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Monday, 14 November 2011.
2.30 pm
Prayers-read by the Lord Bishop of Norwich.
Sure Start
Question
2.36 pm
To ask Her Majesty's Government how many Sure Start centres have been closed since the Coalition came into power; and how many have had their funding cut in real terms.
The Parliamentary Under-Secretary of State for Schools (Lord Hill of Oareford): My Lords, there were 3,631 children's centres in April 2010. Information supplied by local authorities shows that as of 8 September 2011, there were 3,507 children's centres in England. Of the reduction of 124 children's centres, six are outright closures; the remainder are accounted for by local reorganisations such as the merger of two or more centres. A breakdown for each local authority has been placed in the Library and is available on the department's website. The department does not hold information on local authorities' funding allocations to individual children's centres.
Lord Dubs: My Lords, will the Minister confirm that after the coalition was elected, the Government gave an undertaking that Sure Start centres would not be cut? What we are seeing in the Minister's Answer is the first of a wave of cuts. Is it not right that estimates now suggest that up 250 centres will be closed within the 12 months and that the position is getting worse year by year?
Lord Hill of Oareford: My Lords, I have given the noble Lord the snapshot of figures that we have for September. As I said, that shows that there have been six outright closures and a further 120 or so mergers. If one added all those together and accepted that those were all closing, which they are not, that comes to something like 3 per cent of the total of Sure Start children's centres. It is the case that the Government attach high importance to the role that Sure Start children's centres play, which is why through the early intervention grant we have put in the funding to maintain a national network of Sure Start children's centres.
Baroness Walmsley: My Lords, when my honourable friend Sarah Teather, the Minister for Children, made her announcement this morning about the additional free early years places for disadvantaged two year-olds, I noticed that there was something in the consultation about information for parents. The idea is one of moving to an annual report from local authorities about the sufficiency of places, rather than the current assessment. Can my noble friend the Minister say how he feels that this new system will be better than the old one?
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Lord Hill of Oareford: My Lords, the point of having much more information available to parents is that we hope that that will empower them to have more say in the system. We are also looking at trialling payment by results in Sure Start children's centres, which we think will lead to better services, targeted more on those suffering from the greatest disadvantage. This approach will, I hope, improve the quality of the services delivered through this vital part of early years provision.
Baroness Howarth of Breckland: My Lords, does the Minister agree that there is some correlation between the removal of a number of preventive services at local authority level, Sure Start centres being one, and the rise in the number of children who are coming before the courts? This October, a record number of children came before the courts and then went into care. Do the Government not have a view about the need for local authorities to continue to improve their preventive services to keep children with their families rather than having the high level of removal that is happening at the moment?
Lord Hill of Oareford: I agree on the importance of that. We must do all that we can to try to keep families together and children with their families. That strikes me as being vital and that is one reason why the Government are looking at ways of trying to trial more support for parents, looking at ways of putting extra funding into Relate to keep families together and, more generally, looking at the whole adoption system and the range of support that we make available for children. However, I agree with the noble Baroness about the importance of that.
The Lord Bishop of Bath and Wells: My Lords, 83 per cent of all Sure Start centres are facing budget cuts. Of these the worst hit, in Hull, faces a 56 per cent cut. Does the Minister agree that the cuts affect children, many of whom belong to families being helped out of poverty by the Sure Start provision? Does he further agree that by failing to require local authorities to ring-fence Sure Start, it has become a soft target for cash-strapped authorities?
Lord Hill of Oareford: I do not agree with the last point made by the right reverend Prelate. I hope the figures I was able to announce to the noble Lord, Lord Dubs, demonstrate that local authorities are working extremely hard to spend the money they get through the early intervention grant and maintain the important services delivered through Sure Start children's centres. Of the 152 local authorities, I think I am right in saying that 119 have announced no change at all to the number of Sure Start children's centres that they have; of the others a range of measures has been taken. The point of doing away with the ring-fence is to give local authorities greater responsibility and we think that is the right approach.
Baroness Hughes of Stretford: My Lords, for the first time ever we have the prospect, through Sure Start, of a universal integrated service for the under-fives and their parents. It is clear, however, that local authorities are not only closing centres but are cutting their
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Lord Hill of Oareford: As I explained in my answer to the right reverend Prelate, there is a difference of opinion between us and the party opposite about the ring-fence. It is our view that giving local authorities greater discretion over their budget is the right way to go forward; to treat them like the responsible bodies that they are. I recognise there is not as much money around as there was before-I cannot deny that that is the case-but we believe the right way is to put the same funding into the EIG for Sure Start children's centres, which are an extremely important service. We want to focus them on providing better services for the most disadvantaged and we think that is the right way forward.
Lord Campbell-Savours: My Lords, does it remain the policy of the Government to retain ring-fencing of any area of local expenditure, over which the noble Lord has some influence?
Lord Hill of Oareford: My Lords, I fear I have not boned up on the whole approach towards ring-fencing expenditure across local government. So far as my department is concerned, the general direction of travel we want to go in is to simplify funding, to have as few separate grant streams as we can and to delegate responsibility as much as possible, whether that is to local authorities or to individual schools.
Food: Prices
Question
4.45 pm
Asked By Lord Knight of Weymouth
To ask Her Majesty's Government what measures are being taken to assist families in the United Kingdom to cope with increasing food prices.
The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Taylor of Holbeach): My Lords, the impact of rising food prices is of concern to the Government. While it is not the Government's role to control food prices, we understand the need to monitor the impact of price increases on households. I hope it reassures the noble Lord that the Government provide a nutritional safety net to extremely low-income families through the Healthy Start scheme, which offers vouchers for essential foods. As the noble Lord will know, we also take into account food prices when benefits rise annually with consumer price inflation.
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Lord Knight of Weymouth: My Lords, according to the latest statistics from the OECD, UK food consumers face the second highest increase in food prices of anywhere in Europe-ironically, after Hungary. What are the Government going to do about it? Why are British food consumers so hard-hit relative to others in Europe? This is an urgent problem for family budgets-what is the Government's response?
Lord Taylor of Holbeach: My Lords, the House will know that food supplies and volatility in food price markets have been a feature of the past 12 months. We cannot doubt that in this country we have the most efficient food supply chain in Europe. Our supermarkets are extremely price-competitive, as anyone here who has shopped in other countries will realise. I think that the noble Lord was talking about increases rather than absolutes, but I am talking in absolute terms. Of course we are concerned. I think that the secret lies in increasing food production and producing a great deal more self-sufficiently in this country-a policy that was abandoned by the last Government but which this Government are determined to take up.
Lord Howe of Aberavon: I dare say that my noble friend will not recall that my first appearance in the Cabinet was on Guy Fawkes Day 1972, when I was appointed Britain's first Minister for Consumer Affairs-a role described by Sir Edward Heath as the Minister for Keeping Down Prices. Does my noble friend recollect that that task was then taken on by the noble Baroness, Lady Williams of Crosby, and that the most enthusiastic enforcer was the late Lord Cockfield? If there is any lesson to be learnt, it is that we were all wasting our time and burdening the nation to wholly no good. Will he please assure us that that lesson is fully understood?
Lord Taylor of Holbeach: I am very grateful to my noble and learned friend for taking me back to my childhood in politics-names like Aubrey Jones and Fred Catherwood and prices and incomes policies all come back to me. Indeed, my noble and learned friend is right to remind us that there is nothing like a competitive market with a strong retail sector to make sure that prices are kept as competitive and as low as possible.
Lord Pearson of Rannoch: My Lords, can the noble Lord confirm the previous Government's estimate that the EU's agricultural policy costs each family of four in the United Kingdom about £1,000 per annum in higher food costs and tax? Would he also agree that since these higher food costs fall largely on milk, bread and sugar, they hit our poorest hardest? Finally, would he confirm that there is nothing we can do about this while we remain in the European Union?
Lord Taylor of Holbeach: I should inform the noble Lord that in actual fact the world price of sugar is currently higher than the internal European price of sugar. Indeed, the common agricultural policy, despite all the misgivings, at least provides some degree of stability in the huge volatility that there has been in global commodity prices. I cannot share the noble Lord's view.
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The Lord Bishop of Norwich: My Lords, is the Minister aware of the rapid growth of food banks around the country-a Christian initiative which is gaining ever wider support? I declare an interest as the patron of Norwich Foodbank, which has assisted 860 families and individuals in just the past three months. What might be done to better integrate this generous voluntary provision with the work of statutory agencies?
Lord Taylor of Holbeach: Last week I, like a number of other noble Lords, attended an evening on food waste here in the House. Present at that gathering was FareShare, which, with FoodCycle, offers a facility whereby food that would otherwise be wasted can be made available through charity outlets. I think that that is a worthwhile initiative, and I congratulate my noble friend Lady Jenkin of Kennington on arranging the evening. It was most enlightening and, indeed, encouraging.
Baroness Trumpington: Is the Minister aware of the extremely helpful programme going out weekly on the BBC describing British food that is available to everybody but does not seem to be taken up? Can Defra please help the BBC? Cabbages, eggs and everything you can think of are being dealt with most efficiently on the BBC-I hate to give it credit but it is true. It would be helpful if Defra could follow in those valuable footsteps.
Lord Taylor of Holbeach: The BBC has pioneered informative broadcasting on agricultural matters, from "Farming Today" to "The Archers" to "Countryfile", all of which I hope inform the public about what it is to produce food and all the elements that go in to making a strong food supply chain in this country.
Health: Cancer Drugs Fund
Question
2.52 pm
Asked By Baroness Morgan of Drefelin
To ask Her Majesty's Government what assessment they have made of the effectiveness of the cancer drug fund.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, since October 2010, more than 7,500 patients in England have benefited from the additional funding we have provided for cancer drugs. The £600 million we have committed over three years will improve the lives of many thousands more cancer sufferers, giving them precious extra time with their loved ones.
Baroness Morgan of Drefelin: My Lords, I remind the House of my interest as chief executive of a cancer research charity. Can the Minister share with the House thoughts on plans for the fund, following the abolition of strategic health authorities which are currently responsible for administering the fund? Will he share with us any thoughts the department has about emerging patterns of variation in access to the fund? I appreciate that it is a new fund and that patterns are difficult to see in a field where there are
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Earl Howe: My Lords, I pay tribute to the noble Baroness for her work in this area. She asked what would happen when strategic health authorities are abolished. Arrangements from 1 April 2013, which is the planned abolition date, and beyond will be the subject of discussions between my department and the NHS Commissioning Board Authority. So I cannot give her definite news yet on that front.
I know that the regional clinical panels are using their own judgment to come to decisions, and it is entirely right that they should. At the same time, they are alive to apparent variations in the drugs that are being made available through the fund in different regions, and I understand that the SHA clinical panels are working collectively now to better understand the reasons for those differences.
Lord Clement-Jones: My Lords, I welcome the fact that thousands of cancer patients have benefited from the cancer drugs fund, but can the Minister give an assurance that those cancer treatments currently available through the fund will continue to be available when value-based pricing is introduced in 2014?
Earl Howe: One of our aims for value-based pricing is to give patients better access to innovative and clinically effective drugs, which, unfortunately, has not always been the case until now, hence the need for the cancer drugs fund. That is certainly one of our ambitions for value-based pricing.
Baroness Pitkeathley: My Lords, does the Minister agree that one of the problems with this very welcome fund is that still too few patients know about it? Is his department planning any information campaign to ensure that patients know more about it so that they can ask for access to the fund themselves, particularly in view of the more complex structure that they will face in the NHS when the Bill currently before the House is law?
Earl Howe: My Lords, the noble Baroness makes a good point. We endeavoured to publicise the fund in April when it was created. We have reminded the health service to make the fund's existence known wherever possible. The specific answer to her question is no, we do not plan a publicity campaign. However, we wish to ensure that clinicians in the service are as fully aware of the fund as they should be. I believe that they are, certainly at the level of secondary care.
Baroness Gardner of Parkes: My Lords, I have read in the paper that some very expensive cancer drugs will now be approved by NICE on the understanding that DNA testing will assess whether the patient will benefit from them. This was one of the arguments to do with giving terribly expensive drugs. Will these drugs also now be available from the same source after 2013?
