with the point that it may no longer be legally acceptable for the Secretary of State to have that duty?

Owen Smith: As I said earlier, or rather as somebody said on my behalf, I am not a lawyer—I am a historian. As a historian, I agree with the hon. Gentleman that the 1946 Act does indeed say:

“provide or secure the effective provision of services”.

He was entirely right in that, and I could not understand the response from the Minister.

The key thing is that eight months, two Bills and 1,500 amendments later, we are still debating clause 1 and its legal interpretation. That is testament to just how badly botched this Bill has been and just how alarming it is for many people—patients and NHS staff—that we, the legislature, do not understand, or have divided views about, our understanding of the critical responsibility of the Secretary of State.

Steve McCabe: Before my hon. Friend moves on to the next section of his speech, perhaps I can return to the question of a mandate. Given that this is such a botched Bill, given what he says about the tone of the proceedings, given that at this stage nobody seems to understand exactly what are the implications of some of the Government’s claims, given the fact that the Government are not willing to entertain people’s legitimate concerns, and given that there is no mandate in either Government party’s manifesto for this Bill, the other place is presumably not bound by the Salisbury convention, and if the Government will not entertain those concerns here, it will be the duty of the other place to address them.

Owen Smith: It will. I have no doubt that the very many lawyers in the other place will have a field day in addressing these issues—just as, we fear, lawyers the length and breadth of this land will have a field day, not only during the passage of the Bill but for many years to come. That is because so many things will be contested, not only relating to the issues we are debating but, far more importantly, in relation to competition, which we debated yesterday, where it is undoubtedly the case that decisions that have hitherto been made to provide services from within the family of the NHS will be challenged by carpetbaggers—profit seekers—from outwith the NHS. Under the future provisions, those issues will need to be tested in the courts. The Government have conceded that on several occasions, and I am sure that they would do so today if they were asked.

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Finally on the issue of the Secretary of State, and once again to hammer home the point that this is not just Labour scaremongering and that lawyers will be involved at every step of the way, I draw Members’ attention to the independent legal opinion that was provided by Stephen Cragg QC. Paragraph 1 of the executive summary states:

“It is clear that the drafters of the Health and Social Care Bill intend that the functions of the Secretary of State in relation to the NHS in England are to be greatly curtailed.”

It goes on:

“Effectively, the duty to provide a national health service would be lost if the Bill becomes law. It would be replaced by a duty on an unknown number of commissioning consortia with only a duty to make or arrange provision for that section of the population for which it is responsible.”

It states that the Bill is

“fragmenting a service that currently has the advantage of national oversight and control, and which is politically accountable via the ballot box to the electorate.”

That was the view of an independent QC on reading the Bill. It is a view that I and the Opposition share. I suggest that Ministers read it very carefully and do not dismiss it, as they have done today, as an inaccurate reading of the Bill.

Nicky Morgan: Is that the independent legal advice given to the campaign organisation, 38 Degrees? If it is and if the hon. Gentleman has any influence over that group, can he persuade it to release and make public the instructions given to counsel, because any instructing solicitor who instructs counsel to give advice usually gives very clear guidelines on, or an indication of, what they want the advice to say?

Owen Smith: I am ever so grateful to the hon. Lady for that intervention, because it is profoundly rich for anybody on the Government Benches to suggest that we should prevail upon an independent organisation to publish the instructions that it offered to an independent QC, when the Government will not even publish the independent advice that they have commissioned. They have refused to do so repeatedly. They will tell us that they do not agree with this independent opinion, but they absolutely will not publish their own. I suggest that she makes representations to those on her Front Bench, and I will do the same to 38 Degrees if I have a chance.

The independent legal advice goes on to say:

“Encouraged by the structure and clear intention of the Bill to give consortia autonomy from the Secretary of State,”—

which is, of course, in clause 4 of the new Bill—

“there is a real risk of an increase in the ‘postcode lottery’ nature of the delivery of some services, depending on the decisions made by consortia.”

That increase in the postcode lottery takes me on to the second set of proposals that I wish to touch on, which we believe would stop the Government effectively legislating to hardwire the postcode lottery into our NHS. We accept that it is already too variable across the country and that there needs to be greater equity and standardisation, with excellence provided to everybody across the country. That will become all the more difficult with the new provisions.

New clauses 10 and 11, which were tabled by the Labour Opposition, are designed to combat some of the possible malign consequences of the changes that

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hand to clinical commissioning groups the ability to determine the needs of the local health population and to set their priorities without interference or support from the Government, or indeed from regional strategic health authorities.

Dr Poulter rose—

Owen Smith: I am delighted to give way to the hon. Member for Central Suffolk and North Ipswich (Dr Poulter), who has such an acute interest in Wales.

Dr Poulter: The hon. Gentleman is making some good points. Does he accept that within a national framework of gold standard and good treatment, there will be regional or local variations in the needs of patient groups? For example, given health care inequalities, mental health and the higher rates of cardiovascular problems in ethnic minority populations, patients in Bradford may have very different health care needs and priorities from patients in the area of rural Suffolk that I represent. Does he agree that the Bill goes some way towards allowing local flexibility that will better address some of the different local health care needs?

Owen Smith: I accept that there are obviously different needs and that there is a good case for a needs-based assessment model being used by PCTs in the current situation or by CCGs. Indeed, one of the amendments tabled by Liberal Democrat Members on a needs-based assessment is excellent and I wish that we had tabled it. However, the crucial difference, which I alluded to earlier, is that previously the Secretary of State has had a direct duty under section 3 of the National Health Service Act 2006 to provide and secure a whole range of relevant and necessary pieces of the health ecosystem, such as hospitals, within a given area. Under the Bill, that duty will pass to clinical commissioning groups. That is a further crucial removal of responsibility and accountability from the Secretary of State and transference of them to CCGs.

Under the aegis of the Bill, many CCGs may well plan well for their local population, and perhaps better than primary care trusts, but what if they do not? What if they get it wrong and determine for clinical reasons—or, dare I say it, because in this new world they are sitting cheek by jowl in the boardroom with commercial players who have a stake and a skin in the game financially—that they no longer feel it is “reasonable”, as the Bill puts it, to provide certain services? I think that is perfectly foreseeable.

We already know that because of the cost pressures that PCTs are under, they are having to make difficult decisions about which services they will provide and which they will not. They have always had to do that. It is just possible that CCGs will make duff decisions with which local residents disagree. As we heard earlier from my hon. Friends on the Back Benches, they will not be able to be held to account in the way that the Secretary of State, and eventually PCTs through the Secretary of State, can currently be. Those changes are critical, and I suggest that the Minister reflects on them.

Another crucial change to the Bill that we would like to be brought about is in respect of the costs of bureaucracy. We are changing from 150 PCTs to more than 250 clinical commissioning groups and counting. The latter are smaller and less strategic, and certainly

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less experienced in commissioning, than PCTs or strategic health authorities, and they are arguably too small to compete equitably with very large and financially powerful foundation trusts. That is a real risk. Crucially, they will also increase transaction costs, bureaucracy and administration costs.

That is why, in new clause 11, we have decided to ask the Government to put their money where their mouth is. The Minister asked earlier why we had chosen an “arbitrary” figure of 45% for a cap on the volume of expenditure on administration by CCGs. The answer is simple: it was the number that the Secretary of State came up with. He said that that was how many percentage points he was going to trim off the administration and bureaucracy costs of the NHS. He boasted that he could deliver 45% savings, so we are calling on him today to put his money where his mouth is and legislate for that. Let us measure him against that, because there is not going to be much else that we can hold him accountable for.

We have tabled new clause 10, on waiting times, because targets and standards absolutely matter in the NHS. No matter what the Government keep telling the public, we still believe in clinical targets, including some that the Government would denigrate as “bureaucratic” or “administrative” targets. In new clause 10, we ask the Government to take the power to set transparent regulations relating to waiting times. Waiting times are going up under this Government. There have been 400,000 people with long waits since the Tories came to power. The trajectory and the sense of history repeating itself are depressingly clear to me and my hon. Friends.

David Tredinnick (Bosworth) (Con): I think the hon. Gentleman might inadvertently have misled the House. He said that waiting lists were going up in the NHS. My recollection is that they are going up in Wales. He is shadow Wales Minister, I think.

Owen Smith: I was waiting for that intervention and looking forward to it. I was slightly concerned, when the hon. Member for Central Suffolk and North Ipswich intervened and failed to mention the fair and beautiful country of Wales, that I was not going to get the opportunity to put the record straight. I hate to tell the hon. Member for Bosworth (David Tredinnick) this, but he is wrong. Waiting lists in Wales are coming down. We have been hitting 95% of our target week in, week out, month in, month out since September 2009.

4 pm

I will concede that the Labour Government in Wales had a problem with orthopaedic waiting lists because of a lack of capacity and too few orthopaedic surgeons, but they invested an additional £65 million to deal with orthopaedic waiting times. I am confident that that will have an effect, but the key is that we still have and observe waiting targets in Wales, and we expect that people will hold us to account in hitting them, whereas in England we are getting rid of waiting targets. What is happening as a result? Waiting times are going up, as happens every time the Tories come to power.

We have also seen from the Co-operation and Competition Panel, which the Government are keen to pray in aid on other matters, that minimum wait times are now being set by PCTs in England in anticipation of

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the increased autonomy that they will have. They are already deciding they will carve out their budgets and curb costs by setting minimum waiting times, and by introducing independently determined—not NICE-determined—clinical thresholds for treatment. Those things are entirely unacceptable, as the Secretary of State conceded in a letter to my right hon. Friend the shadow Health Secretary. However, they are symptomatic of what we will see in a busted-up, fragmented and disaggregated NHS. Without strategic regional oversight, local decision making will compound the postcode lottery.

New clause 14 is an important proposal. It is designed to prevent those who shout the loudest under the new fragmented system from gaining the most, and from gaining an inequitable share of health care resources. That has been a traditional concern of health care policy under different Governments, and it remains a concern of the Opposition.