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Earl Howe: We plan to ensure that value-based pricing will take care of the gap that currently exists in the availability of cancer drugs, which the cancer drugs fund is trying to address. In theory, until then any drug that a clinician wishes to prescribe for a cancer patient is available under the cancer drugs fund. There is no restriction that we have set; it is a clinical judgment.
Lord Roberts of Llandudno: My Lords, many patients from north Wales go to Christie's Hospital in Manchester or Clatterbridge on Merseyside. How will this fund be available to them? How does Wales come out of the complexity of this situation?
Earl Howe: My Lords, it is of course for the devolved Administrations to make their own decisions about their individual needs and budgets. It will depend on whether commissioners in Wales are willing to accept the cost of treating a patient with a drug that is not normally available in Wales. I cannot generalise but it is up to Welsh commissioners to take that decision.
Baroness Howarth of Breckland: My Lords, I am aware that 2013 is approaching very fast. Does the Minister's department have a timetable for the strategy that will be in place once the strategic health authorities have gone? Will there be consultation on those plans?
Earl Howe: My Lords, as I told the noble Baroness, Lady Morgan, discussions are ongoing as to the arrangements that will be in place after the abolition of strategic health authorities. I cannot say that we have definite plans in place but I hope that we will be able to announce our plans soon.
Baroness Farrington of Ribbleton: My Lords, cancer treatment drugs are often used in a range of measures to treat people suffering from cancer, including both chemotherapy and radiotherapy. Is it not the case that concern is being expressed about the closure of access to radiotherapy in some hospitals, and that people are having to travel for up to three hours? I understand that this is a problem in Essex and other parts of the country. Does the Minister share the concern about people not being able to get the treatment they need if these centres close? Who is responsible now, and who would be responsible in the future under the Government's proposals, for ensuring that reasonable access is maintained?
Earl Howe: We are concerned to ensure that patients have reasonable access to the treatments that they need, including radiotherapy. I can tell the noble Baroness that part of the additional funding that we are making available under the strategy for cancer that we published earlier this year will go towards widening access to radiotherapy-not only better utilising the facilities that we have but commissioning new facilities. However, I am afraid it is the case that we increasingly see specialised units being concentrated in fewer locations. Unfortunately, this will mean that some patients have to travel a little further than they otherwise would have.
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Media: Ownership
Question
3 pm
Asked By Baroness Scotland of Asthal
To ask Her Majesty's Government, in the light of the recent News Corporation bid for full ownership of BSkyB, what assessment they have made of the legislation relevant to the bid; and what deficiencies in the legislation they have identified.
Baroness Rawlings: My Lords, the News Corporation bid for BSkyB raised a number of issues in respect of the existing media ownership regime. The Secretary of State will consider these issues, alongside any others and the recommendations from the Leveson inquiry, as he undertakes the communications review.
Baroness Scotland of Asthal: My Lords, does the Minister accept that there is general concern across the House about the adequacy of the current legislation? Does she also accept that the provisions of Section 58(3) and (4) of the Enterprise Act were created to enable the Secretary of State to amend the conditions in Section 58 if he or she felt that the need arose? In those circumstances, will the noble Baroness tell us why the Secretary of State refuses to take advantage of Section 58(3) and (4) to ensure that in future, if there is a fundamental mistake, misrepresentation or act of bad faith, advantage cannot be taken of the same?
Baroness Rawlings: My Lords, yet again the noble and learned Baroness raises a very technical and important point. This follows our extensive correspondence about Section 58(3) and (4) of the Enterprise Act 2002, all letters relating to which have been placed in the Library. With all due respect to the noble and learned Baroness, Lady Scotland, we may not agree on specific points, but I want to clarify that there is already a requirement on Ofcom to make certain that anyone holding a broadcasting licence is and remains a fit and proper person. I again stress that this is an ongoing requirement and not one limited just to a merger situation. I am most grateful to the noble and learned Baroness for raising this important point again and we will consider it. The Secretary of State is not refusing to act; he will bring this up at the Communications Bill committee while also awaiting the results of the Leveson inquiry.
Lord Fowler: My Lords, does my noble friend agree that over the past 10 years, and way before that, Governments and media owners have become far too close to each other? Would it therefore not be sensible to ensure that Ministers do not make the final decisions in media takeovers?
Baroness Rawlings: My noble friend makes a very good point. He has brought it up before and he knows that the Secretary of State agrees with it. The Secretary of State said this in his speech in Edinburgh on the Royal Television Society. He said that he wanted to explore this option in more detail and welcomed any views. At the same time, he will take into account the recommendations of the Leveson inquiry before making any final decisions. This is on the table and I am pleased that my noble friend has brought it up.
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Lord Razzall: My Lords, obviously this is an occasion on which we are slightly intruding on private grief, bearing in mind the travails of News Corporation. Does the Minister not agree that the concern at the time of the original bid was that, if the merger were allowed, there would be no further power for either Ofcom or the Competition Commission to intervene, even if the News Corporation share of the market got bigger and bigger? Does she accept that there is an opportunity in the future Communications Bill to ensure that intervention can take place not just when there is an act such as a merger or a takeover but at any stage thereafter if the organisation gets too big?
Baroness Rawlings: My noble friend is very expert in these matters and has gone to the core of the subject. We are looking at the existing rules, particularly in the light of the News Corporation merger. It is important that these rules that we have in place do not allow one person or organisation to have too much control over the whole media landscape. We want a vibrant media market which attracts investment, ideas and skill. The challenge is to come up with suitable restrictions on media ownership which do not unduly restrict those. We recognise the gap that he mentions.
Lord Prescott: My Lords, the noble Baroness will realise that in the debates that we have had in this House on the Murdoch press and its application to BSkyB she has constantly told us that it is an issue not of criminality but of plurality. However, those crimes have continued under Murdoch. Indeed, only four months ago the Secretary of State for Culture assured us that he had interviewed Murdoch and was satisfied that he was increasing the independence of the editorial board and the financial viability of BSkyB. I hope the Minister will understand that it is not acceptable for this company to be in control of BSkyB or, indeed, to own the shares that it has at the moment as it is not a fit and proper company. Will its present shares be now reconsidered as the company is not a fit and proper one in view of all its criminal activities?
Baroness Rawlings: My Lords, I understand the concern of the noble Lord, Lord Prescott, and how he has suffered in this matter. We acknowledge that so far one newspaper in particular was responsible for the hacking and that it was the solid investigative journalism of another that exposed it. I am sure he agrees that we need to restore public trust in the regulation and activities of all our newspapers, and we expect that newspapers on the whole will welcome this. We trust that the Leveson independent inquiry will be able to do this and we trust in self-regulation in the capable hands of my noble friend Lord Hunt of Wirral.
Al-Qaida (Asset-Freezing) Regulations 2011
Motion to Approve
3.07 pm
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Relevant documents: 29th Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 9 November.
Health and Social Care Bill
Main Bill page
19th Report from the Delegated Powers Committee
18th Report from the Constitution Committee
Committee (5th Day)
Relevant document: 19th Report from the Delegated Powers Committee, 18th Report from the Constitution Committee.
3.07 pm
Baroness Thornton: My Lords, I rise to intervene at this stage because I think this is the only place where I can ask the Minister about an important matter concerned with the ability of the House to conduct a comprehensive consideration of the Health and Social Care Bill.
On Friday last week my honourable friend John Healey MP made available the report that he had received from the Information Commissioner. What he asked for a year ago was the risk register which would have set out the key risks with information about them and an assessment-RAG, which is the traffic lights system-of their likelihood and impact on the implementation of the Bill through the transition period. His request was initially refused and has gone to appeal. Noble Lords will realise that this information is completely pertinent to the further consideration of the Health and Social Care Bill in Committee here. The issue I seek clarification on is the very damning judgment of the Information Commissioner. He says that the Department of Health must disclose this information within 35 days of receipt of his notice. Were the Secretary of State to wait until the last possible minute, this would take us near to the very end of our Committee stage on the Bill. In the spirit of open and transparent government, I ask the Minister to make the information available to the House as soon as possible, and certainly in time for consideration of the Bill on Wednesday morning at 11 am.
The risk register is available immediately because it is a regularly updated component of good governance of any major programme, and as such can be easily accessed. In other words, it is not a difficult document to duplicate or forward to anyone. The commissioner finds that there is a very strong public interest in the disclosure of this information given the significant change to the structure of the NHS proposed by the Government. I hope that the Minister will be able to assist the House by making this information available very quickly, because I am sure he will realise its relevancy. I hope very much that I will not find myself back here on Wednesday morning asking why the release of this documentation has not been possible. I regret that, under those circumstances, I may be asking what the implications for the future consideration of the Bill might be if the House does not have access to this potentially very important information.
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Baroness Williams of Crosby: I hope that the Minister will give very careful consideration to this request. I believe it will enrich our debate substantially and of course enable us to deal with issues that may change as we learn more about the effect of these statements. I plead with him on behalf of these Benches to consider whether the department could release these documents as quickly as possible.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I am grateful to the noble Baroness for giving me prior notice of her question. I am grateful too to my noble friend Lady Williams for her remarks. As I stated in my letter to Mr John Healey some time ago, I am of course conscious that there will be public interest in the contents of the risk register. However, from a government perspective, we need to balance this with the public interest in preserving the ability of officials to engage in discussions about policy options and risks without apprehension that suggested courses of action may be held up to public and media scrutiny before they have been fully developed or evaluated. We also need to balance the need for my ministerial colleagues, our officials and me to have sufficient space in which to develop our thinking, explore policy options, and weigh all this against the risk that disclosure may deter candid discussion in the future, which may in turn impact on the quality of decision-making. Those are the issues.
We are therefore currently considering the decision notice from the Information Commissioner. We have to respond by 6 December and we intend to meet that deadline. Unfortunately, I cannot go beyond that commitment today. In the mean time, it is perhaps right for me to point out that we have already made public a very considerable amount of detail about our reforms, including information on key sensitivities and risks by policy area in the impact assessments that were published in January and September this year. I refer the noble Baroness to these documents. In addition, we continue actively to engage with stakeholders, building on the work of the NHS Future Forum and listening exercise.
46: After Clause 5, insert the following new Clause-
"Secretary of State's duty as to promoting equality of provision
After section 1D of the National Health Service Act 2006 insert-
"1E Duty as to promoting equality of provision
In exercising functions in relation to the health service, the Secretary of State must have regard to the need to promote equality for those providing services on behalf of the health service and shall within one year of passing this Act, lay a report before Parliament on the treatment for Value Added Tax of supplies by charities to bodies exercising functions on behalf of a Minister of the Crown of healthcare services or associated goods."
Lord Patel of Bradford: My Lords, we have discussed many aspects of equity and equality in relation to this Bill. In moving this amendment, I wish to draw attention
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It was only in January this year that we debated the unfair burden placed on charitable organisations that take on public services but cannot claim the same VAT exemptions as the health service providers they have succeeded. A major inequality exists with respect to irrecoverable VAT for charities providing healthcare services. While the NHS is able to recover VAT on, for example, certain non-business supplies, charities are unable to do so. Of course, the NHS's ability to recover VAT on certain non-business supplies is written into Section 41 of the Value Added Tax Act 1994. Under current legislation, when services are transferred from the NHS to the charity sector, there is a VAT gap that needs to be filled either by charitable funds or by the local PCT.
3.15 pm
I shall give one small example, provided by Sue Ryder, one of they UK's largest specialist palliative care providers. One of Sue Ryder's hospices incurs £44,000 in VAT each year. If that hospice were run by the NHS, it would be able to recover 57 per cent of that amount under Section 41 of the VAT Act. That would allow the hospice to employ a nurse for around 44 weeks, or provide 1,500 bereavement sessions to families who had lost a loved one, or provide 2,500 hours of support from a carer. This amendment recognises that the Treasury has been engaged with the hospice sector to try to find a solution to the problem. I want to ensure that it remains on the Government's agenda, so the amendment asks them to present a report to Parliament on this critical issue.
I am grateful to Sue Ryder Care for making me aware of this issue. As many noble Lords are aware, Sue Ryder provides specialist palliative and long-term care for people living with cancer, multiple sclerosis, Huntington's disease, Parkinson's disease, motor neurone disease, stroke, brain injury and other life-changing illnesses. It is one of the largest specialist palliative care providers in the UK, offering 4 million hours of care, over 100,000 days of long-term residential care, with the help of more than 8,000 volunteers. It provides vital services for people in their darkest hours of need. Who would argue that we should not do all we can to ensure that this continues? Yet these services are threatened. They face an additional burden at a time when the Government are asking organisations such as Sue Ryder to do more. It could be one of the many "any qualified providers" that are invited to take over services such as hospice care under the Bill.
As far as I am aware, there are currently 36 NHS hospices, all of which are rightly exempt from VAT. I understand that the issue is complex. It concerns EU legislation as much as our own national fiscal policies. Moreover, the Government have previously expressed concern that addressing the unfairness for the charitable sector would subsequently create problems for the private sector. Nevertheless, I am not convinced by
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This issue is not limited to hospice services but affects many charitable organisations providing a range of health services. The situation is made all the more grave by the recent increase in VAT to 20 per cent. Estimates by the Charity Tax Group state that, prior to the rise in VAT, charities were paying more than £1 billion in irrecoverable VAT and that, after the rise, this figure has gone up by an extra £143 million. Sue Ryder informs me that approximately one-third of its income is from statutory services. What this means in effect is that, without its valuable contribution to care, the cost of providing it in the NHS would be two-thirds more.
We should not expect the charitable sector and those individuals who give their hard-earned money to support it to subsidise care that everyone agrees is vital, yet we do. We not only ask the sector to continue to provide these services at such significant cost-savings but we add insult to injury by saying that it should do so without the tax benefits given to the NHS.
I am aware from a discussion on this same issue in the other place that various solutions have been put to government to rectify the problem. One is the so-called "poppy" solution, whereby a matching grant for the VAT is given by way of return to the charitable organisation. This solution worked well for the Royal British Legion, and it should be possible to have something similar for hospice-care providers. It has also been proposed that relief enjoyed by local authorities and other public bodies under Section 33 of the VAT Act 1994 and certain healthcare provisions under Section 41 of the same Act could be used to assist hospices. Alternatively, similar exemptions to those in operation across the education sector, where academies are able to enjoy the same exemptions as those given to local authorities, could be used.
To date, the Government have taken no action on any of the proposed solutions. Given the scope in the Health and Social Care Bill for additional services to be taken on by the sector, the need for action is even more urgent. The amendment seeks to strengthen the duty on the Secretary of State to promote equality in health service provision and would require the Secretary of State to report to Parliament on the way in which VAT has been treated with respect to charities providing health services. This would enable us, in a transparent way, to see clearly the impact of any inequity in this kind of provision and also the total impact on the sector.
I am aware that more will be needed. There will almost certainly need to be two solutions to the problem-one pre and one post NHS reform. It is for this reason that the amendment seeks a report and not a solution. We want to ensure that we create a sustainable solution that applies when the clinical commissioning groups commission care. In order to do that, we need to have the information about how this affects voluntary sector service providers. I am sure noble Lords will
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Lord Noon: My Lords, I wish to support the amendment moved by my noble friend Lord Patel of Bradford. I declare an interest as chair of the Noon Foundation, which has made significant donations to charitable organisations and others concerned with the care of those living with cancer and those in hospices or receiving palliative care in the community.
My noble friend has outlined many of the key issues faced by the charitable sector with respect to VAT exemptions. I do not want to repeat these arguments, but let me add further information on the scale of the services that we are discussing. The combined contribution of these services amounts to more than 26 million hours of care every year. In excess of 2,000 adult in-patient beds are provided by the voluntary sector and more than £1 million is raised in charitable donations every day.
Of course, these are voluntary sector services that rely on thousands of people who give up their time to ensure the work is done. In fact, the estimated value of the 100,000 volunteers is said to be more than £112 million each year. The value of this sector as a whole in providing hospices and palliative care is in the order of £3 worth of care for every £1 invested. This is an outstanding achievement that should make all of us very proud. It is also why we should be doing much more to protect the sector and ensure that it can operate and grow on a level playing field.
I am a businessman so I know something about VAT and the need for equality in financial arrangements when different providers are in the same market. I am perhaps less anxious than some about the use of competition as a driving force in healthcare. I believe that competition can be harnessed for good and that there are many benefits to be realised by opening up the healthcare sector to this kind of discipline. However, competition must be fair and the current arrangements on VAT between health services and the charitable sector are certainly not fair.
One of the charities that I have been most closely involved with, as a donor and a supporter, is Marie Curie Cancer Care. Marie Curie provides high-quality end-of-life nursing care throughout the UK and has more than 2,000 Marie Curie nurses, who care for half of all cancer patients who die at home. These nurses provide essential care for patients and their families at the most stressful time of their lives. I have met many of these nurses, and their dedication and passion is second to none. They not only provide essential practical support to people as they face the end of their lives but are an emotional support for the whole family.
In addition to a range of community and home nursing services, Marie Curie is one of the largest providers of hospice care outside the NHS in the country. It runs nine specialist hospices which deal with all the patients' needs-physical, social and emotional-across in-patient and day-care services.
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It is clear that we need more of these provisions, and the Health and Social Care Bill will help to extend them. The new arrangements for commissioning mean that other organisations can provide more health services. This will also mean that there will be much more competition from lower-quality commercial organisations, but we must support them to be able to do this. Part of that support must be to ensure that there is a level playing field in respect of VAT. We should not expect charities to take up an extra burden in providing these vital services by expecting them to take on costs that do not currently apply to the NHS. The amendment provides a way of achieving this social goal by placing a clear duty on the Government through the Secretary of State's report to Parliament on the treatment of VAT provisions across the charitable sector. I hope the Minister agrees that it is an important move in the right direction and will support the amendment.
Baroness Finlay of Llandaff: My Lords, I declare all my interests in relation to hospice and palliative care services.
The amendment is particularly important because of the any qualified provider provision which seeks to bring in more charitable sector providers, working with NHS commissioners, to provide essential services where the NHS is not able to plug the gap. That is why there was a debate in the other place in May this year on the effect of VAT on hospices. However, it goes much wider than simply hospices.
The VAT gap means that the private sector can claim back VAT by passing on the cost to customers; the public sector pays VAT, which is then refunded by government; but the charitable sector can do neither-it fund raises. In the hospice world-I am grateful to Help the Hospices for the figures-an average hospital in the UK, supporting about 1,000 patients and spending £8 million on care, may receive about 30 per cent of its funding from the NHS but it will spend about £82,000 on irrecoverable VAT. So money has to be raised just to cover that VAT gap.
As the hospital takes on more and more responsibilities, the problems become greater. As we try to get hospices to work together on joint ventures and share services with other providers and other charities, one hospice has to recharge services to another-one voluntary sector provider to another-including VAT, and that cannot be recovered. It also cannot recover any VAT on the repair and construction costs of charitable buildings. As there is increasing use of its buildings and it needs to upgrade to meet more modern quality requirements, VAT becomes a problem because, for the hospital to provide the quality service that we need, it has to outlay on capital expenditure.
The other difficulty is that VAT is fairly complicated for charities and requires expertise to manage the VAT process for them, which of course also incurs a cost on them in terms of personnel, which again is irrecoverable.
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This is an extremely important amendment and the principle behind it has to be tackled if the fundamental idea of any qualified provider is to work in practice in the long term and provide stable, quality clinical services.
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Baroness Pitkeathley: My Lords, charities have been campaigning about the VAT issue for many years. My charitable interests are declared in the Register of Members' Interests. Without doubt, the VAT issue is an unfair burden and a major inequality in the charitable sector. Why should it be of concern to us? Let us think of what charities are good at. In addition to the services outlined by noble Lords already, charities are good at spotting gaps and funding innovative solutions. They are good at bridging gaps, especially between health and social care. They are very good at seeing patients or service users in their particular situations and providing services which meet their needs and not some notional need determined by an assessor. Those things are going to be tremendously important in the new NHS going forward.
Noble Lords should think of the contributions to care and health made by helplines, information provision, carer support groups and specialist nurses. They should think of the particularly significant service of incontinence supplies and advice-so vital to people with disabilities and to older people and their carers-provided extensively by charities. It is vital that charities are not only encouraged to continue to participate, but are also supported to do so-and not to be made subject to additional burdens such as those that noble Lords have outlined. The NHS and social care service cannot do without these services and, most importantly, patients, users and carers cannot do without them. Therefore, we must make it as easy as possible to provide for all qualified providers, including charities. I support the amendment.
Lord Turnberg: My Lords, I rise to lend my support for this amendment. I speak here as a trustee of the Wolfson Foundation, which has a programme of support for hospices and care homes and over the years has given many millions of pounds, largely for capital projects. VAT is a constant source of unhappiness to the trustees, and, in fact, they have reached the conclusion that they will no longer pay VAT for capital projects. This means, of course, that the hospices and care homes themselves will have to find that money, which is unfortunate. Therefore, I hope that the Minister will take this amendment seriously.
Lord Warner: My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a source of grievance. It often goes with another grievance-one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs-the
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I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government's own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.
Baroness Armstrong of Hill Top: My Lords, I rise briefly to lend support to the amendment. I work with charities for the homeless and for children. If the Government's ambition is to enable the NHS to work with the patient on the full pathway-rather than work being done in little bits by different organisations-then making the playing field level for the voluntary sector is absolutely critical to developing those pathways. In my experience, the voluntary organisation is frequently the glue in making sure that the pathway for the patient works for the patient.
I remind the Minister that when this works well there are often savings for the National Health Service. I have experienced that in homelessness, where we have been able to work with the PCT to get a community matron. That has reduced the number of expensive admissions to hospital and A&E for the most disadvantaged-the homeless. I have also seen that work well with, for example, children with disabilities and children who are very ill. They have been enabled to remain at home with the proper support instead of being frequently admitted to hospital.
It is to the advantage of the NHS that we get this right. What will the Government do to bring forward in the Bill comfort and encouragement for the voluntary sector? After the pause, that sector has been left with a rather large amount of confusion.
Baroness Barker: My Lords, for over 25 years I have worked either in or as a consultant to voluntary organisations. Consequently, my eyes lit up at the sight of an amendment that said VAT and charities. In my time, I have sat with wet towels around my head trying to figure out this, one of the most complicated subjects. I have attended seminar after seminar with the Inland Revenue at which people with bigger brains than me have come away with their heads reeling from trying to understand the issue of VAT and charities. It is infinitely more complicated for charities than it is for the private or public sectors. That is not new. As various people have said, this issue has been running for some considerable time.
I want to correct two impressions that might have been given inadvertently in the debate. First, there is the impression that there is a view in the charitable sector on this issue. There is not, because the issue effects different organisations disproportionately. While there may well be a consensus among hospices that it
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Secondly, we have this new generation of social enterprises. These organisations are not charities but businesses. They are intended to be big players in the provision of services. The noble Lord, Lord Patel, has been clever here in not asking for the Government to take a particular step. He simply asks for a report on a subject that will fascinate some of us quite deeply. Were the Government to take on board the point that the noble Lord makes, apart from looking at a whole range of different charities-not just hospices-would they also consider the effect on social enterprises? I do not think that it is possible to come up with a set of legal proposals that relate simply to health and social care. By definition, they would have to go across the whole of public services. I hope that the noble Lord, Lord Patel, would accept that an exercise of this kind should do that.
Finally, be careful in the questions that you ask of HMRC. As someone who advised charities, I was always brought up never to ask a question of HMRC unless I was pretty confident that I would get back the answer that I wanted. This may be an answer that the hospices want but I would wish to be pretty clear that it worked for charities across the board. I simply finish by saying that if this subject were straightforward, it would have been sorted out a long time ago-but it is not and that is why it has not been.