The Bill makes commissioning bodies—CCGs—responsible for both the people on their practice lists and people living within their boundary area who are not on the practice list of another CCG. The Opposition have argued against that for two key reasons. First, as Liberal Democrat Members will recognise, the measure makes population-based needs assessment impossible. That kind of structure means that totting up potential customers and patients within an area cannot be done, because they will not live in a single, defined area. Some people who do not live in the area might need to be covered because they are on the list, and others will not need to be covered even though they live in the area. Secondly, the Opposition are against the kind of system in which the most vocal and well informed, and perhaps the wealthiest, can shop around for the best GP practice, and therefore the best consortium, which could be outside their immediate area.

New clause 14, alongside amendment 5, which would delete clause 10, would make the people in the area of a CCG its primary responsibility. Regulations would allow CCGs provision for other people, such as those on their practice lists, but they would always remain responsible for the people in their area.

Education and training is another crucial measure in the Bill that we are shoehorning into this very short debate—it is perhaps one of the greatest concerns of the medical fraternity. We have tabled several proposals on that: new clauses 12 and 13, amendments 7 and 47. On staff terms and conditions, we have tabled amendment 1168. In addition to providing the strategic, regional tier of NHS government, SHAs have a key role in education and training, including, crucially, hosting deaneries and in work force planning. Those are obviously linked to questions of emergent innovation, changing need in a local area, and any potential consequent reconfigurations of hospitals. They are absolutely central to how we run the NHS and plan for its future.

It is therefore scandalous that we come to this juncture, many months after we started our debates on the Bill, with SHAs—the repositories of the training and planning function in the NHS—on the verge of being abolished. Their abolition has shifted from seven months to around 14 months, but in legislative terms SHAs are on the verge of being done in by the Government. However, the Government have absolutely no idea what they will replace the education and training facilities with—and

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the Minister has had the temerity to come to the House today and inform us that a new amendment is to be tabled in the House of Lords to deal with this crucial part of the Bill.

Paul Burstow: I have said that before.

Owen Smith: The Minister has not said it before in a public realm of which I am aware. He certainly did not say it in the Public Bill Committee, all 40-odd sessions of which I feel I sat through. The Minister knows that the issue is crucial, because the Future Forum that he commissioned said so. Indeed, it said that

“one of the most widely voiced criticisms of the proposed changes was a deeply felt concern at the risks to healthcare education and training in England posed by the fast pace of change.”

The Government responded by saying:

“we will introduce an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service.”

We are still waiting. What will that duty look like? [Interruption.] The Minister says “We have said that we are going to do it”, but here we are, eight months and 1,500 amendments later. How long must we wait? Are we sure that we will see the duty introduced in the House of Lords? Are we positive about that? I must say that I am not certain about it.

Paul Burstow: The shadow Minister rarely criticises the Government for telling the House again what they said in the response to the Future Forum, which is that we would introduce that explicit duty. We will introduce it in the House of Lords, as I have told the House today. We are committed to doing so, having listened carefully to the concerns of NHS professionals.

Owen Smith: The very simple question to be asked is “Why the delay?” Why could the Minister not have introduced it earlier? We have known about the problem for eight months and more. The Secretary of State, who has been keen on changes such as this for a long time, must have given some thought to what he was going to do about staff training and work force planning in the NHS.

Mr Barron: It was clear from the day of its publication that the Bill, which abolishes the structure that had kept education and training in place, would create chaos in the national health service. Here we are, hundreds of amendments later, with a resubmitted Bill. Our debate on the outcome has been crammed into two days, which is wholly unsatisfactory, and the Government still cannot tell us what will replace the structure that has been in place for so many years. That is a nonsense.

I listened to the Minister’s speech earlier. He was telling people—people outside, including professionals who want this kind of professional development on a continuing basis—to have faith in what might happen at some stage. I have to say that I have little faith in what the Government have done with the Bill from the very beginning.

Owen Smith: I entirely agree, and my faith is diminishing by the minute. I do not understand why the Government cannot simply concede that they have signally failed to deal with this crucial aspect of the Bill. It took them months to produce the revised failure regime. They managed to drag that out in time for Report, but they

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have not produced the impact assessment, they have not produced any figures showing how much this will cost the public purse, although we know that the amount is rising—I should love the Minister to tell us by how much—and they have not produced a solution to the crucial problem of staff training and work force planning. That is a disgrace. They could have and should have done it by now.

New clause 13 would place a further duty on providers, related to what is in the earlier new clause. It would oblige them to make provision for training and work force planning for their own staff, thus filling another gaping hole in the Bill. As the Minister might say if he intervened on me, Monitor may well have powers, under the pricing clauses, to pay less under the tariff to providers who do not engage in training, but nothing in the Bill compels new entrants—especially private providers—to give their staff any training, or to deal with any costs that the NHS has traditionally had to bear for the education of the work force.

We all know that in the incredibly fast-moving and innovative world of health care, keeping staff up to date is absolutely crucial. That is why—I hate to say it—despite the news that we are to have an amendment ín the Lords, we will attempt to press amendment 7 to a vote. It proposes the retention of SHAs until and unless we know precisely what the Government will put in their place in respect of training and administration.

NHS staff is another group that is profoundly concerned by the shambles, chaos and confusion that Ministers have overseen. Under the Bill, they are described as assets and will be transferred lock, stock and barrel between new providers. The new providers may be a private company—such as Helios, Bupa, UnitedHealth, or whoever else decides it is interested in running the NHS in future—and the staff may be transferred to the new providers. The Minister shrugs, suggesting that that is a misrepresentation, so I challenge him to intervene on me and state what he seemed to imply earlier: that what I have just said is not the case.

Schedule 23 makes that explicit, however. It provides for the transfer of NHS staff and other assets. It allows such so-called assets to be passed in future from NHS entities to the new CCGs. That can happen to any

“person who provides services as part of the health service in England and consents to the transfer”.

Under schedule 23, any NHS member of staff—or a building or intellectual property—can, so long as they agree, be transferred to anybody else who is licensed to provide services to the NHS. I find that extraordinary, but not quite as extraordinary as the next provision, which refers to NHS bodies being able to transfer all such assets—what a delightful way to refer to people—to a “qualifying company”, whatever that means. I will be delighted if the Minister tells us what the term “qualifying company” in schedule 23 means.

Alison Seabeck (Plymouth, Moor View) (Lab): Does my hon. Friend join me in sharing the concerns of many public health consultants in this regard? They sometimes cover three areas of work, so in one area they could go to the commissioning board, in another they could go to children’s health commissioning, and in another area of their job they could go to the local authority. What are those people supposed to do? I suspect some of them will leave the service.

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Owen Smith: My hon. Friend is close to health workers and health professionals in her constituency, and she knows that people are leaving the service in droves. It is not just managers who will be sacked from primary care trusts or transferred across to they do not know what kind of organisation elsewhere. Clinicians are also deciding that they no longer think the job is worth the candle, because of the endless top-down reorganisation—something we were told we would not see from this Government, although it just keeps on coming. I fear that the situation will get worse in coming months. We will have to wait and see what the capacity of these new CCGs—and, potentially, the national commissioning board—will be, because we do not yet know who will be left standing at the end of this endless round of changes.

In summary—[Interruption.] It is a long summary, and if hon. Members keep talking it will get longer. In summary, we have had eight months of debate in this place, two—and soon to be three—versions of the Bill, with 1,500 amendments, hundreds of protest meetings across the country, and 450,000 signatories to a petition trying to “kill the Bill”. Those extraordinarily high numbers are a reflection of the importance of the NHS to the British people, to the NHS workers and to us, the Labour party.

For many in our society the NHS remains the shining symbol of the civilised collectivist values that first informed its creation 60 years ago, and they rightly view its continuation and their stake in it as part of their British birthright. We in the Labour party view it as a cherished part of our heritage. It also shines a light for us to the future, and we will not stand by and let how we have known it to be for these past 60 years fall into the pages of history. In 1946 we legislated to realise the vision of a collaborative and comprehensive national and public service, as part of the essential glue of that post-war society. This Bill promises instead to give birth to a denationalised NHS—a denatured NHS—divided by competition law, and conquered by profit seekers and carpetbaggers from across the globe.

Ministers, especially the Secretary of State, should remember that it is never too late to change one’s mind—it is never too late to save the NHS. We are appealing for them to do so and they would do well to do so. They should remember, too, the dire and, I trust, accurate prediction and warning given by the man who was proud to be the midwife to the NHS—the Welshman, Nye Bevan—in 1946. He said that

“no government that attempts to destroy the Health Service can hope to command the support of the British people.”

That was true when he wrote it in 1951 and it will be true in 2015 when the Prime Minister asks the people to trust him on the NHS. I hate to tell the Secretary of State and, indeed, the Prime Minister this, but no amount of Ashcroft-funded airbrushed billboards pleading with people to trust the Tories on the NHS will count, because the evidence of their perfidy is written in black and white throughout this Bill, and it will be remembered at the next election.

4.15 pm

Guy Opperman (Hexham) (Con): I wish to start by making it clear that I am a big supporter of the NHS. I probably should declare an interest, because I have spent too much of the past six months discovering it from the inside. As is commonly known, I had a brain

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tumour in April, which was removed by the national hospital for neurology and neurosurgery in Queen square, where I received outstanding care and treatment from the doctors and nurses.

That was not the first time that I had had my life saved by the NHS. Although my girth would deceive hon. Members, I used to be a jockey, and when I was trying to win a race at Stratford, the second last fence proved too much for the horse and me, we turned over and on my left hand side I was entirely crushed by a steeplechaser. I broke about 11 bones and cut my left kidney in half. I had a splenectomy and a very good doctor at Warwick hospital saved my life. I also wish to make the point that I have an NHS background: my grandmother was a matron in a district hospital, and we have spent an awful lot of time in the Hexham constituency supporting the Hexham hospital and the Freeman hospital, in particular.