The Lord Bishop of Chester: I am very grateful to the noble Baroness, Lady Barker, for what she just said about the complexity of the question. However, I would like to go back to what the noble Baroness, Lady Pitkeathley, said about what charities do well. Particularly important is their face-to-face concern with the whole needs of whole persons rather than the abstract application of principles. I would add two things that some charities offer that intersect with other bits of our social agenda at the moment. One is the passion of those volunteers who work particularly for local, small charities. A lot of energy is sapped by precisely the issue that we are discussing this afternoon. If we are concerned for what might be called in the most general way the big society, how you engage people in maximum participation at a local level in concerns and charities-particularly small ones, which are very close to the action-is extraordinarily important, it seems to me. Passion and localism are two aspects of this that must not be forgotten.
Lord Cormack: My Lords, I thought that the noble Lord, Lord Patel of Bradford, moved an absolutely model probing amendment, and the complexity of the issue was very well illustrated by the brief contribution of the noble Baroness, Lady Barker. I came not to take part in this debate but to listen, but I just want to say, as someone who represented a constituency in Parliament for 40 years, that I saw the enormously valuable work that so many charities did, particularly hospices and organisations that provide support, such as the Macmillan nurses and, as the noble Lord, Lord Noon, mentioned, the Marie Curie nurses, who do a very similar job.
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As we have this seminal opportunity to get it right, I hope that my noble friend the Minister, for whom I have enormous respect and regard, will be able to respond to this exemplary probing amendment in his customary exemplary way by indicating that the Government are indeed taking these matters exceptionally seriously. I hope that the Government are anxious to ensure, when this Bill emerges from Committee and goes to Report, that the Minister will have some remedies to meet the extremely important and pertinent points raised by the noble Lord, Lord Patel, when he moved this amendment and others who have supported him in this brief but, I think, important debate.
Lord Beecham: My Lords, like other noble Lords, I declare an interest in charitable organisations that are in the register. When it comes to the details of VAT and its complications, my expertise is roughly equivalent to that of Vince Cable. In the light of that, I took the very sensible advice of my noble friend Lady Wheeler and discussed matters with a charity here in London. It was quite an enlightening experience. I was told that the change in the world of voluntary organisations has made a significant difference to their position in relation to VAT. At one time, much of their income came from grants; now it is increasingly contracted. As contracting organisations, they become liable for the tax. For example, a new build for that particular organisation at one time would not have attracted VAT, but now it does; and as we have heard, there are other examples of that happening. Moreover, some of the services that it provides are exempt, as in education and social care, while others are not. As the noble Baroness, Lady Finlay, told us, smaller organisations in particular have to invest resources in getting the necessary advice to deal with their VAT problems. The organisation to which I spoke had an even more complicated position. It has a building, and because it is carrying out work that is both subject to VAT and not subject to VAT, it has effectively had to split the building into those parts that provide services that are exempt and others that are not; and there is a problem with mixed use in part of the building. It has to monitor and record everything scrupulously and file returns accordingly, so it is an extremely difficult position for such organisations.
I congratulate my noble friends Lord Patel of Bradford and Lord Noon on bringing this amendment to the House, as it throws light on a significant anomaly affecting very many voluntary organisations-the very sector that all of us, especially I suppose the Government, in the light of their proclaimed belief in the big society, would wish very much to encourage. The amendment does not require a change in the law at this stage; it merely seeks a report. It is time that this long-running matter, which has endured for many years under Governments of both political persuasions, should be resolved on the basis of a report. It is of growing importance, as the noble Baroness, Lady Finlay, again reminded us, because of the position of any qualified provider, which would now be open to a wider range of organisations.
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At the moment, the anomaly exists in relation to the charitable sector and the National Health Service,
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- "a strain on its managerial, administrative, operational, financial, information technology and other resources and could affect its ability to provide a consistent level of service to its patients".
I cannot imagine that any voluntary organisation, or most other social enterprises, would have come within a mile of obtaining a contract under those circumstances, and it seems strange that that contract should be given to an organisation of that kind while the voluntary sector is significantly handicapped by the current VAT regime.
I hope very much, therefore, that the Government accept the amendment and undertake the review that it suggests, so that we might take matters forward and relieve them of a burden which reduces nobody's profits but does reduce the capacity of the sector to provide a better and wider-ranging service to the people whom it seeks to serve, and in whom we all have an interest.
Baroness Masham of Ilton: My Lords, how could one not accept this amendment?
Earl Howe: My Lords, I begin by saying that I completely understand the seriousness of the issues raised by the noble Lords, Lord Patel of Bradford and Lord Noon, and others noble Lords. The noble Lord, Lord Patel of Bradford, suggested that part of his purpose was to ensure that this issue remained on the government agenda. Let me assure him that the issue is very firmly on the Government's agenda, and I am pleased that we are having this debate today so that I can outline exactly what we are doing.
Before I turn to address the amendment, I think it would be helpful if I briefly laid out the Government's view of the role of the voluntary sector in the NHS. We firmly believe that voluntary sector organisations have a strong and often crucial role to play, due to the experience, expertise and insights that they can offer to commissioners and the system more widely. I of course acknowledge and pay tribute to the valuable work performed by Sue Ryder and numerous other charities, including most especially hospices. We recognise that they can play a vital role in delivering innovative, high-quality user-focused services in their local communities, along with improved outcomes for patients and increased value for taxpayers. We also acknowledge, as Amendment 46 highlights, that taxation treatment is one potential barrier to voluntary sector organisations' entry into the provision of NHS services and to their increased involvement in those services. Access to capital is another. We are very keen to explore ways to overcome these challenges. The department is discussing this, as part of a wide range of issues, with voluntary sector providers of NHS-funded services.
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When I was preparing for this debate, I asked whether the Treasury was looking at these issues, and the answer is that it is. I understand that Treasury officials are already working with representatives from the voluntary sector to explore the value added tax treatment of charities supplying the NHS, taking into account the legal limitations and the potential complexities around possible solutions. We are keen that they should make speed over this. However, the introduction of an artificial one-year timetable, as this amendment proposes, would limit the scope for a full and thorough discussion and consideration of this issue. I cannot commit to that limitation. However, I emphasise that we are very keen to work at possible solutions as fast as we can. It is a complex issue. My noble friend Lady Barker pointed us towards some of those complexities.
It is worth my repeating a general point here. The Government are committed to fair competition that delivers better outcomes and greater choice for patients and better value for the taxpayer. We want to see providers from all sectors delivering healthcare services. We have not the least wish to favour one type of provider over another. Indeed, as a result, and to ensure that the Secretary of State, Monitor and the Commissioning Board do not confer preferential treatment on any type or sector of provider, the Government have introduced amendments to Clauses 144, 59 and 20, inserting a new section, Section 130, into the National Health Service Act 2006.
We know very well that the voluntary sector plays a strong role in bringing the voices and experience of patients, service users and carers to the work of improving services, often reaching individuals who are excluded or who cannot access mainstream services. The voluntary sector brings advocacy and information to support individuals to exercise choice and control over the services that they access. These are major prizes, and we wish to capitalise on them. Opening up services to greater choice, for example, through "any qualified provider"-as was pointed out by the noble Baroness, Lady Finlay-allows for greater involvement by social enterprises or voluntary sector organisations. To a great extent, this is already happening.
Listening to noble Lords, I felt that there was a great deal of consensus around those points. There is a shared feeling across the House that charities have a key part to play in NHS provision, that the current VAT rules can act as a barrier and that this needs to be looked at very closely and urgently. I completely agree with that, and I would like to reassure the noble Lord, Lord Patel of Bradford, that we will ensure that this taxation issue continues to be considered urgently, as we develop work on a fairer playing field for delivering NHS services. In establishing Monitor's new functions, the department and Monitor will continue to consider these issues and the priorities to be addressed.
The noble Baroness, Lady Armstrong of Hill Top, asked in particular what comfort there is in this Bill for the voluntary sector. She quite rightly mentioned the Future Forum in highlighting the work of the sector. The noble Baroness will be aware that the forum gave a very strong endorsement to the Bill's creation of a bespoke provider regulator, Monitor, in order to oversee a level playing field. Such a commitment to a fair
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With those remarks, although I am sure that I have not completely satisfied the noble Lord, Lord Patel of Bradford, I hope that I have given noble Lords the sense that we are onside with this issue and shall be pursuing it with as much urgency as we can. I therefore hope that I have done enough to persuade the noble Lord to withdraw his amendment.
Lord Patel of Bradford: My Lords, I have listened carefully and with great interest to the many excellent contributions on this proposed amendment. I am grateful to the Minister for giving a very considered and what I believe to be a very sincere response by recognising the issues. Noble Lords have spoken eloquently about many of the issues: the huge numbers of services and people involved-it is absolutely the big society in action. Yet they also clearly talked about what goes to the heart of this Bill: the barriers that are there to stop the provision of equal services. My "unpopular" noble friend Lord Warner clearly outlined those barriers and I will not repeat them.
We have heard from my noble friends about the importance of the voluntary sector. The Minister clearly repeated the importance of the role of the charitable and voluntary sectors, and the fact that they work with some of the most vulnerable people in our society. I completely agree with the noble Baroness, Lady Barker, about the complexity of the situation. She raised the important issue of social enterprises and the potential exemptions and disbenefits there as well.
We are not asking to make a single-line solution to the problem; we are asking for clarity and transparency. This Government have clearly talked about transparency throughout, and it is so important for us to have that information. I listened to what the noble Earl said about them still discussing how the Treasury will go ahead and that they are in the process of taking urgent actions, but those urgent issues have been there for a long time. I suppose that I go back to the issue of my day job, when I am working with service users and local communities. When working with people with mental health problems and drug issues, nobody disagrees with me. Everybody says, "Yep-this is really important and urgent. We have got to look at it and we will. We will talk and we will make sure users are on the panel", but we are still talking about it 20 years on. We need a document or something that focuses the mind. That is why the amendment seeks to ask the Secretary of State to give us the data.
I do not think that a year is problematic. I think it should be six months. Why do we not have these data? The whole premise of lots of the services we provide is that we need high-quality data to tell us what is missing and what is wrong. I am hoping that a report will be presented to give Members of the House an opportunity to reflect on that data and to look at what is going wrong, and where, because the big danger is that there will be a discussion between the charity sector and the Treasury, and that the Treasury will say, "This is what we can and cannot do-accept it". It is important that the House and others outside look at
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Contents 195; Not-Contents 183.
Adams of Craigielea, B.
Adonis, L.
Ahmed, L.
Andrews, B.
Armstrong of Hill Top, B.
Bach, L.
Bakewell, B.
Bassam of Brighton, L. [Teller]
Beecham, L.
Berkeley, L.
Bichard, L.
Billingham, B.
Bilston, L.
Blackstone, B.
Boothroyd, B.
Borrie, L.
Brennan, L.
Brooke of Alverthorpe, L.
Brookman, L.
Brooks of Tremorfa, L.
Campbell of Surbiton, B.
Campbell-Savours, L.
Chichester, Bp.
Chorley, L.
Christopher, L.
Clark of Windermere, L.
Clarke of Hampstead, L.
Clinton-Davis, L.
Cobbold, L.
Collins of Highbury, L.
Crawley, B.
Davies of Coity, L.
Davies of Oldham, L.
Davies of Stamford, L.
Dean of Thornton-le-Fylde, B.
Dixon, L.
Donaghy, B.
Drake, B.
Dubs, L.
Eames, L.
Elder, L.
Elystan-Morgan, L.
Emerton, B.
Evans of Temple Guiting, L.
Evans of Watford, L.
Falkland, V.
Farrington of Ribbleton, B.
Faulkner of Worcester, L.
Finlay of Llandaff, B.
Ford, B.
Foster of Bishop Auckland, L.
Foulkes of Cumnock, L.
Gale, B.
Gavron, L.
Gibson of Market Rasen, B.
Giddens, L.
Glasman, L.
Gordon of Strathblane, L.
Goudie, B.
Gould of Potternewton, B.
Grantchester, L.
Greengross, B.
Grenfell, L.
Grey-Thompson, B.
Grocott, L.
Hannay of Chiswick, L.
Hanworth, V.
Harries of Pentregarth, L.
Harris of Haringey, L.
Harrison, L.
Hart of Chilton, L.
Haskel, L.