I support the Bill, and I wish to touch on a couple of the points that have been raised. For a time I earned a living as a barrister, reviewing health care bodies and public bodies of a general nature. I hope that that qualifies me to discuss competition law briefly. If hon. Members were to read, as I have had to over the past few months, some of the representations that have been made about competition, they would believe that it is a new evil being introduced into the NHS. However, that is manifestly wrong, as the Enterprise Act 2002 and the Competition Act 1998 were introduced under the previous Government and have been operating in the health service for a considerable time. I see some hon. Members shaking their heads, but the argument supported by the shadow Minister cites that exact point: in the form of a variety of institutions and undertakings, the UK health service is subject to competition law under the 2002 Act, the 1998 Act and European community laws on competition. This is therefore not a new thing, nor should it be, because it was introduced by the previous Government and large parts of the Bill follow on from what was done previously.

I shall touch briefly on procurement, because the issue has been raised in this House. It is not a new thing for procurement matters to be challenged or to be subject to judicial process. Judicial process itself is not a bad thing. I have heard people say countless times in these past two days of debate, “This is going to be a den of iniquity for lawyers. It will be so bad that there will be lawyers all over this case. It will be really difficult for people to proceed with the health system.” I brought a case against a primary care trust in 2005, 2006 and 2007, with a view to trying to change the law and the way in which that PCT was operating. Before anyone jumps up to discuss that approach, I am pleased to say, first, that we changed the law to assist the patients, secondly, that the whole case was conducted entirely pro bono—for free—and thirdly, that two separate Labour Attorney-Generals gave me national awards to support my efforts. I do not expect that to happen again in a hurry. The point is that if we operate the process correctly—I shall talk about the process briefly in a second—we, and the commissioning consortia, will not be the subject of legal challenge.

That will always be the case with any public body: if it operates in a statutory and well-authorised way and provides the degree of consultation that it should, it is

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not open to challenge. It is not myself or the Government who would decide that, but a High Court judge considering a matter of judicial review. But if the public body—in the form of the NHS or the commissioning consortia—does not act properly, behaves beyond its powers or breaches natural justice in any way, it should and will be open to judicial review and other legal process. That is entirely proper.

I therefore do not believe that this will be a process through which huge numbers of judicial reviews will arise, as new issues for the NHS. I do not think that that will be the case at this stage. The hon. Member for Pontypridd (Owen Smith) talked at great length about the commissioned barrister’s opinion and 38 Degrees, but that barrister’s opinion makes the simple point:

“The Bill does nothing to make the system more amenable to challenge in the courts”.

Let me finish my points about competition and the duty to provide. I suggest that there is no fundamental change whatsoever. That is also the suggestion that the individual counsel made clear. I make the point that he is a junior counsel, not a Queen’s counsel, and there is no disclosure of instructions, the conference notes or any of the other things that would be vital to an understanding of the opinion. It has been wholly misrepresented by 38 Degrees, and there is no change—

Owen Smith rose

Guy Opperman: I am sorry, but I am going to keep going. The hon. Gentleman had about an hour to talk, and there are an awful lot of people who would like to talk about these matters.

I suggest that there is no fundamental change, and this is clearly a way forward that is being implemented for the benefit of patients. We are concerned with patient care and the quality of outcomes. I as a patient, like many other people in this House, am not concerned with the quality of outcomes other than to ask, “Is it a good outcome?” That is the important thing, and to suggest that private provision of the outcome and of the service provided is fundamentally bad is simply wrong. Such provision was introduced and brought in by the previous Government, and it assisted the public provision. The two can work together, and that is a good thing. I shall support the Bill, and I make this point to finish: the NHS is clearly a wonderful institution that all in the House cherish and support, and this is a Bill that supports it.

Valerie Vaz (Walsall South) (Lab): It is always a pleasure to follow the hon. Member for Hexham (Guy Opperman), and it is good to see him sitting in his place. I welcome him back to the House and commend him on his great recovery. He is actually looking better than before, if I may say so.

Let me take up one point that the hon. Gentleman made. As a barrister, he will want people to go to litigation, but as a solicitor I mostly counsel people not to. It is the most terrible, prolonged and costly event—but I appreciate that he wants litigation, because that is his bread and butter.

As for the legal advice, I asked on a number of occasions for the legal advice that the Department had and it was refused on all those occasions. The hon. Gentleman can talk about 38 Degrees, but thankfully that organisation is interested in the public and knows

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that they need the legal advice that was not provided, even though it was paid for with taxpayers’ money. I challenge the Secretary of State to lay it in the House of Commons Library, if the other advice is so hurtful to him. What is the problem? His Bill is being discussed and there is nothing to hide. I say that he should place his legal advice in the Library.

I am a Member of the Select Committee on Health and Sir David Nicholson, the new chief executive of the NHS commissioning board, appeared before us when I was first elected. He was then on the verge of retirement—

Mr Lansley: No, he wasn’t.

Valerie Vaz: He was: he had a very big smile on his face and he said, “I’m about to retire.” [ Interruption. ] With the greatest respect, the Secretary of State was not there. Sir David was asked to stay on to preside over the NHS commissioning board, which he has described as

“the greatest quango in the sky.”

I think that the NHS commissioning board is going to be the new Secretary of State for Health, with all the powers but none of the accountability. The NHS has been quangoed—not coloured orange, as in the advert, although that might happen when the Bill goes to the other place, but coloured the blue of betrayal. These are not reforms: they are a complete dismantling and looting of our precious resource. This is not selling off the family silver, but selling off the whole estate, the freehold and the family crest.

It is not just Opposition Members who are concerned about accountability. There are widespread concerns about the accountability of the NHS commissioning board and commissioning consortia regarding public money.

Andrew Percy: Will the hon. Lady give way?

Valerie Vaz: No, I will not.

I again ask the Secretary of State for Health what discussions he has had with the Cabinet Secretary about the change regarding accountability for the public money that will be transferred—£60 billion of it—to those quangos. If he is asked questions about this in the House he will say that it is an operational matter.

I want to show hon. Members what the scenario will be like, because this is already happening in my constituency and this is what it will be like throughout England. The out-of-hours GP and urgent care service provider Waldoc has just lost the contract to provide out-of-hours services after 16 years, without a right of appeal to the strategic health authority and despite a patient satisfaction rate of 95%. When the contract was lost and staff turned up to find out whether they had jobs, they did not even know whether they would have a job the next day. That is how they have been treated. This has been happening in most PCTs, as some Members will know from their constituencies. People have left, vital expertise has gone and no one from the Government side has been able to give us a figure for the redundancy costs. When I asked the Minister how much this whole reorganisation would cost, he said he did not know the figure and that there was no new money. That must mean that money has come out of services.

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We have, however, had a figure—£1.4 billion—from Professor Kieran Walshe of Manchester university. No wonder waiting times have gone up. Members of the public need to know that in an increasing number of areas, consortia will be conducting competitive tenders in which, potentially, foundation trusts, the constituent members of consortia and commercial providers will be bidding. Clearly, there will also be a conflict of interest. It has been estimated that a single procurement process can cost from £5,000 to £30,000. That is a waste of public money, and the whole regime of procurement is a waste of costs.

Paul Burstow rose

Valerie Vaz: What is so extraordinary is that the Secretary of State does not want to be the Secretary of State; he wants to let the Future Forum consult and listen to people, but that is not how decisions are made in government. In government people hear the evidence from all sides—[ Interruption. ] I have made it pretty clear: the Minister has had his time, but I am a Back Bencher and I do not get much time to speak.

People in government hear the evidence from all sides and weigh things up. Then they make a decision reasonably and give their reasons. The Secretary of State is hiding not only behind the Future Forum but behind the NHS commissioning board. He is like Macavity the mystery cat:

“At whatever time the deed took place—MACAVITY WASN’T THERE!”

I would like to draw hon. Members’ attention to a paper dated 29 August 2011 by Dr Lucy Reynolds, Dr John Lister, Dr Alex Scott-Samuel and Professor Martin McKee, “Liberating the NHS: source and destination of the Lansley reform”, which I will place in the Library. It draws a link between a paper written in 1988 by the right hon. Member for Wokingham (Mr Redwood) and the Minister of State, Cabinet Office, the right hon. Member for West Dorset (Mr Letwin). It is therefore no surprise that when the Minister of State, Cabinet Office was called in to look at the proposals he endorsed them, because they were his. Paragraph 3 of the paper is entitled “Implementation of the Redwood/Letwin Plan in the Lansley reform”. The paper was sent to me by a young academic who said that his life had been saved twice by the NHS but would not have been saved under an American-style privatised health system.

The most recent satisfaction survey by Ipsos MORI last March showed 72% public satisfaction with the NHS, but it was not published by the Department of Health even though the Department had asked for it to be done. Members will have seen a report from Colin Pritchard and Mark Wallace which said:

“In cost-effective terms, i.e. economic input versus clinical output”,

the UK health service was “the most cost-effective” in reducing mortality rates, compared with the US health care system.

Finally, I say to hon. Members—including the hon. Member for Hexham—as they think about what has been said, “Stand up for democracy, stand up for the trust between elected representatives and their constituents, and stand up for the NHS: vote against this Bill.”

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4.30 pm

David Tredinnick: I am most grateful for being called to speak and for the opportunity to follow my colleague on the Health Committee, the hon. Member for Walsall South (Valerie Vaz), and my hon. Friend the Member for Hexham (Guy Opperman), and to say how pleased I am to see my hon. Friend in his place. I know from experience—not personal experience—just how tough that operation can be, so many congratulations to him on his recovery.

I want to make a short speech on just one issue—patient choice, which is one of the most important, if not the most important, aspects of the Bill—and to challenge my right hon. Friend the Secretary of State on one or two points. Chapter A1 13H sets out the duty that the board has, in the exercise of its functions, to

“promote the involvement of patients, and their carers and representatives…in decisions about the provision of health services to…patients.”