Hayman, B.
Hayter of Kentish Town, B.
Healy of Primrose Hill, B.
Henig, B.
Hennessy of Nympsfield, L.
Hilton of Eggardon, B.
Hollick, L.
Hollins, B.
Hollis of Heigham, B.
Howarth of Newport, L.
Howe of Idlicote, B.
Howells of St Davids, B.
Howie of Troon, L.
Hoyle, L.
Hughes of Stretford, B.
Hughes of Woodside, L.
Hunt of Kings Heath, L.
Hutton of Furness, L.
Imbert, L.
Irvine of Lairg, L.
Jay of Paddington, B.
Jones, L.
Jones of Whitchurch, B.
Jordan, L.
Judd, L.
Kennedy of Southwark, L.
Kerr of Kinlochard, L.
Kestenbaum, L.
King of West Bromwich, L.
Kinnock, L.
Kinnock of Holyhead, B.
Kirkhill, L.
Knight of Weymouth, L.
Laming, L.
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Liddle, L.
Lipsey, L.
Lister of Burtersett, B.
Listowel, E.
Low of Dalston, L.
McAvoy, L.
McCluskey, L.
McDonagh, B.
Macdonald of Tradeston, L.
McFall of Alcluith, L.
McIntosh of Hudnall, B.
MacKenzie of Culkein, L.
Mackenzie of Framwellgate, L.
McKenzie of Luton, L.
Mar, C.
Martin of Springburn, L.
Masham of Ilton, B.
Massey of Darwen, B.
Mawson, L.
Maxton, L.
Monks, L.
Morgan, L.
Morgan of Drefelin, B.
Morgan of Ely, B.
Morris of Aberavon, L.
Myners, L.
Noon, L.
Norwich, Bp.
Nye, B.
O'Loan, B.
Owen, L.
Pannick, L.
Patel of Blackburn, L.
Patel of Bradford, L.
Peston, L.
Pitkeathley, B.
Plant of Highfield, L.
Prashar, B.
Prescott, L.
Prosser, B.
Quin, B.
Radice, L.
Ramsay of Cartvale, B.
Rea, L.
Rendell of Babergh, B.
Richard, L.
Richardson of Calow, B.
Rosser, L.
Rowlands, L.
Royall of Blaisdon, B.
St John of Bletso, L.
Sawyer, L.
Scotland of Asthal, B.
Sewel, L.
Simon, V.
Soley, L.
Stern, B.
Stevenson of Balmacara, L.
Stoddart of Swindon, L.
Symons of Vernham Dean, B.
Tanlaw, L.
Taylor of Blackburn, L.
Thornton, B.
Touhig, L.
Triesman, L.
Truscott, L.
Tunnicliffe, L. [Teller]
Turnberg, L.
Turner of Camden, B.
Wall of New Barnet, B.
Walpole, L.
Warner, L.
Warnock, B.
Warwick of Undercliffe, B.
West of Spithead, L.
Wheeler, B.
Whitaker, B.
Wigley, L.
Wilkins, B.
Williams of Elvel, L.
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Wills, L.
Wilson of Tillyorn, L.
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Worthington, B.
York, Abp.
Young of Hornsey, B.
Young of Norwood Green, L.
Addington, L.
Ahmad of Wimbledon, L.
Alderdice, L.
Anelay of St Johns, B. [Teller]
Ashton of Hyde, L.
Astor of Hever, L.
Attlee, E.
Avebury, L.
Baker of Dorking, L.
Barker, B.
Bell, L.
Benjamin, B.
Berridge, B.
Blackwell, L.
Bonham-Carter of Yarnbury, B.
Boswell of Aynho, L.
Bottomley of Nettlestone, B.
Bradshaw, L.
Brinton, B.
Brooke of Sutton Mandeville, L.
Brougham and Vaux, L.
Browning, B.
Byford, B.
Cathcart, E.
Clement-Jones, L.
Colwyn, L.
Cope of Berkeley, L.
Cormack, L.
Courtown, E.
Cox, B.
Craig of Radley, L.
Craigavon, V.
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Elton, L.
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Fellowes, L.
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Flight, L.
Fookes, B.
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Framlingham, L.
Freud, L.
Garden of Frognal, B.
Gardiner of Kimble, L.
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Geddes, L.
German, L.
Glasgow, E.
Gold, L.
Goodhart, L.
Goodlad, L.
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Hamwee, B.
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Henley, L.
Higgins, L.
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Howe, E.
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Hussain, L.
Hussein-Ece, B.
James of Blackheath, L.
Janvrin, L.
Jay of Ewelme, L.
Jenkin of Kennington, B.
Jenkin of Roding, L.
Jolly, B.
Jones of Cheltenham, L.
Jopling, L.
Kakkar, L.
Kirkwood of Kirkhope, L.
Knight of Collingtree, B.
Kramer, B.
Lamont of Lerwick, L.
Lee of Trafford, L.
Lester of Herne Hill, L.
Lexden, L.
Lindsay, E.
Lingfield, L.
Liverpool, E.
Loomba, L.
Lucas, L.
Luke, L.
Lyell, L.
McColl of Dulwich, L.
MacGregor of Pulham Market, L.
McNally, L.
Marks of Henley-on-Thames, L.
Marland, L.
Marlesford, L.
Mawhinney, L.
Mayhew of Twysden, L.
Miller of Hendon, B.
Morris of Bolton, B.
Murphy, B.
Newby, L.
Newton of Braintree, L.
Nicholson of Winterbourne, B.
Noakes, B.
Northover, B.
O'Cathain, B.
O'Neill of Bengarve, B.
Oppenheim-Barnes, B.
Palmer of Childs Hill, L.
Parminter, B.
Perry of Southwark, B.
Plumb, L.
Popat, L.
Ramsbotham, L.
Randerson, B.
Rawlings, B.
Reay, L.
Redesdale, L.
Rennard, L.
Ribeiro, L.
Risby, L.
Ritchie of Brompton, B.
Roberts of Conwy, L.
Roberts of Llandudno, L.
Rowe-Beddoe, L.
Ryder of Wensum, L.
St John of Fawsley, L.
Sassoon, L.
Scott of Needham Market, B.
Seccombe, B.
Selborne, E.
Selsdon, L.
Shackleton of Belgravia, B.
Sharkey, L.
Sharp of Guildford, B.
Sharples, B.
Shephard of Northwold, B.
Shrewsbury, E.
Shutt of Greetland, L. [Teller]
Skelmersdale, L.
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47A: After Clause 5, insert the following new Clause-
14 Nov 2011 : Column 468
(1) The Secretary of State shall establish a body to be known as Health Education England, answerable to the Secretary of State and charged with the responsibility of ensuring and maintaining high standards of education and training of the NHS healthcare workforce.
(2) In pursuit of that responsibilities, Health Education England shall have due regard to-
(a) the responsibilities of the universities and the Royal Colleges and of other bodies involved with education and training;
(b) the statutory responsibilities and authority of the regulatory bodies operating in the healthcare field; and
(c) the necessity of ensuring that commissioning groups, foundation trusts, general medical practices and other qualified providers offer appropriate facilities for education, training and research."
Lord Kakkar: My Lords, I beg to move Amendment 47A, which stands also in the names of my noble friends Lord Walton of Detchant and Lord Patel, who, regrettably, cannot attend the Committee this afternoon.
In moving this important amendment and speaking to Amendment 133 in this group, I wish to recognise the important statement made by the Minister on the first day in Committee on 25 October, when he made the case for an amendment to place a duty on the Secretary of State to exercise his function so as to secure an effective education and training system. This is an important and much welcomed recognition of the fact that education and training is absolutely critical to the delivery of healthcare.
The Minister will recognise that, without an appropriate system of education and training, whether it be for a surgeon or a physiotherapist, a neurosurgeon or a nurse, a physician or a radiographer, or indeed a psychiatrist or an occupational therapist, patients will be put at risk. The important gains that the Bill proposes in terms of improving clinical outcomes will not be achieved and vital resources will be squandered.
Education is at the heart of delivering effective healthcare. The professions, the public and indeed government have had previous experience of the introduction of changes in education and training with modernising medical careers that cause severe anxiety and disruption and have made all exceedingly sensitive to the importance of ensuring that any change in systems in the future provides the best opportunity for the patients who have to use health services in our country.
It is well recognised that Her Majesty's Government wish to deal with education and training in a responsible and sensitive way, and it is broadly recognised that the changes proposed by the Bill raise anxieties about how education and training might be discharged in the future. In this regard, the commitment of the Government to seeking further clarification and the views of the NHS Future Forum is an important initiative. However, it would be impossible for the Bill to proceed unless there were absolute clarity with regard to education and training.
The intention is that employers will play a much greater role in the future discharge of education and training functions, and there is no doubt that the education and training system must be sensitive to the needs of the service and, most of all, to the needs of
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With regard to interaction with those bodies, authorities and universities that have an expertise in the education of the healthcare workforce, will the Minister confirm that it is indeed the Government's intention that, in the proposal to establish Heath Education England-whether as a special health authority in the intervening period and, thereafter, ultimately as a statutory arm's-length body in a future Bill-there will be a requirement for Health Education England to engage fully with the academic sector? Will the development of curricula for the training of different disciplines in the healthcare workforce be set in partnership by service providers, employers and academic institutions working together to develop the curriculum? Will the working of local education and training boards be such that there is a clear relationship between them and Health Education England? Will the boards be composed of appropriate academic-health service partnerships to ensure that the valuable expertise in both the service and the academic sector can be brought into play to develop appropriate curricula and ensure that they are delivered to the highest standard; that those curricula are developed to meet both service needs and, most importantly, patient needs; and that, within the structure of local education and training boards, there are non-executive independent directors who ensure that any potential conflicts of interest are overcome?
We have certainly been fortunate in having strong deaneries that have accumulated large volumes of expertise in and insight into the delivery of postgraduate medical education and training. It is important that these functions and this expertise are not lost in the system, and that postgraduate deans are potentially housed in universities in the future so that their important functions can continue to be delivered as part of the local education and training board structure.
It is critical that there is an obligation on Health Education England to have an appropriate level of engagement and interaction with the royal colleges in medicine and other professional colleges. They are the regulatory bodies that play an important role in the supervision of training and the development of standards for practice in our country. Heath Education England should also be under an obligation to ensure that any qualified provider-NHS trusts, general medical practitioners and others-who ultimately has the responsibility and privilege of delivering NHS services has regard to providing appropriate education and training opportunities. This is vital, as the basis of
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I recognise that the Government are considering these matters through the work of the NHS Future Forum and in other consultations. The purpose of tabling these amendments is to probe the Government's view about education and training, and to determine whether there remains a strong commitment to academic service partnerships to drive forward education, training, innovation and research opportunities. These are all vital in ensuring that we have the highest-quality healthcare workforce for the future. They will also help us to understand better how Her Majesty's Government envisage the relationship between Health Education England and local education and training boards.
Other amendments in this group deal with the important question of the future funding of education and training, and the importance of funding being ring-fenced and applied only for this purpose, rather than being put into potential jeopardy and used for other elements of the responsibility of the NHS Commissioning Board.
Lord Warner: My Lords, I rise to speak to Amendment 47B, which to some extent overlaps with Amendment 47A, which the noble Lord, Lord Kakkar, has moved so eloquently. I fully support the remarks that he made, particularly in relation to medical deaneries.
I want to start from the position in which we find ourselves. This Bill contains a major reorganisation, which affects 1.4 million employees. As David Nicholson has said, the size of this reorganisation can be seen from space. I can remember making these rather trite speeches as a Minister about the NHS being the largest organisation alongside Indian Railways and the Red Army. Ministers before me made the same speeches just to emphasise the sheer scale of the NHS and the number of employees working in it. Therefore, it seems extraordinary that the Government could have considered for a long time reorganising this organisation in such a way without taking into account the education and training of probably the most labour-intensive and largest workforce in the country. It is not surprising that, in these circumstances, people in the NHS are very concerned about what is going to happen to education and training in this brave new world that the Government are taking us into.