That patient choice depends on clinical commissioning, the subject of the amendments before us, and that in itself hangs on the “any qualified provider” policy, modified recently from “any willing provider”. There I have some concerns.

The TUC brief summed up “any qualified provider” very well:

“Under AQP, patients will be able to choose which provider to use for their treatment, from a list of approved providers (private, public or voluntary sector) who perform the service in exchange for a locally or nationally set tariff.”

Where I have a slight problem is that although the categories of treatment that can be employed, certainly in the transitional year 2012-13, have been set out in the operational guidance, I think there is a strong case for the guidance to be in the Bill itself.

However, I am very pleased to see at the top of the list musculoskeletal services for back and neck pain, and I presume, although it is not set out, that that means greater use of osteopathy and chiropractic, both regulated by Acts of Parliament, in 1993 and 1994. I had the honour to serve on the Committees considering those Bills. As the public are to have greater choice, we must look at providing that choice, and they will be asking for those services. They will also want acupuncture for musculoskeletal problems. Acupuncture has been approved by NICE and there are now NICE guidelines supporting acupuncture for use in these services. I would like my right hon. Friend the Secretary of State to consider at some point making a more positive, more specific commitment to the use of those services in the provision for patient choice.

There is a strong case for the “any qualified provider” policy to be set out in the Bill too, although it is set out in the operational guidance. The problem that may occur is in the qualification process. I have no problem with its asking for safe, good-quality care or with the governing principle of qualification being that practitioners be registered with the Care Quality Commission and Monitor, but what about those therapies that do not have those badges in their passport? What about traditional Chinese medicine, which is about to be regulated by the Health Professions Council? May we have a specific assurance that its practitioners can be part of this patient system? Traditional Chinese medicine and

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acupuncture have increased in popularity dramatically—Chinese practitioners may now be found in any town in the country.

I suggest to my right hon. Friend the Secretary of State that other therapies should be included in the list. He has produced a second list of services to be introduced in 2013-14, which includes community chemotherapy and home chemotherapy. If we are to offer patients choice on those chemotherapy services, we really ought to consider those who can support people who are exhausted after chemotherapy and radiotherapy. I am thinking of not only those who practise traditional Chinese herbal medicine and acupuncture, but the healing fraternity and those who use therapeutic touch, many of whom now work in NHS hospitals to great effect.

I should also like to refer to homeopathic medicine, which I have discussed when you have been in the Chair before, Madam Deputy Speaker. I think I am right in saying that your constituency is not far from the Bristol homeopathic hospital, so perhaps you will not call me to order on this, especially as I am trying to stay in order. Many people use homeopathy every day to cure simple ailments, because it is cheap, easy to understand and very effective. Even if there are not umpteen double-blind placebo-controlled trials, there is a wealth of evidence that it works. I would draw my right hon. Friend’s attention to the fact that the Royal London hospital for integrated medicine, which used to be called the Royal London homeopathic hospital, has the highest patient satisfaction rating of all hospitals in the United Kingdom.

There is a case for including in the Bill clearer direction about the services that will become available. I ask my right hon. Friend to smile on those other disciplines that do not have statutory regulation but perhaps have robust non-statutory, voluntary regulation, such as acupuncture, and ensure that when patients go to their doctors and say, “Doctor, this is what we’ve used; this is what we really want,” they will not be turned away.

Joan Walley (Stoke-on-Trent North) (Lab): Following the hon. Member for Bosworth (David Tredinnick) illustrates the problems that we have with the Bill: even at this stage, specific details need to be discussed and have a case made for them, so that the future of NHS provision can be fully taken on board. At the same time, because of how the Bill has been handled—we have had a re-committal—we have a political debate.

The debate on this specific group of amendments is taking place on two levels. I certainly want to ensure that the true principles of the NHS and its founding fathers, such as Nye Bevan, are followed in future provision. We need that political debate to ensure that the NHS is politically accountable. We have almost lost that opportunity, because we are in this mess, with all this uncertainty and not knowing how the Bill will shape up and go forward. We risk losing the whole of the NHS altogether.

Many people who are part of the medical profession and others who are concerned about their own future health care have contacted me, because they want the Government to be in control and the Secretary of State to have a duty to procure and provide services. This is a political debate, as much as anything else, but it is difficult to have that political debate within the confines of the amendments, although they are central to that debate.

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Lyn Brown (West Ham) (Lab): One of my biggest worries about the Bill is that it will stop me intervening in the health service to encourage outcomes for my constituents who come to me for help and advice. Does my hon. Friend agree that it will diminish my ability to represent them, rather than enable me to do so?

Joan Walley: My hon. Friend is right. Constituents go to Members of Parliament as a last resort to try to ensure fairness in how the system deals with everything. I have just had a high-profile case in my constituency relating to the postcode lottery, which my hon. Friend the Member for Pontypridd (Owen Smith) referred to.

Paul Burstow: The hon. Lady is making some important points and is trying to respond to that raised by the hon. Member for West Ham (Lyn Brown). Interestingly, the hon. Member for Leicester West (Liz Kendall) earlier recounted all her concerns about the PCT and how it has dealt with GP services in her area. The anxiety seemed to be that the PCTs were not accountable, but the hon. Member for Stoke-on-Trent North (Joan Walley) now seems to be saying that they are.

Joan Walley: We have just had an awfully long debate about precisely that issue. Many of us would say that the PCTs were not operating accountably, but Members of Parliament could have influence and bring pressure to bear. The last resort is through the Secretary of State, and it is important that that should be retained in the Bill.

Owen Smith: Does my hon. Friend agree that the critical points are that there is an unknown into which we are stepping with the Bill and that the presumption is that the culture will be different? There will be a presumption of autonomy, being hands off, less accountability and more localised decision making. It is therefore perfectly reasonable to presume that we will have less input.

Joan Walley: That is right and it comes back to the fact that, somehow or other, under the new regime, whatever it ends up being, there will not be the fairness or the universal provision. In certain areas—perhaps those such as mine, which have much greater deprivation and much greater health inequalities than others—things will be more difficult.

Andrew Percy: I do not recognise the picture that the hon. Lady is painting. The real issue with the provision and availability of services is more to do with the funding model that is in place. When my local PCT was unable to provide dental services and when the bed numbers at Goole hospital were reduced a couple of years ago, local people had no ability to influence those decisions, no matter how much they appealed to the Secretary of State, because it comes down to money.

Joan Walley: Of course it comes down to money, but it also comes down to fairness in how the money is allocated. That must relate to an overall sense of direction to deal with health inequalities.

I want to discuss very specifically three amendments that I have tabled, but I did not want to go into the detail without associating myself with some of the concerns that exist across the country which have not yet been resolved. I speak as an honorary vice-president

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of the Chartered Institute of Environmental Health. I tabled the amendments to ensure that we do not just pay lip service to environmental and public health, and that we truly get a Bill that is fit for purpose in respect of the prevention agenda and the new arrangements under which we will be operating, which should give more status and priority to environmental health.

I want to speak in favour of the Government looking either now or in the other place at the case for a chief environmental health officer for England. The reason for that is the fact that, historically, there was a post of chief environmental health officer, going back to the days before 1974 when local authorities last had lead responsibilities for public health services and when each authority had a medical officer for health.

Today, England has a chief medical officer, but not a chief environmental health officer. I heard what the Minister said about that, but I urge him to have further talks, if necessary, with the professionals to see how we could ensure that a chief environmental health officer for England was appointed. Earlier we talked about Wales, where there is a chief environmental health officer post. In all the arrangements in Wales and in Northern Ireland, there is a recognition of the role played by environmental health in promoting health and well-being, and of the importance, therefore, of ensuring there is an environmental health input to policy making at the highest level and at the strategic level. I believe that is what England currently lacks. If the Bill is to give a higher profile to public health services, and the lead in public health is to be provided by local authorities, which is where the environmental health work force is located, it is necessary to make corresponding arrangements such as my new clause could facilitate, if the Government gave it serious consideration.

4.45 pm

It is envisaged that if we had a chief environmental health officer, he or she could focus on a preventive approach to achieving good health outcomes, and in particular the wider determinants of good health and well-being. I see that post holder reviewing relevant data, advising the Department of Health, Public Health England, NICE and the chief medical officer on preventive strategies and the wider determinants of health, as well as overseeing the development of good practice within local authorities and their partner organisations. In response to points made earlier, let me add that an annual report to Parliament by the Secretary of State on the work of the chief environmental health officer could ensure the accountability of that official.

Amendments 1242 and 1243 would place a duty on public health authorities to work in co-operation with their public health partners. Without that duty, the co-ordination that was mentioned earlier will not be achieved. There will be no mechanism for all the different strands of policy and health care provision to come together. As all Members know, not all local authorities in England are to be public health authorities. For example, in areas of England with two-tier local government, the powers and duties apply to county councils but not to district councils. For example, in my constituency Staffordshire county council, rather than Newcastle borough council, will have the responsibility but not the environmental health officers to perform the role.

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A duty to co-operate could make a significant difference. The public health work force directly controlled by local authorities will be carrying out the work. I urge the Secretary of State to consider that. There is a precedent in respect of children’s safeguarding and in respect of the emergency services. Although I object to many aspects of the Bill and will not support it, if it goes through it should at least contain the safeguard for public health that a duty to co-operate would provide.

Andrew George: It is a great pleasure to follow the hon. Member for Stoke-on-Trent North (Joan Walley), who addressed the issue of political accountability in a considered way. I shall return to that and relate it to a number of amendments in my name and those of some of my hon. Friends. I shall refer to a number of amendments that the Minister of State, my hon. Friend the Member for Sutton and Cheam (Paul Burstow) covered in his opening remarks and dealt with in a fair and balanced manner, although not entirely to my satisfaction in every case. I shall also raise further questions.

I have enormous respect for all that my hon. Friend has done. His contribution to the debate on social care is second to none. That expertise is especially beneficial to the Government at present and some important advances have been made, for which we are all grateful. I acknowledge that he approaches all aspects of his work with the best of intentions, and I do not question those. The amendments that I have tabled indicate that I believe we may need to reconsider some of these issues. I should also mention at this stage that I may seek to push one or two of them to a vote.

On Second Reading, I made a speech that was critical of the Bill and refused to support the Government by abstaining at that stage, and of course the Bill has gone through a number of significant changes since then and concessions have been made. I have been criticised by some for making that speech and refusing to support the Government, but I feel vindicated as a result of the pause and the listening exercise. I might be criticised and accused of disloyalty, but that is how Back Benchers exercise our role of holding the Government to account. It is reasonable for us to use our powers to bring forward amendments and, in so doing, probe the Government and ask them to be accountable for the policies that they are bringing forward. I hope that in the weeks and months ahead, I will be vindicated for having done so, but I do not necessarily expect that acknowledgment to be provided now.

I was relatively content with the original coalition agreement. I am no great defender of primary care trusts, but I think that using the existing institutional infrastructure, grafting in accountability to the patients and communities that the commissioning bodies will serve and ensuring clinician involvement in those commissioning decisions, would strike entirely the right balance. That would provide a way of going forward without scuppering, dismantling or exploding the whole system in the way the Bill is doing.

There was no mention in the coalition agreement of changing the duties of the Secretary of State, and I have read a number of legal opinions on that issue. I also believe, as I have indicated in several interventions so far, that some of us have been misled on that point. Some of the legal advice that I have been given by colleagues suggests that the Secretary of State in fact

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never had a duty to provide in the 1946 Act. That is fundamentally wrong. Perhaps I will discuss this with the Minister after the debate and show him the documents that I have been given and some of the comments that have been made. As some of my colleagues who were there at the time and heard the advice will know—




I hasten to add that they were not there in 1946—I know that I have aged in my time in Parliament, but I cannot recollect that time. My colleagues know that we have been briefed that there was never any duty to provide in the 1946 Act, but there is evidence—I do not need to give the quote a third time—that there was clearly a requirement in the 1946 Act to provide and secure effective provision. That requirement has always been there in successive health Acts in this country. I want to relate that to a point the hon. Member for Pontypridd (Owen Smith) made in a more tribal manner.

Paul Burstow: May I just make it clear that I do not think that I or any other Minister at any point, either at the Dispatch Box or in other discussions, ever suggested that the 1946 Act or any subsequent Act did not have the duty to provide? What we have said is that the duty to provide has progressively, particularly over the past 20 to 30 years, become a duty that is not exercised. It has been delegated and is increasingly exercised instead by separate bodies, such as NHS trusts and foundation trusts, using their own independent power to provide services.

Andrew George: Yes, and my new clause 16 proposes to address that issue through an opportunity for the Secretary of State to intervene as necessary.

The Secretary of State in his intervention on the hon. Member for Pontypridd made it clear that in any case Secretaries of State tend not to micro-manage by intervening or by providing on every whip and flip, and there is no suggestion of that, but as a backstop we require the guarantee that, if all else fails and the whole system does not provide what we believe needs to be put in place to provide for a comprehensive health service, the Secretary of State will be there. There would be no harm in putting that word back in the Bill in one form or another. I do not understand the obstinacy, and in my view there is no legal impediment to the Government doing so.

Stephen Lloyd (Eastbourne) (LD): Does my hon. Friend agree that, because this is such a totemic issue, the key reason behind the proposed change in the wording is totally to reassure the public that, come what may, and even if delegated powers mean that the Secretary of State has not been involved for a number of years, the buck will stop with the Secretary of State?

Andrew George: I am grateful to my hon. Friend. He has referred to the issue as being totemic, and although I do not want to detain the House for too long because many others have referred to it, he is absolutely right. Now that it has been raised in such a manner, unless there are good legal reasons not to insert it in the Bill, it should be.

On the comments of the hon. Member for Pontypridd, I make a further point. We are talking about major changes, and the issue is not only totemic but contextual, because, in the context of a major—in fact, the most

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major—reorganisation of the health service, the reassurance of that backstop being in place would be all the more important.

I do not questions the intentions of the Secretary of State, for whom I have tremendous respect, but, having opposed the creation of the health service in the first place, the Conservatives have a problem, because the context is one of a major change, and whether we like it or not the assumption is that, if the Secretary of State is a Conservative, the hurdle will have to be set higher to reassure the nation that there is no untoward intention behind the legislation.

Simon Hughes: My hon. Friend knows that I share his views, and the hon. Member for Stoke-on-Trent North (Joan Walley) made the point that this is both a political and a legal debate. First, there is certainly a political argument for keeping the definition the same as it has been throughout the history of the NHS, which was created in concert by a Liberal and implemented by Labour. Secondly, there is a legal justification for doing so, because there are specific powers to provide, and therefore there is a generic logic in stating that, as part of the initial definition, there is provision for and security of health services. I am therefore sure that my hon. Friend will be on a winning wicket in the end.

Andrew George: I hope so, but sporting my cricketing injury I hope that that analogy does not apply.

Nick Smith (Blaenau Gwent) (Lab): I congratulate the hon. Gentleman on this point and think that he should absolutely stick to his guns. In my constituency, the birthplace of the national health service, 40 people have written to me about the issue in just the past few days, so it is important that he sticks to his guns and we get the message over to the Secretary of State this evening.

Andrew George: I am grateful to the hon. Gentleman, but I should also say that the Minister acknowledged in his opening remarks that there was an issue that needed further work and clarification. I entirely welcomed that statement and will be happy to be involved in any discussions that might advance the point. However, in spite of the discussions and debates so far, the issue remains unresolved. It might be resolved in another place, but until then it is important to make the totemic point that the matter is of such significant concern that it is worth our while pressing the matter further.

5 pm

I shall canter through my many amendments as briefly as possible. We are under a time constraint, and I will try to move through them as quickly as I can. I hope that hon. Members will bear with me if I do not take further interventions.

New clauses 16 and 17 would remove the independence of the commissioning groups from the NHS board by restoring the Secretary of State’s power to delegate functions to NHS commissioners and direct them where appropriate. That allows the restoration of the Secretary of State’s duty to provide or secure provision of the health service as per the 1946 Act, which used those very words. That would restore fully accountable spending in respect of the £80 billion of taxpayers’ money that

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goes through that route. We cannot provide a duty without providing the power, so the two things are clearly linked.

Amendment 1197 would delete clause 4; it involves the “hands off” issue that has been raised before. Clause 4 would otherwise prevent the Secretary of State from directing clinical commissioning groups and the NHS commissioning board. Amendment 1198 would delete the same duty in respect of the NHS commissioning board, but would not interfere with clinical commissioning group autonomy.

Rather than just asserting the opposite, will the Minister publish the legal advice that appears to contradict the advice that has been obtained? That states that the “hands off” clause is a real barrier to the Secretary of State’s intervention—as, after all, it is designed to be. Members could read the two bits of advice and see which was more convincing. Better still, will the Minister amend the Bill to put the matter beyond doubt?

Paul Burstow: I draw my hon. Friend’s attention to the Department of Health’s website. Yesterday we published a detailed response to both 38 Degrees opinions. It obviously draws on the legal advice given to Ministers and provides a full exposition of why we believe the points that I set out in my opening remarks.

Andrew George: I am grateful to my hon. Friend for that. During his remarks, he said that he believed that there was a risk that the Secretary of State might be drawn into micro-managing; that was one of his primary arguments. All I can say is that if there were a risk of the Secretary of State micro-managing, the Secretary of State could decide to do or not to do it. Simply removing the power comes back to my point about at least making sure that the Secretary of State has the ability to direct where appropriate. If the Secretary of State had that duty to provide, it would follow that he must have the powers to intervene as I have described.

Paul Burstow: My hon. Friend is making some important points, which give me the chance to underscore the important points that I have made. The Bill retains for the Secretary of State the capacity to intervene and exercise the functions of all the bodies established by it, and—in extremis, as a last resort—to make sure that services are provided. It is clear that that capacity has remained, not least in regard to the Secretary of State’s ability to establish special health authorities.

My hon. Friend is asking for back-stops, and back-stops have to be real and have effect. That is why we put them into the Bill as we have, so that the Secretary of State does have, in extremis—in the circumstances that concern my hon. Friend and others—the ability to take the steps necessary to secure and ensure that services are provided to ensure a comprehensive health service.

Madam Deputy Speaker (Dawn Primarolo): Order. May I gently remind the Minister of two things? First, he has to address the whole House. Secondly, it is not a private conversation between him and his hon. Friend, and his interventions are supposed to be brief. A lot of people are waiting to speak.

Andrew George: On that basis, Madam Deputy Speaker, I will end that part of the conversation and move on, acknowledging that my hon. Friend has made a point that is worth considering.

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Amendment 1224 would restore the duty to provide or secure provision of health services. Although that is seen as the headline proposal, it is consequential on new clauses 16 and 17, hence my intention to draw attention to the likelihood of my seeking to divide the House on those issues.

Amendments 1222 and 1223 seek to establish why the Bill has never provided for the Secretary of State to provide or secure a comprehensive health service rather than promote a comprehensive health service. This is an either/or situation, but I draw attention to the possibility that instead of pressing new clause 16, I may, in discussion with others, seek to divide the House on amendment 1222.

Amendment 1183 would beef up a duty of the Secretary of State—a theme that runs through a number of amendments. The purpose of amendments 1183 and 1194 is to address the conflict between having regard to reducing inequalities and placing above that duty the other duties that apply—for example, on choice. Amendment 1183 seeks to ensure that it is the duty of the Secretary of State, in reducing inequalities, to

“act with a view to”

rather than merely “have regard to”. Otherwise, the responsibility, and the duty, on the Secretary of State is rather weak. That applies to amendment 1194 in the same manner.