That is why some of us want to move amendments that go a good deal further than did the Government's amendment in this area, which seemed to me not unlike those Russian dolls-once you open one doll, another is inside and a smaller doll is inside that-in its endless reference back to other bits of legislation. We need something much clearer than that if we are to reassure the people working in the NHS that education and training are going to be safeguarded and looked after in a period of major disruption to the way we run our health service.
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Amendment 47B imposes a clear duty on the Secretary of State,
- "to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size ... to discharge his duties under this Act".
That seems to me to be the focus that we should have in our discussions in this particular area. It tries to produce a clearer duty on the Secretary of State than the Government's Amendment 43, but goes further by requiring the establishment of a new body, Health Education England, to oversee, supervise and manage the current functions and national budget relating to multidisciplinary training.
As we take the Bill through this House, it is not enough simply to say, "Oh dear, we are waiting on the Future Forum". I am sure that the Future Forum will have something good to say, but before this Bill leaves this House as an Act we need to produce much more certainty about how this service is to be continued and how the money is to be safeguarded. The size of the budget involved is considerable-somewhere in excess of £5 billion a year. Much of that money is looked after and spent by the rather maligned strategic health authorities, which will disappear in 2013 as I understand it. That money passes through them to the end-users of the money that deliver education and training. There is great uncertainty and concern about how national and regional planning of education and training, including the medical deaneries, will actually work, how they will be funded and how the current budget will be safeguarded.
I recognise that employers need to play a full part in education and training, as the noble Lord, Lord Kakkar, has said, but I have seen the briefing by NHS Employers on this issue. That briefing makes pretty clear that there is huge uncertainty below the national level about how education and training will be managed when the strategic health authorities are abolished in 2013. People seem to be fumbling their way around, searching for a way forward when the SHAs go. We know that some activities cannot be left to local employers alone. A prime example of this is the specialist training that has to go on in securing placements for younger doctors coming through the early stages of their training and needing to have specialist postings to ensure that they can progress along the specialist route to fill the consultant posts of tomorrow.
At the national level we need to achieve greater clarity on how the Secretary of State will discharge his responsibilities in relation to education and training. The Government seem to think that this can be left to legislation in the next Session but as far as I can see they can give no assurances, other than resting on good will and the Future Forum, to say clearly what this system would encompass, what it would look like and how it would work. The more sceptical among us have doubts about whether the Government will have the appetite for another Health and Social Care Bill in the next Session. If one was Prime Minister for a day, it would not be surprising to doubt whether one would entrust another Bill in this territory to the team that gave us this Bill. That thought must have occurred to the Prime Minister at some time in his busy life.
In closing, I would like to say a few words about the third subsection in this amendment. This is in response
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Of course, the Minister may be able to reassure us all and give us some guarantees, and I look forward to hearing them. These need to be guarantees about how the amount currently spent on education and training will be safeguarded. We will also want to know: what is to happen to the money when the SHAs are abolished? What division of responsibility between Health Education England and employers are the Government planning? Do the Government envisage a role in this sphere for the national Commissioning Board? I hope the Minister will not simply say that the Government are waiting for the Future Forum to report.
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Lord Turnberg: My Lords, my name is attached to Amendment 47B, so ably introduced by my noble friend Lord Warner. I simply wish to emphasise some of the points that he has raised and some of those raised by the noble Lord, Lord Kakkar. The amendment is an attempt to fill a conspicuous gap in the Bill in relation to education and training-namely, to introduce at this stage the idea that we have a Health Education England. I recognise of course that we are waiting for further information from the Future Forum and that we should expect further legislation on this in due course, but this is a subject on which we cannot afford to wait. We need something in this Bill, if only to try to settle some of the many uncertainties that are so disabling for many out there. We cannot wait for a second Bill at some uncertain and probably distant time.
The White Paper Liberating the NHS: Developing the Healthcare Workforce is frankly disturbing in some of its recommendations. Putting responsibility for education and training at the local level entirely in the hands of provider networks-so-called local skills networks-is to my mind, and that of many I have spoken to, both dangerous and potentially damaging. Of course we need, and should have, local input in planning for local workforce needs. However, the standards of education and the level of skills and knowledge that patients deserve have to be set on a national scale. It is
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At the moment, for medicine at least, the GMC sets the overall standard and the royal colleges and their specialist advisory committees provide all the curricula and set the exams, assessments and qualifications so that employers and patients can rely on the fact that a newly appointed cardiologist or surgeon, for example, has reached a recognised and approved standard on a national scale. However, most of the medical, nursing and other training takes place at the coal face: in the wards or in general practice by trainers who are themselves practitioners. Here, out and about, the postgraduate deans play the pivotal role because they oversee the whole process of training and planning of the workforce for their part of the country. The deans are the glue that makes it all happen. They control, of course, the budgets for the salaries of all the medical trainees. At the moment, they are employed by the strategic health authorities. When those authorities disappear, the current proposal is for them to be taken over by local provider skills networks. I have already suggested that it would be unfortunate if these bodies were purely NHS providers with little input from those with experience of what education and training entails. Providers may know something about what they want out of it at the end, but they are not set up to oversee and provide the education by themselves.
There are two things that must happen if we are to have a reliable system. First, Health Education England must be set up now, as this amendment suggests. This organisation should become a focus for the postgraduate deans and should probably be their employer. Secondly, we must make more use of the expertise in education that lies in the universities across the country. While universities are engaged in nurse education and that of some other healthcare workers, we must be one of the few countries in the world where universities play little or no formal role in postgraduate medical education. Of course, most clinical professors and their staff are engaged in teaching postgraduates, but the universities have no formal roles. It makes quite a bit of sense, therefore, to consider having the universities play a much bigger role in the local skills networks with the NHS providers. The postgraduate deans might indeed be employed by the universities if they are not to go into Health Education England, although I am not suggesting that their budgets go across to the universities-that may be a step too far.
Perhaps I may ask the Minister whether it would be possible for the deans to be seconded to the local university. It might well be a valuable outcome if the deans could then work closely with local NHS/academic partnerships rather than with NHS providers alone. The example of the academic/health service partnerships set up as collaborations between the NHS and universities to encourage research and the transfer of innovation into practice, as initiated at UCL, might be worth
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I understand that there is an intention to set up an interim Health Education England some time next year, but unless it is given the budget for education, some £5 billion a year, and if the money is instead diffused into local skills networks in the meanwhile, I fear that it will be lost for ever. That is why we should have a clear statement in the Bill now about Health Education England and its funding.
The other part of the amendment refers to the need to ensure that the funding for education and training is not eroded in the changeover, and I hope that the Minister can give us some comfort there, too.
I know that there is much more work to be done by the Government, but we should not leave this until some uncertain future. We must have something a little more concrete in this Bill, and I hope that the Minister will be able to help us.
Baroness Emerton: My Lords, I have put my name to Amendment 47B. At Second Reading, I referred to why I thought it important that education and training be mentioned in the Bill, even though it was understood that work was already under way. Noble Lords who have spoken have underlined the importance of education and training being mentioned in statute now.
The Health and Social Care Bill proposes a comprehensive health service reliant on an effective workforce that is capable and competent to deliver a service that demonstrates improved patient outcomes. For this to happen, there needs to be an effective partnership between the NHS and universities. The introduction of local commissioning of services will also require local commissioning for education and training places for the agreed workforce plan at both local and national level. There must be multi-professional involvement if professional silos are to be avoided, both in relation to funding and the structures and governance arrangements that underpin the workforce. For too long, silos have been the problem in the funding arrangements for education, training and research.
Developments around the establishment of Health Education England are now being considered, but, as has already been said, progress is slow and is causing anxiety out in the field. The intent to move to an integrated health and social care service calls for these partnership arrangements to be made. There is a need to ensure the right balance of responsibility and accountability between Health Education England and the provider-led networks-employers/professions, the education sector and the whole workforce, plus patient
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Universities should not be considered simply providers of education programmes but also co-producers of the workforce through this wider role of research, innovation, releasing social capital, and the globalisation of healthcare, which is integral to the development of advanced clinical care, service redesign and workforce planning. Universities should work in co-operation with the NHS to ensure the delivery of high-quality education and training and then be held to account by Health Education England. Ensuring that universities are a central part of the local education will facilitate effective partnerships, improved quality outcomes and a multi-professional approach.
The intent to move to this is very important and the establishment of budgets, which has already been mentioned, is also crucial. As already stated, silos should be avoided so that an integrated approach can be established to the education and training of the workforce. The challenge for the new education system will be whether it can truly ensure the co-product of a workforce that can deliver the new way that care can be delivered-one that will provide holistic care, especially adapting to the demographic changes, demanding more care in the community for the elderly, frail, vulnerable and for end-of-life care. Budgets will need to reflect the most cost-effective provision of care to enable hospital expenditure to be reduced.
Nursing, midwifery and other allied healthcare professions are committed to evidence-based practice and would warmly welcome the multi-professional involvement in education and training programmes as well as the benefit gained from multi-professional buildings and shared facilities. Not only would this be of benefit for the learning environments but it could be cost-effective in the use of expensive educational facilities, tutorial staffing and equipment. Could the Minister clarify some of these issues in his summing up?
Baroness Finlay of Llandaff: My Lords, I have an amendment in this grouping. It addresses the duty that I would like to see on clinical commissioning groups to promote education and training of the current and future NHS workforce. The reason for putting the future in is because of the undergraduates who are studying to become healthcare professionals. This is important because we know that primary care placements at undergraduate level have a significant influence on career choices and therefore on career progression. The quality of training and the quality of care given by the tutor who is their tutor in primary care is influenced by having undergraduates with them. That applies across all the disciplines that work in the community.
The other point is that general practitioners will need training in commissioning responsibilities in the future. Therefore, if we are to attract the brightest and
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I also support the other amendments in the group so eloquently introduced by my noble friend Lord Kakkar. I strongly support the comments made by all the other noble Lords who have spoken. We need to have this duty at every level-at Secretary of State level, at Commissioning Board level and, as I have suggested, at clinical commissioning group level. The one area that we have not addressed and that is not in the amendments is the way that Monitor grants licenses. We might need to come on to that at a later stage when we discuss Monitor.
There is a particular need for planning medical education and training and having it planned nationally. It takes 15 years, on average, from start to finish to develop a specialist in highly technical, very complicated areas of medicine. There are about 32 small specialities, and in-depth local intelligence and intelligence within that speciality are needed to know both the numbers that are needed in the future and to horizon-scan and look at the type of training that will need to be delivered and whether things will change. A simple example is in surgery, to which reference has already been made, where keyhole surgery came about. My discipline, the development of palliative medicine as a distinct speciality, has completely altered the face of some of the care in both hospitals and the community, and it has a significant workforce which is still developing.
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There is also a need for reliable information on education and training so that the Centre for Workforce Intelligence can work with the proposed Health Education England to ensure that there is good information underpinning decisions. Quality management of education and training in medicine is currently undertaken by the deaneries, by and large, and that should be built on. They provide independent quality assurance. If the dean is the responsible officer and has a ring-fenced budget and a financial lever, they can withhold funding for posts and have been shown in many parts of the UK to rapidly drive up quality where there have been concerns about the training environment into which trainees were going. It is not difficult to expand that system to take on postgraduate deanery structures for the other disciplines as well.
I strongly endorse the need for the allied healthcare professionals and nursing to come under the new structure as well. There is a need for inter-professional working and learning. Inter-professional learning and integrated delivery of services with integrated learning will drive up the quality of care and ensure the development of good clinical leadership so that we bring the level of the best into the delivery and content of education and training.
The commissioning groups, in particular, must ensure that there are appropriate facilities for education and training. The quality of the commissioning they do at a local level, with both NHS and other providers, will ensure that undergraduate and postgraduate students can be placed in and learn from a wide range of services. We will then have a workforce fit for the future.