New clause 18 would impose a new duty on the CQC, the NHS Commissioning Board and clinical commissioning groups not to undermine existing NHS services in an unplanned way through the operation of competition. Rather than extending my description of this issue, it might be worth referring to the debate that we had yesterday about the regulations surrounding the functions and duties of Monitor, as the same question arises. We have to look at the impact that competition is likely to have on the provision of essential services such as major trauma and accident and emergency, where its existence may destabilise emergency services through the loss of, for example, important underpinning elective services provided by the hospital.

New clause 20 would ban the wholesale outsourcing of commissioning work with regard to clinical commissioning groups. That was demanded in a Liberal Democrat conference motion but has still not been delivered. The commissioning process is a public function, not a private function. The amendment therefore seeks to change schedule 2 in different ways to prevent private entities on clinical commissioning group committees and sub-committees from commissioning and making other decisions. This also applies to amendments 1224, 1245, 1244 and 1249.

The Minister said that the work of the Neurological Alliance is important to preserve. I hope he will recognise that new clause 20 talks only about commissioning work being

“predominantly retained as a function by staff directly employed by the clinical commissioning group.”

There is nothing in the Bill that prevents the bulk of the commissioning work—not the decision, but the work—of a clinical commissioning group from being done by a private company and thus, potentially, in secret. I hope he will accept that under the current wording of schedule 2,

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private entities will be able to sit on clinical commissioning committees and sub-committees and make commissioning decisions.

Amendments 1184 to 1188 and 1195 would demote choice to a subsidiary duty of commissioners to tackle fair access and inequality of outcomes. They relate to page 17 of the Bill. The priority of choice over inequity and inequality was introduced by the Government after the pause and the NHS Future Forum report as a way of promoting competition in ways other than through the role of Monitor. The amendments would reverse that priority for the NHS commissioning board.

Amendment 1211 provides that clinical commissioning groups should be more coterminous with local authorities than is the case under the Bill. The Minister said that there is no intention that clinical commissioning group boundaries will cross local authority boundaries. However, we all know that district councils do not cross local authority boundaries. In Cornwall, for example, we are likely to move from one PCT to three clinical commissioning groups, which will make the streamlining of the pathways between health and social care a lot more difficult. The purpose of amendment 1211 is to enforce that point.

I am aware of time and I hope that the House will appreciate that I will not explain every aspect of the many other amendments I have tabled. I am aware that there are significant issues that other people wish to raise. I simply emphasise that what the Minister said about health and wellbeing boards being able to refer matters to the Secretary of State is once again something that we have always argued for. Local authorities should of course be given a far greater say in commissioning decisions and in setting the strategy for health services in their area. As a back-stop, it is important that matters can be referred to the Secretary of State. My hon. Friend the Member for Cheltenham (Martin Horwood) has tabled some important amendments in respect of public health, some of which I have supported, and I hope that the Minister will consider them. I apologise for the amount of time I have taken, but I hope that the Minister will address the important issues advanced by the amendments.

Caroline Lucas (Brighton, Pavilion) (Green): I apologise for not being present for the first half hour of this debate. I was in the Environmental Audit Committee, where I had specifically asked for certain witnesses to be invited, and I have not yet worked out how to be in two places at once, although it is on my list.

I will make a few general points about this part of the Bill before turning to a couple of the amendments that are in my name. I echo the many concerns that have been expressed around the Chamber this afternoon. Many of us argue that there is no legal duty on the Government to provide health services. The new hands-off clause limits the Government’s ability to intervene should health care provision be deemed inadequate, because it says that clinical commissioning groups, the new agents of health provision that can include private companies, must be free to exercise powers and duties without “unnecessary burdens”. I am equally concerned that the powers and duties of a commissioning group, including its ability to award contracts and charge for commercial activities, could be exercised by a private health care company. The Bill opens the way for private companies

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to determine much of English health care and takes away the Government’s duties and powers, which is why I believe it should be opposed.

5.15 pm

I should like to say a few words about a couple of amendments in my name, starting with amendment 48. It offers Members the chance to return the NHS to its core ideals by making all health services in the UK, including dental care, eye care and prescriptions, free at the point of delivery based on each individual’s needs and not their ability to pay.

I am sure some Members will say that the argument was lost some 60 years ago, but I argue that, unfortunately, the facts show that returning the NHS to being a fully free service is as important as ever. In 2008, an Ipsos MORI poll for Citizens Advice revealed that about 800,000 people in England had failed to collect a prescription because of the cost involved. An Asthma UK survey found that 34% of people who had to pay for their asthma medication sometimes chose not to take some of their treatment because of the expense. Research published by Rethink in 2008 showed that 38% of people with severe mental illnesses such as schizophrenia had to choose between paying household bills and paying prescription charges.

Despite 85% of us admitting that we have problems with our vision, 37% are put off having a sight test because of worries about money. That shocking statistic shows the extent to which fear of cost is as much of a barrier as actual cost, as more than 30 million people in the UK are entitled to free eye care paid for by the NHS and many more are entitled to free eye care paid for by their employer. The result of that confusion is that more than 20 million people are putting their sight at risk by failing to have regular sight tests.

Andrew Percy: The hon. Lady is making an interesting argument, and I would just ask her two things. First, how is she suggesting that we should pay for the idea? Secondly, is she seriously suggesting that we should return to millionaires being provided with dental treatment and eye care free of charge?

Caroline Lucas: It seems to me that if Wales and Northern Ireland have been able to abolish prescription charging altogether, it is certainly possible to do it. I would also argue that although everyone collectively having a stake in our public services may well mean that millionaires get a free eye test, under the type of regime that I would like to see they would be paying an awful lot more tax than they are under the Conservative party’s regime.

Fiona O'Donnell: I am aware that the hon. Lady sits close to Scottish National party Members, who may not have given an accurate picture of what has happened in Scotland. We have free prescriptions, but we also have 1,200 fewer nurses. People such as me are getting our prescriptions free, but that puts strain on other parts of the service.

Caroline Lucas: I thank the hon. Lady, but I do not agree that the two points that she makes are causally linked. Of course I do not want to see the abolition of nurses, but that does not mean that we should have to pay for our prescription charges. Either we want an NHS free at the point of delivery and with free eye

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tests and so forth or we do not.


Someone is speaking from a sedentary position, no doubt asking how we will pay for it. I will be very clear that there is massive potential in cracking down on tax evasion and avoidance, higher tax for the rich, higher corporate tax and so forth. We are essentially talking about political priorities. The priority that I represent—a great many more people are coming to this view—is that we should be willing to pay for the public services that we want.

Hon. Members may oppose amendment 48 on the basis that charging for prescription or for dental and eye care is an important way of raising revenue. In England, eligible patients pay a prescription charge of £7.20 an item. In Scotland the charge is £3 and Wales and Northern Ireland have abolished prescription charging altogether. England raised just £470 million through the charges in 2009-10, which was just 0.5% of the NHS resource budget.

Crucially, we should remember that income from charging in the NHS is not pure profit. There is a real cost to administering the plethora of exemptions and reduced charging rates for which different groups are eligible. For example, there are 11 different groups that are eligible for free dental care, 15 that are eligible for free sight tests and 12 that are eligible for free prescriptions. I hope that hon. Members will see the benefit of doing away with that convoluted and complex system, which provides little benefit in terms of income, and which goes directly against the NHS principles by significantly reducing people’s access to all forms of health care simply because of their inability to pay.

Much has been said by hon. Members on both sides of the House about the founding principles of the NHS, and it will continue to be said. However, I put it to hon. Members that amendment 48, more than any other, seeks to point out that much important NHS care and treatment is charged for, and that we need to go back to NHS services as they were envisaged by its architect, who has been referred to many times this afternoon. Hon. Members might recall that he resigned as Health Secretary as early as 1951, in protest at his Chancellor’s efforts to impose charges for prescriptions, dental treatment and eye care.

Amendment 1181 raises serious concerns about the way in which CCGs will be able to charge for services. Although the power to charge, under proposed new section 14Z3 to the National Health Service Act 2006, is intended to be of benefit to the health service, it is very disturbing. Its scope is unclear—I wrote to the Minister last week to ask for clarification—but the fact is that important limitations on how the Secretary of State can exercise that power would apparently not apply to CCGs. The measure could run a coach and horses through the principle of a free health service, and Parliament needs to be clear on its impact in practice.

It is extremely worrying that CCGs will be able to decide that certain specialist services—for example, for pregnant women or women who are breast feeding young children, or aftercare—are not appropriate as part of the health service. That would mean that the statutory guarantee that the NHS will be free will not apply, because CCGs can decide that certain services and facilities should not be provided as part of the NHS. If that happened, CCGs could use the charging

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power to decide to charge for supplying, for example, goods to pregnant women, or for instructing people how to use their rehabilitation equipment.

Amendment 1181 would ensure that that could not happen. Ministers might say, “CCGs are commissioners and not providers”. If so, why is a measure that allows CCGs to charge necessary in the first place? The amendment would make it absolutely clear that there is no way in which a CCG could charge for anything that is related to the basic core health service, such as hospitals, doctors, nurses or ambulances, whether they are acting under section 3 or proposed new section 3A of the 2006 Act. The amendment would also impose on CCGs the same limitation that is already imposed on the Secretary of State. Why was that omitted from the Bill?

It is right that raising funds under that power should not interfere with a CCG’s functions. However, the Bill says that raising funds should not interfere significantly, but what on earth does “significantly” mean in that context? How is it to be determined or measured? If companies such as UnitedHealth got hold of that power and reckoned they could make money out of it, they will be on to it in a flash. The very least that they should be required to do is demonstrate that dealing in land and supplying goods and the like will not take them away from fulfilling their commissioning role. I would prefer it if those giant profit-driven companies were nowhere near the health service, but while they are, we need far greater safeguards than currently exist.