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Health Education England, when established, can audit the local education and training boards and maintain a national perspective. There is worrying information about the way things are going. I have spoken to the Medical Schools Council, which recently surveyed medical school involvement in the development of the emerging local education and training boards. It indicates a variable extent to which higher educational institutions are involved in planning and suggests that the structures will vary widely. In some areas, such as the north-west and the east Midlands, medical schools and higher educational institutes appear to be actively excluded from the developing local education and training boards. This is extremely worrying because in service transformation there needs to be quality control and academic rigour. Medical schools are required by the General Medical Council to act as quality managers of clinical placements but, by excluding those which are providing education from the local education and training boards, we risk having a serious disconnect in the way that services develop and are delivered, and in the way that our workforce is trained.
Lord Ribeiro: I have listened to the debate with considerable interest, particularly as it brings to our attention the whole concept of Health Education England. I think Health Education England is a work in progress, and the reason I say that is that, as a result of the MMC/MTAS debacle that took place in 2006-07, one of the major recommendations of the inquiry that followed by Sir John Tooke was that a new body should be set up called Medical Education England. That recommendation was accepted by the Government at the time, and by the Opposition. It started work under the chairmanship of Dr Patricia Hamilton, who has come to this House to give her views on the development of education and training.
The reason I mention that is that Medical Education England was designed to deal with medicine. Yet, as the noble Baroness, Lady Emerton, has said, more than 50 per cent of the multiprofessional education budget actually goes on nurses and other non-medical members. Therefore, it is totally inappropriate to be moving on to a Medical Education England model when clearly we have to encompass all the other health providers, and hence we have Health Education England. I understand the desire of the noble Lord, Lord Warner, to get on with this but, to get this to work, it needs to be thought through very carefully. One of the reasons-certainly from the medical point of view-is that, among the questions we asked in 2006 was, "What is the end point of training? What are we training these doctors for?". One has always assumed that most medical treatments will occur within the hospital sector but we know, because of the ageing population, that more and more is being done in general practice and in the community. We therefore need to think very carefully about how we train doctors for the future and where they are going to work.
It is important, therefore, that we give time for the development of the workforce as well as the training and the education of the workforce. The noble Baroness, Lady Finlay of Llandaff, referred to the Centre for Workforce Intelligence, which is very important, but
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I think this is work in progress. I welcome that this is a probing amendment, but I do not feel that at present we are in a position to roll out Health Education England without having heard the full report from the Future Forum.
Lord Owen: My Lords, I reiterate some of the comments that have already been made by many noble Lords on the sense of urgency about this issue. Above all, I feel rather like the man in the Bateman cartoon who mentions the words "party politics" in the Health and Social Care Bill in the House of Lords. There is here a very deep question. It is frankly inconceivable that there will be legislation in the next Session; I would think it would be almost inconceivable that there would be legislation on this before the next election, which is currently scheduled for 2015. Politicians simply do not usually go in for a repeat hiding, and this Bill has already had one hell of a political controversy. If we have legislation, it may be all on medical education, but it opens up a whole realm of party politics, which I just do not see being done.
Therefore, I want to make a practical suggestion to the Minister. There is a way through this if there could be bipartisan agreement. One only has to think of a situation in which there is no legislation until 2016 to realise that we are facing a real chasm in medical education and continuity. As I understand the legislation, the Secretary of State is empowered to create special health authorities. Whether he does that or removes the ones that are necessary, that power is there. If not, he could easily take it in the Bill.
There is so much cross-party agreement that doing something about health education is pretty urgent. I would have thought that it would be perfectly possible to meet most of the demands. The noble Lord, Lord Ribeiro, is completely right. We are not in a position to legislate now on anything other than a structure. That structure might be a temporary special health authority. It is not worth prejudging the question but, if it was a special health authority, it would need some form of regulation passed. As long as an agreement could be made-first on the clause that would be in the Bill, along the lines more of Amendment 47B than 47A; and, secondly, with the main substantive regulations for the special health authority done through an affirmative resolution-then it would be perfectly possible for us to move on the creation of this training authority, which has to embrace all the health professions and be pretty wide-ranging, some time at the end of 2012 or early 2013. That would meet the wishes of most people in the National Health Service.
It is really not enough to rest on the fact that there will be a Bill in the next Session of Parliament. I have already tried to convince my own college, the Royal College of Physicians, that it is highly unlikely that this will be fulfilled. As practical politicians, we should
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The Archbishop of York: My Lords, I too support the amendment of the noble Lord, Lord Warner. Proposed new subsection (2) simply says that:
"In discharging this duty, the Secretary of State must establish a body known as".
It does not tell us the rest of the details. It puts a duty on him or her to establish a body responsible for,
- "the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries".
How will it deliver that? What is going to be its content? That is for the Secretary of State in the future. But we fail in our responsibility if we miss the opportunity right now in the Bill to flag that up as part of the duty of the Secretary of State.
Noble Lords may remember from Second Reading that I spoke against supporting the Motion of the noble Lords, Lord Owen and Lord Hennessey, because I wanted to ensure that the constitutional duty of the Secretary of State is to promote a comprehensive health service and improve the quality of that service. I told the House that I have recently spent time in three different NHS hospitals: University College, London; St Thomas's Hospital; and York Hospital. These are teaching hospitals. I was more than content that whenever the doctors saw me they came with a large range of nurses, doctors and those in training of all kinds. I became a guinea pig. I did not mind because I knew that I was in a training hospital. How are we to ensure that our National Health Service has that responsibility of making sure they are training hospitals? We must not assume that our NHS delivery of clinical care is almost like the assembly line of a motor car where you fix it and it goes out okay. It is not that kind of thing. What distinguishes most of the best clinical practice is the fact that our National Health Service has these training hospitals. I would be unhappy to know that the Secretary of State had not established a body, known as Health Education England, with responsibility,
Where will those lie when the Bill has been passed?
Last time, when we debated other amendments, there was a worry about the diagram of the proposed structure of NHS reforms in the Bill. I drew one up for myself. Listen: the Secretary of State is on top, then there are other bodies-Public Health England, HealthWatch England, the Care Quality Commission, Monitor, NICE, clinical senates and networks, the NHS Commissioning Board, local Healthwatches, health and well-being boards, the community voluntary sector, local government social and public health, and multiple clinical commissioning groups. Where is education in all this? When the Minister replies, will he tell us where he thinks education is going to lie? If it does not lie within this Bill, with its already very complicated structure, the next time I am being treated in the NHS I will be crying, "Where are those learning as I am being treated?".
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Lord Mawhinney: My Lords, I do not intend to detain your Lordships very long. However, I very much hope that my noble friend the Minister will consider, as I do, that these amendments and this debate are premature. I do not think that we should be focusing on the substance of these debates other than to point out to my noble friend, as was pointed out when we did this a few sittings ago, that there is a broad sense of the importance of putting on the face of this Bill the responsibility of the Secretary of State for education and training. In that sense I agree with the most right noble Prelate-with the Archbishop of York.
The Archbishop of York: Call me whatever you like.
Lord Mawhinney: I am a just a simple Belfast boy. Archbishop of York seems pretty good to me; most of the clergy I know can only fantasise.
The timing of this debate is important in that it reinforces the message that my noble friend got the last time this was debated in this Chamber. I hope that he will tell those who tabled the amendments that they are premature. If he does, he will need to tell them that he will take away the contents of this debate and the previous one and bring back, in whatever way the Government think is appropriate, a means to attach the principle of education and training to this Bill. He knows that I hope that he will do that, but I hope that he is encouraged that I share the views expressed that this is not yet the time.
The noble Lord, Lord Owen, has addressed particularly well the element of perplexity and perhaps confusion in the NHS about the Government's intention. My noble friend and his colleagues keep going on about the Future Forum. I am sure that it is doing a fine job, and no word of criticism about it will cross my lips-except to say, as a simple Belfast boy, that in a democracy it seems to me that the role of this House is to try to persuade Ministers; it is not its role to try to persuade those who are going to try to persuade Ministers. The Future Forum may have an important role, but I would like us to discharge our role quite clearly. The noble Lord, Lord Owen, has the experience of having served in Cabinet, and I have been extremely fortunate and blessed to have had a similar experience. If my noble friend or the Secretary of State can go to the Dispatch Box and say, "I undertake that there will be legislation", and specify the Session, we will all believe him. However, if that is not possible, it adds to the importance of bringing forward at least the principle to get this issue into this Bill.
Those of us who are in favour of education and training but want to support the Government are not entirely clear whether we should be tempted by Amendments 47A, 47B or 133, and I have to say to the noble Baroness, Lady Finlay, that I am not tempted by her Amendment 199A. But at some point this House has to make a decision, so I hope that my noble friend will stand up, look the noble Lords who tabled these amendments in the eye and say, "Thank you, it's been very helpful and I've heard what you've said. I'll take it away and I'll bring something back on Report,
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Baroness Finlay of Llandaff: I hope that the noble Lord, Lord Mawhinney, will be tempted by this comment. If commissioning groups do not have a duty towards education and training, there is a real danger that they will commission services that are equal in quality but undertake no education and training and are therefore of a lower price as they do not incur the expenditure of having to have facilities, and so on, to provide education and training as well. In that case, we will deny the developing workforce expertise of quality placements in many parts of Britain as local commissioning will not take account of it.
Baroness Thornton: My Lords, at the risk of stating the obvious, the massive reorganisation of the NHS proposed in the Bill, combined with the need to make £20 billion of efficiency savings, without doubt, and with common agreement across many of the professions, threatens the quality and delivery of medical training, post-graduate training and workforce planning. That is why noble Lords have been exercised about this matter from the outset.
The concern is that responsibility for medical training will be given to healthcare providers who, as I understand it, have a history of allowing service and research to dominate the agenda at the expense of education. That brings with it risks of its own. Many trusts, as other noble Lords have said, have persistently failed to support education supervisors by recognising this activity in job plans and increasingly failed to support their staff in fulfilling important national roles related to standards setting and training. I think that most noble Lords who have spoken would agree that there is an insufficient mention of the safeguards that need to be put in place to protect the quality of medical training.
The noble Lord, Lord Kakkar, and my noble friend Lord Turnberg mentioned their concern about post-graduate deaneries. Indeed, that was a major stream of work for the Future Forum. I would like to say to the noble Lord, Lord Mawhinney, that as he made his remarks about the Future Forum I wrote in my notes that I do not understand why the Department of Health seems to have franchised that particular piece of policy-making out to the Future Forum. I think that the Future Forum was right in what it said about the dangers and risks involved in abolishing the strategic health authorities and its recommendation that it was mandatory and critical that alternative arrangements should be made.
We know that post-graduate deaneries are currently pivotal in quality-managing the delivery of medical training in trusts, but the planned replacements, being answerable to and funded by healthcare provider units, may lack the impartiality required to drive the quality agenda at a time when it is most needed because of the fiscal pressures and the associated threat to education quality. We all agree that effective management of the complexities of post-graduate medical training require professional leadership skills and experience, which take many years to develop. The noble Baroness, Lady Finlay, underlined that point in her remarks. My noble
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I was very struck by the briefing on this matter by the Royal College of Nursing. The noble Baroness, Lady Emerton, referred to this. The Royal College of Nursing expressed its concern that Medical Education England would dominate the new organisation, HEE. I think we would all agree with the RCN that:
"It is essential that nurse educators are treated as equals and the membership of HEE is representative and not led by the medical deaneries".
The Royal College of Nursing also believes that there is an essential role for national planning in the delivery of these important functions. I think that there are great risks in the decentralisation of education and training in terms of quality, standards and safeguards. It is unclear how the skill networks or the LETBs will be held accountable for performance issues. It is not clear what authority Health Education England will have to enforce performance issues or how its overseeing of the skills network will take place.
There are some key questions for the Minister to address. The crucial one, which was mentioned by the noble Lord, Lord Owen, who used the expression "chasm in continuity", is how long we will have to wait for legislation. We cannot be sure that the primary legislation that will be required in this area is going to come down the track in the next year. The Minister needs to recognise that it is too risky to leave this to chance and we have to put the appropriate duties and powers in the Bill to ensure the continuity that the noble Lord, Lord Owen, mentioned. On these Benches, we are very happy to discuss how to resolve that particular issue and how to ensure that medical education is safeguarded.