Unfortunately, the previous Government gave overseas companies the legal route into the NHS, and this Government are seeking to smooth that route yet further. Hon. Members may recall that at Prime Minister’s questions on 18 May, the Prime Minister claimed that he had not heard of Mark Britnell, one of his health advisers, who was also a key adviser under Tony Blair, until he googled him the previous Sunday. The Prime Minister’s interest was stoked by a report of a speech that Britnell, global head of health care at KPMG, gave to a group of private health companies in New York last October. Dr Philip Hammond pointed out in Private Eye that according to a brochure summarising the conference, Britnell said:

“GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process…In future, the NHS will be a state insurance provider, not a state deliverer…The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.”

That is a shocking thing to say, and no wonder the Prime Minister was keen to distance himself from it, at least in public.

My last point is about the final proposal in amendment 1181, which would mean that:

“Income raised by a clinical commissioning group as a result of the exercise of powers under this section shall be specified in its annual accounts, referred to in its annual report under section 14Z13, and paid annually to the Secretary of State.”

Without the amendment, it is completely unclear what CCGs will do with the money that they raise and how, if at all, it will affect their budget allocations. I think it would be madness for Parliament to give CCGs the right to charge for supplying goods, dealing in land and providing instruction for the purposes of raising more

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funds for the NHS, and then not to require them to account for it in any way, and not to ensure that the funds find their way back to the public rather than the private purse. This part of my amendment seeks to ensure that that is done.

Amendment 1234 refers to the fact that once they managed to get into the CCGs, multinational health companies such as UnitedHealth would be allowed to do the actual commissioning, thus creating a very unhealthy form of what is effectively in-house outsourcing. I understand that they will be able to charge for the supply of goods if the Government do not accept the amendment. Parliament cannot trust companies whose primary duty is to their shareholders to be in charge of so much taxpayers’ money, nor should such companies be given the right that the Secretary of State currently holds to charge for the supply of goods or for land deals. We should make it clear that CCGs cannot agree among themselves that their functions will be carried out by one of their private company members. Commissioning is a public function that should be exercised in the public interest, and private companies such as UnitedHealth should not be entitled to charge for any it.

Nick de Bois (Enfield North) (Con): I refer Members to my entry in the Register of Members’ Financial Interests. I wish to speak to amendments 1172 and 1173, in my name, which require the Secretary of State to collect haematopoietic stem cells. The issue is, of course, that of the collection of umbilical cord blood and cord bank policy, which was first raised in the last Parliament.

I pay particular tribute to the work of the all-party parliamentary group on stem cell transplantation for its work under the leadership of the hon. Member for Alyn and Deeside (Mark Tami), and to the enormous contribution and determination of my hon. Friend the Member for Enfield, Southgate (Mr Burrowes). My previous lack of knowledge of the subject was probably no different from that of many other people, but after giving my hon. Friend and neighbour a lift home on several occasions I became a speedy convert. Quite simply, the collection of cord blood can be life-saving. I pay tribute to the work of the Anthony Nolan trust in that regard.

In 1974 the Secretary of State was not obliged to facilitate stem cell transplantation from unrelated donors. Because the Governments of the day took that position, advances made took longer to achieve, which undoubtedly cost lives. The situation is different now: both the Government and the Opposition support expansion of the practice, and in particular of the more modern use of umbilical cord blood for such purposes. However, it would be fitting for the Minister now to make it clear in the Bill that this issue is important, to lock in the bipartisan support while it is strong, and to send a message to future Governments and civil servants that for as long as the Bill remains on the statute book, the issue is not to be lightly disregarded or de-prioritised at a future date.

The amendments involve no financial or political cost, but they are not merely symbolic. They could be described as an insurance policy against the risk of thoughtlessness or distraction on the part of future Governments—a risk that would ultimately cost lives.

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Mr Burrowes: It will not surprise the House to learn that I strongly support what my hon. Friend has said about the importance that should be attached to the life-saving cause of collecting cord blood and transplantation. As he has said, the Government are wholly committed to investing in and improving collections and to transplantation, but is it not important for us to consider whether that should form part of the duty of the Secretary of State? Is it not a priority, given that one in five members of black and ethnic minorities cannot obtain a match for the purposes of the transplantations that are sorely needed for life-saving operations?

Nick de Bois: My hon. Friend raises a key point. If we were to make prospective parents aware of the possibility of donation, we could address the major deficit in the BME community.

5.30 pm

I will not take up too much of the House’s time, but I hope Members will bear with me as I reiterate some of the important points that drove me to table these amendments. Patients in the UK requiring a bone marrow donor have a one in four chance of survival. Only 50% of those looking for a donor will find one, and of those who do so only 50% will survive. Many of those who find a bone marrow donor do so too late for the treatment to be successful, which contributes to the failure rate. Greater provision of cord blood could help patients get treatment faster and improve the chances of survival.

Greater provision of cord blood would give many who currently have no bone marrow donor a potentially life-saving option. The baby’s blood that is left behind in the umbilical cord contains many different types of cells, and some of them are stem cells, which have been shown to have a number of medical applications. Over the past 20 years, collected cord blood has been used for transplantation in the same way as bone marrow, so we can square the circle and see the advantages of drawing attention to the benefits of collecting cord blood and requiring the Secretary of State to ensure that this is done consistently and banked accordingly.

Researchers believe that cord blood has the potential to treat many more diseases once adult stem cells are properly understood. Trials have shown that cord blood may be helpful in treating brain injuries in children. It has also been developed for other possible treatments, including for testicular cancer, multiple sclerosis and diabetes, and for regenerating damaged heart cells. The potential is exciting, therefore. It is particularly valuable in the treatment of leukaemia. It can be used as an alternative to bone marrow transplantations.

Collection of umbilical cord blood is a far less invasive procedure than extracting bone marrow, and the units can be collected, frozen and stored for years, which leads to fewer complications and makes transplants more readily available than for bone marrow. More importantly, it is easier to find matching stem cells from cord blood than from bone marrow. If we can develop a proper infrastructure for the collection and storage of cord blood, that will do much to alleviate the severe shortage of life-saving stem cells.

Mr Burrowes: Is it not also important to ensure, through the Bill or other means, that commissioners are able to make the right decisions? Evidence of some commissioners questioning the economic value of

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proceeding with stem cell transplants was brought before the all-party group on stem cell transplantation. It is important that we pursue commissioning excellence.

Nick de Bois: I understand that the UK Stem Cell Strategic Forum recommended to the Government that there should be a regional centre of excellence, and I hope Ministers will let us know by letter if that policy is indeed being pursued, as I think it might deal with the issue that my hon. Friend raises.

Cord blood is a natural, safe, ethical and sustainable resource, and it offers many advantages over using traditional bone marrow transplants. We in this country should be proud that the NHS was one of the first bodies to recognise the potential importance of cord blood and significant breakthroughs were made in Britain. In 1996 an NHS cord bank was established, which is now working alongside the Anthony Nolan trust. At a time when the health service is mindful of the need to inform patients fully about their health care, the issue of the collection of a mother-baby’s cord blood does not seem to get the same degree of attention. The principles of full information and consent do not seem to apply to cord blood, which is, in general, treated as a waste product, unbeknown to parents, apart from in exceptional circumstances. By agreeing to my amendments, we can change that situation and the Government can demonstrate that they are giving a lead in the dissemination of information to expectant parents.

Last year academic research said that in order to have a truly effective operation we should strive to obtain 50,000 units of cord blood. I congratulate the Government, who have already committed £4 million to reach the first benchmark of 20,000 cord blood units. I commend the work of the Anthony Nolan trust and the NHS, which have also been sharing in building up to this target. Of course this is only the start, and I know that the Government have already expressed their commitment to helping to develop this very important work.

We have an opportunity for more lives to be saved, for valuable scientific research to be undertaken and for the UK to become a centre of excellence in cord blood. We can avoid the current situation whereby every day two people die waiting for a stem cell transplant, and 65,000 litres of cord blood are discarded every year. I welcome the Minister’s words of support and I appreciate the sentiments behind the Government’s thinking. I urge them to continue to get behind this valuable cause.

Rushanara Ali (Bethnal Green and Bow) (Lab): I speak in support of amendment 1169, which seeks to strengthen the Secretary of State’s duty to reduce health inequalities. As presented in clause 3, the Secretary of State’s duty is insufficient to tackle the health inequalities in our society. The clause lacks strength, invites the Secretary of State to disregard its meaning and changes little in the way in which health inequalities will be tackled in the future. By supporting amendment 1169 we can ensure that the Secretary of State can be regularly and properly held to account for his duty to tackle health inequalities across England.

Tackling health inequalities is vital because this is, in many cases, a matter of life and death. The World Health Organisation’s Commission on Social Determinants of Health has said:

“Social justice…affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in

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wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others.”

In our own country, Bevan’s dream for the NHS was for a service in which:

“No longer will wealth be an advantage nor poverty a disadvantage.”

Yet, despite the great strides that have been made there is much more to do, and the link between poverty and poor health remains.

Dr Wollaston: Will the hon. Lady give way?

Rushanara Ali: As there is not much time left, I would like to proceed in order to allow other colleagues to speak.

That link can be seen as clearly in London as anywhere else. According to the London health inequalities strategy,

“for men, life expectancy at ward level ranges from 71 years in Tottenham Green ward in Haringey to 88 years in Queen’s Gate ward in Kensington and Chelsea—a span of seventeen years”.

Despite the progress made nationally, in the borough of Tower Hamlets, in which my constituency sits, the rate of heart disease or stroke before the age of 75 is more than twice that of a more affluent area such as Surrey, and early cancer rates are nearly 50% higher.

We know that with the right resources and leadership it is possible to reduce health inequalities. In the past 10 years, the rates of early death from cancer and from heart disease and stroke have fallen in my constituency, but they remain worse than those in other parts of the country. That is why it is vital for the Secretary of State to continue the focus on tackling health inequalities, for us to look at the cross-cutting issues affecting health and for there to be co-ordination across government, led by the Health Secretary.

Tackling health inequalities was central and integral to Labour’s policy making in government. I urge this Government to think again, to recognise the vital importance of continuing that commitment and to make sure that there is genuine accountability for reducing health inequalities.

I was saddened to see last month that the Government plan to reduce the funding allocated to tackling health inequalities by altering the weighting given to inequalities in the weighted capitation formula from 15% to 10%. That will lead to a reduction in funding of £20 million over the next three years in Tower Hamlets—

Ben Gummer (Ipswich) (Con): Will the hon. Lady give way?

Rushanara Ali: I will not give way, because there is not much time left.

The borough is one of the poorest in the country, with high levels of health inequalities, and the change will have a direct and damaging effect on the health of my constituents and many others around the country.

Mr Lansley rose

Rushanara Ali: I will not give way, because the Secretary of State has had long enough to speak. He has had far too long to speak, and I have two minutes left.

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The change will have a very damaging effect on my constituents, and if the formula is applied across the country it will increase inequality. I ask the Secretary of State again to show leadership and take responsibility—

Mr Lansley rose

Rushanara Ali: The Secretary of State has spoken for long enough—[ Interruption. ] He has spoken, but there has not been much content—[ Interruption. ]

Madam Deputy Speaker (Dawn Primarolo): Order. The hon. Lady is entitled to make her speech and to be heard in this Chamber. As all Members know, this debate ends at 6 o’clock and there are still quite a few Members who have been present all the time who wish to speak.

Rushanara Ali: Thank you, Madam Deputy Speaker.

Amendment 1169 would be of great benefit in tackling health inequalities. It would make a real difference to people’s lives. Requiring the Secretary of State to lay an annual report before Parliament on progress towards ending health inequalities is therefore key in ensuring that proper accountability continues to exist. What is he afraid of? He could see the impact and put in place mechanisms to continue to improve, learning from the evidence and making progress. Considering how we can reduce inequalities in constituencies such as mine is a constructive way forward. I call on the Secretary of State to think again and accept this sensible amendment.

In conclusion, as the Marmot review stated, the

“link between social conditions and health is not a footnote to the ‘real’ concerns with health…it should become the main focus.”

Tackling health inequalities should be a central aim of health care policy for any Government, and the amendment would be crucial for achieving that. I hope that Members on both sides will back it and that the Secretary of State will take note.

Margot James (Stourbridge) (Con): I want to support the leadership that the Bill ascribes to public health and the role of the patient and empowered individual in taking responsibility for their health care as far as is possible. I congratulate the Government on setting public health free, as I see it, and taking it out of its ivory tower. It has been in the preserve of the primary care trusts and although in some PCTs it is given life, in others it gathers dust and is vulnerable to financial raids from time to time as budget pressures build and people seek to take money from an area where the public do not necessarily see the results for a fairly long time and to give it in preference to things that cause short-term pain. Regardless of which party has been in government, that has always been the case with public health.

If we consider where public health can make a difference in preventing ill health, we can see that the future of the NHS depends on a much better preventive strategy. Perhaps the best thing that the previous Government did in health care policy was the smoking ban, which will probably save more lives in the long run than anything else. We could consider some of the other areas that are ripe for similar treatment. I do not mean that we should ban alcohol, but we could consider public health policy and what it could do to reduce the incidence of sexually transmitted diseases, HIV,

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alcohol abuse and mental health problems. Many of the issues to do with drugs are about education and prevention, too.

I am pleased to see links being built into other aspects of the Bill. Our proposals for public health in relation to mental health have been strongly welcomed by the Samaritans, because there is so much to do with mental health that takes place in the community. The involvement of local authorities and the leadership role given to them in the Bill should enable aspects of local government policy such as housing, children’s social services and adult and social care to be brought to bear in dealing with these problems.

5.45 pm

Sarah Newton (Truro and Falmouth) (Con): Will my hon. Friend give way?

Margot James: I would love to but I am aware that others are waiting and I am trying to curtail my comments. [Hon. Members: “Hear, hear!] I will take that as a prompt to get a move on.

I want to address a point that was made earlier about where the director of public health should sit in a local authority. I think it is important that the public health director should report to the chief executive because the public health function will cover so much that is part of children’s services, adult and social care and housing that it is hard to see how they will fit in unless they report at the top level.

In conclusion, I believe that the elevation of public health will enable public health to be placed at the centre of commissioning and that the link between the wellbeing boards and the primary care commissioning groups will enable public health to be instrumental within commissioning. That is where we will see the long-term benefits outrunning the short-term imperatives.

Alison Seabeck: I shall cut to the chase because other Members want to speak and many colleagues have spoken powerfully about the benefits of the NHS. I have two very specific questions regarding concerns that people in the south-west have raised with me. These issues relate to part 1 of the Bill, the role of the director of public health, and the making of complaints, as covered by new clause 1. I want to link these issues to the duty of the Secretary of State to ensure that the basis on which actions are taken—indeed, the information that is used—is in the hands of and is accessible to people in the new set-ups who need that information and can use it.

The concerns that have been raised with me relate to the movement of national health service public health staff into local authority control and the fact that the Office for National Statistics currently has a duty to release certain data only to directors of public health, who are part of the NHS. I gather that the ONS has had concerns about this and I am interested to know whether it has waived the requirement for directors of public health to sign a confidentiality and proper use statement every year, or whether it has agreed to the passing of this role into local authorities. I cannot find that in the Bill, although I must admit that I am coming to this a little late—my apologies to colleagues about that—and I would be very grateful if the Minister could tell me whether that issue has been resolved.

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Secondly, the Minister will know that we carry out nuclear decommissioning in Plymouth. Is he confident that public health can be fully protected in the way that it has been in the past? I note clause 54 on radiation, but will the Minister look at how H1N1 was dealt with? The first confirmed case of swine flu was in Paignton and the response was carried out by PCT public health staff in Plymouth and Torbay. They worked together rapidly to administer antiviral drugs to nearly 500 pupils and they provided reassurance and support to extremely anxious children and parents. That response was set up within 45 minutes of the initial phone call, despite the fact that it had not been done before, and it was done without any practical help from the Health Protection Agency, which was swamped with other work. The PCT public health staff just got on with it and they did a fantastic job—no other child was infected. Indeed, they compiled a guide on how to do it all, which was passed on and was commended by the Prime Minister. There is a view that such a response will not be possible in a few years’ time, so complaints from the public—this takes us back to new clause 1—will inevitably follow. Clearly, if we get health protection wrong, we can kill people.

In order to avoid complaints on new clause 1, will the Minister say what power the director of public health, sitting within the local authority, will have to galvanise staff across organisations? Will they be the appropriate authority, or will responsibility sit elsewhere? Will they have to go through another senior officer? Who is ultimately responsible if they get it badly wrong—the local authority, the director of public health or the Secretary of State? Or is it another instance when the Government are saying, “Not me, guv” and passing the buck to the local council and the political leadership of that council? If there was a viral outbreak in various parts of the country, widely spread, would the individual local authorities be held responsible for dealing with it, coming up with solutions and coping with the outcomes, or is this a case in which the Secretary of State actually has a clear duty to take the lead?

Martin Horwood: I am extremely grateful to you for calling me, Madam Deputy Speaker, as you have a tough job this afternoon. I have to declare an interest. I rarely speak in the House on NHS organisation, particularly public health, because my wife is employed as a director of public health. Obviously, the Bill and the public health section of clause 27 will affect her significantly, and by extension those of us in her family, but I make it clear to the House that although my knowledge of her role and profession has informed amendments 1255 to 1260, which stand in my name, she had no knowledge of them or their contents before I tabled them. However, I am grateful to the Faculty of Public Health and others who have given me advice.

Public health is pretty poorly understood, not least in this Chamber at times. There is a constant tendency to confuse it with the traditional, established local authority function of environmental health, and although I have great respect for the hon. Member for Stoke-on-Trent North (Joan Walley) in many respects, I think the risk of her new clause 23 is that it extends that confusion between environmental health and public health. There are many key functions to public health, not just the vital five-a-day style health promotion and health improvement work, but a critical role in health protection, including the management of outbreaks of communicable

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diseases—serious diseases such as meningitis and influenza—and a key role in influencing, at the moment, NHS commissioning at local level, using population-wide data and medical analysis. That, at the moment, happens very simply and straightforwardly within the primary care trust. Under the Bill at the moment, there is no role for the director of public health within the new clinical commissioning groups, and they have to exercise that kind of influence at several removes. That point was well made by the hon. Member for Plymouth, Moor View (Alison Seabeck).

It was suggested to me at one stage by some civil servants working on the Bill that in order to make up for the gap left by the director of public health in the new clinical commissioning groups—then called consortia—they might actually want to employ someone with public health expertise to make up for the reorganisation. That does not seem to me a very good use of public money.

Some of the things that Ministers have announced are to be welcomed. I will have to skip over them briefly, but principal among them is the very good decision to make Public Health England a separate Executive agency and not part of the Department of Health. That was a key request of the faculty, and I think it is very important that it retain that status and objectivity.

I pay tribute to the Minister of State, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), for taking a great deal of time and care over the concerns that I had in this whole area, but questions remain to be addressed and my six amendments are an attempt to address three main areas.

The first area is, as the hon. Member for Plymouth, Moor View pointed out, that under this scheme directors of public health will be removed from the NHS, as will their staff. One of my amendments suggests, therefore, that they should continue to be employed by Public Health England and retain that integration within a wider public health profession. At the moment directors of public health sit within primary care trusts and it is reasonably straightforward, but within the spaghetti-like structures created by the Bill, public health responsibilities and leadership are now to be split among Public Health England, the Secretary of State, the local authorities, the national commissioning board, the health and wellbeing boards and clinical commissioning groups. The threat is not just confusion and the unclear fragmentation of public health functions, but the fragmentation of the profession itself and of the career paths, whereby people might move from one bit to another and have to leave and rejoin the NHS, and so on. That is one of the issues addressed.