This is an important group of amendments. I am slightly worried by the statement of the noble Lord, Lord Ribeiro, that this is work in progress. The problem is that there is too much work in progress and there will be too much work in progress for the next few years. This is an area where we cannot take chances. We know from previous reorganisations, for which my Administration were responsible, that we have to be absolutely sure that we are safeguarding the education and training of future generations of workers in the National Health Service.
The most reverend Primate said that continuity and certainty are vital. I agree with him. Certainty in this area is vital. I look forward to hearing the Minister's views, but I suspect that we have not heard the last of this subject.
Earl Howe: My Lords, the Government are clear that the education, training and continuing development of the healthcare workforce are fundamental in supporting the delivery of excellent healthcare services across the NHS. I am very pleased that so many noble Lords here today share that view. It is certainly the Government's view. I very much welcome what have been excellent comments on this subject.
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Amendment 47A, tabled by the noble Lord, Lord Kakkar, seeks to insert a new clause placing a duty on the Secretary of State to establish a body called Health Education England. Similarly, Amendment 47B, tabled by the noble Lord, Lord Warner, seeks to place a duty on the Secretary of State to "provide or secure" an education and training system and to establish Health Education England to take responsibility for these education and training functions. Amendment 47B also specifies that the budget for education and training should be calculated on the basis of total health service expenditure and,
- "should be no less than the level of expenditure on education and training at the time of Royal Assent".
The Government recognise the importance of having an effective education and training system for the healthcare workforce. The NHS invests approximately £4.9 billion centrally in the education and training of health professionals. It is vital that there is a robust system in place to manage this investment wisely, with clear lines of accountability to Parliament. I would point out to the most reverend Primate that that is exactly why we tabled Amendment 43 which, as the Committee will recall, we debated in our first session. The Committee has already approved that amendment, which is now in the Bill and which says that there is a duty on the Secretary of State to exercise his,
education and training system. It is perhaps worth my flagging up that that amendment has received a positive response from the British Medical Association, which, in the current circumstances, is a rather remarkable fact. I reiterate that it is designed to ensure that the healthcare workforce has the right skills, behaviours and training to deliver a world-class health service. But we want to put flesh on the bones here. We recognise the need to do that and I therefore undertake that we will publish detailed proposals for the education and training system ahead of the Bill's Report stage where we will describe how this duty will be enacted in practice. However, there are parts of our plans that I can set out now.
It is vital that we ensure a carefully managed transition into the new system and protect staff and students currently undertaking training. We are taking a number of actions in developing the new system to achieve this that I would like to highlight. The Future Forum recommended that the establishment of Health Education England should be expedited to provide leadership and stability in the system. We agree and it is heartening to see that many noble Lords support this course of action. We have appointed a senior responsible officer to drive this forward and inject pace into the design and development of Health Education England.
To respond to the noble Lord, Lord Owen, while I do not share in any way his analysis of the future prospects of the next health Bill, he was right on one matter: we plan to establish Health Education England as a special health authority in 2012. This will enable it to take on some of its functions from October 2012 and be ready to be fully operational from April 2013. There is not and there will not be the chasm that the noble Lord referred to. Noble Lords will have a chance to scrutinise the establishment order and regulations to set up Health Education England as a special
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However, I can say in particular to the noble Lords, Lord Warner and Lord Kakkar, that Health Education England will provide national leadership for education and training, overseeing workforce planning and the commissioning and delivery of education and training across the system. We have been clear about its accountability to the Secretary of State to ensure that, at national level, there are sufficient health professionals with the right skills, education and training to meet future healthcare needs. Providers of NHS services will be expected to meet the obligations set out in the NHS constitution, including the right of recipients of NHS healthcare to be treated with a professional standard of care by appropriately qualified and experienced staff. Health Education England will hold responsibility for the management of the NHS multi-professional education and training budget, or MPET. To ensure that this budget is sufficient to support the development of the future NHS workforce, equipped with the right skills, our intention is to base the size of this budget on the needs of the service, supported by robust analysis of local workforce and education and training plans.
The question of postgraduate deaneries was raised in particular by the noble Lord, Lord Turnberg. The SHAs will continue to be accountable for postgraduate deaneries until 31 March 2013. Securing continuity for the work of the deaneries will be a key part of a safe transition. It is expected that deans and many of their staff will continue to take forward the work of deaneries with an emphasis on a new, multi-professional approach in the new system architecture.
To pick up one point made by the noble Lords, Lord Kakkar and Lord Turnberg, we also want to see stronger partnership working between postgraduate deaneries and universities. Further work is under way on the detail of these arrangements, with the right accountabilities for the quality of education and training lying with Health Education England and the professional regulators.
I was asked by the noble Lord, Lord Kakkar, about ring-fenced funding. As he knows, the MPET budget currently funds the education and training of the healthcare workforce and it is the responsibility of SHAs to invest the budget appropriately. We have proposed transparent systems to ensure that organisations receiving MPET funding under the future arrangements are held to account for using it for the education and training of the workforce.
The noble Lord also asked whether there will be a requirement to engage fully with academics. I partly covered that point but I emphasise that the new system presents a golden opportunity to build stronger links between the NHS and the academic health sector and to strengthen the educational foundation for research and innovation. Health Education England will ensure that research capability and capacity is maintained and it will forge strong partnerships with academia.
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The noble Lord, Lord Turnberg, asked me about standards. I reassure him that standard-setting will be the role of Health Education England at a national level, and this is in addition to the important role that the professional regulators play in this area.
However, despite the progress that we have made, a lot more work has to be done to get these important arrangements right. In my view, that is why it is important that we do not try to amend the Bill in a way that later turns out not to be appropriate. The Future Forum is now leading a second phase of engagement on education and training, focusing particularly on the need for greater flexibility in training, variation in standards and quality, and the need for stronger partnership working between education, academia and service providers. I take this opportunity to mention that tomorrow I am hosting a seminar with Professor Steve Field, chair of the forum, and I welcome your Lordships' involvement.
I appreciate that the service is waiting for detailed plans for the education and training system to be finalised and published, and I have two promises that I can make on this. The first is the one to which I have already alluded. Once the Future Forum has concluded its work, and prior to Report, the Government will publish more detail on the changes to the workforce planning, education and training system. That, incidentally, will include more detail on postgraduate deaneries. Secondly, it is likely that primary legislation will be required to support the continuing development of the education and training system, including establishing Health Education England as a non-departmental public body, but we think it is important to spend time to make sure that these arrangements are correct rather than legislate at this stage. However, I can tell the Committee that we intend to publish draft clauses on education and training for pre-legislative scrutiny in the second Session in the same way as on research. This approach will enable us to ensure that the legislation is fit for purpose and that it allows additional opportunities for parliamentary scrutiny of the legislation. I hope that this undertaking will be welcome to noble Lords and will indicate the Government's strong desire to provide maximum clarity on these matters at an early stage. Therefore, I hope that noble Lords will feel able not to press those particular amendments.
The noble Lord, Lord Kakkar, and the noble Baroness, Lady Finlay, have tabled remarkably similar amendments-Amendments 133 and 199A respectively-also on the subject of education and training. The noble Lord, Lord Kakkar, wishes to impose a duty on the NHS Commissioning Board to,
The noble Baroness, Lady Finlay, wishes to introduce a similar duty on clinical commissioning groups. As I have indicated, the Government's intention is to delegate responsibility for education and training to healthcare
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Responsibility for education and training is of great importance to employers and the various professional bodies that the noble Lord, Lord Kakkar, mentions in his amendment, but commissioners will also have a role. I agree entirely that education and training needs to be effectively linked with the wider system. I am aware of concerns voiced by the royal colleges and professional bodies on precisely that matter. I wish to reassure the Committee that I recognise the vital interrelationship between education and training, and commissioning decisions. That is exactly why national and local education and training plans will need to respond to the strategic commissioning intentions set out by the board and clinical commissioning groups.
Similarly, in commissioning decisions there will be a need to consider the implications for education and training-it works both ways. The NHS Commissioning Board has to work closely with Health Education England and it will be a mutually supportive relationship. Indeed, this will be a prime example of the co-operation duties that will apply to the board and to other NHS bodies. Commissioners must also promote and have regard to the NHS constitution, which of course contains the pledges that I have already referred to.
I do not intend to speak for very much longer but there are a couple of points that I ought to cover. A number of noble Lords pointed to the lack of medical school involvement in the set-up of local arrangements. I need to be clear about this: the new arrangements are underpinned by the desire to strengthen both the provider voice at the local level and the role of professionals and education providers. We envisage that one of the functions of local bodies will be to ensure strong partnerships with universities and medical schools. Providers of services will have to work in partnership; they cannot just sit alone and ignore everybody else. The form of the local provider-led arrangements is still being developed. More details will be available prior to Report, but I have stressed the links that we envisage with academic colleges at a local level.
I hope that I have indicated that, contrary to the statement from the noble Lord, Lord Warner, that within the modernisation agenda we somehow forgot about education and training, this is not at all the case. As I mentioned when we debated this before, this has been an active programme of work ever since the general election. It is a complex issue and we want to get it right. My noble friends Lord Ribeiro and Lord Mawhinney were spot on in their judgment on this. We are taking action now. We are not losing time over this.
To sum up, we have made provision for education and training in the Bill. We will publish our detailed proposals before Report and we will publish draft clauses on education and training for pre-legislative scrutiny in the second Session. With those assurances, I hope that the noble Lord will feel able to withdraw his amendment.
Lord Kakkar: My Lords, I thank the Minister for his very detailed and extensive response, which is genuinely welcome. He has dealt with a number of the issues that were covered in this important debate. The
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5.30 pm
The noble Earl has also confirmed a number of other important actions that he and his department propose to take as we move forward with this Bill. His confirmation that draft clauses of any future legislation dealing with education and training will be available for pre-legislative scrutiny and that an understanding around those draft clauses will be provided prior to the Report stage is welcome, as is the confirmation that the work of the NHS Future Forum will also be available to inform any potential discussion that we have in this matter on Report.
The confirmation that it is envisaged that Health Education England and any local arrangements for education and training boards represent true partnerships-academic service partnerships across the broad discipline, representing elements of the healthcare workforce-is also warmly welcomed. The question of the budget for Health Education England will require further discussion but the confirmation that Health Education England will have responsibility for supervision of the budget for postgraduate education and training is important, as is the recognition that postgraduate deans need to have an ongoing and developing relationship with the universities.
I wish to address the implied criticism that it was inappropriate to bring this group of amendments at this stage, the Committee having on its first day considered government Amendment 43. As I said at the outset, Amendment 47A and the others in this group were probing amendments to build upon the welcome comments of the Minister on the first day of Committee when Amendment 43 was moved. The Government's approach to specifying in the Bill a responsibility for education and training for the Secretary of State for Health was an important announcement. Many noble Lords felt therefore that probing amendments thereafter to explore the opportunity for the establishment of Health Education England in whatever form to relieve anxieties about the situation described by the noble Lord, Lord Owen, were appropriate to bring at this stage.
I am grateful to the Minister for having dealt with these matters with such clarity and in such a way that anxieties around the areas of education and training can now be addressed in a constructive and co-operative fashion with broad support from all parts of your Lordships' House. This will ensure that this vital function is developed for the benefit of patients who need to use our health services by ensuring that we have the best trained healthcare workforce to deliver the highest standards.
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Earl Howe: Before the noble Lord decides what to do with his amendment, I should say that I did not wish in the least to imply that this debate was inappropriate in any way. If I did, I apologise. If I may correct one thing that he said, the draft clauses for pre-legislative scrutiny will come forward in the next Session of Parliament rather than before Report. However, we will be publishing much more detail before Report about what our plans will look like.
Lord Kakkar: I welcome those comments. It was not a criticism made by the noble Earl about this but by other noble Lords; there was a suggestion that it was not appropriate to discuss education and training in any detail at this stage. These were probing amendments, designed to provide Her Majesty's Government with the opportunity to address issues, to allay concerns and to allow for further appropriate and constructive evaluation of this matter in the Bill in such a way that noble Lords could fulfil their function of scrutiny and revision to ensure that the best possible Act is finally delivered for the people of our country. With those comments, I beg leave to withdraw the amendment.
47B: After Clause 5, insert the following new Clause-
"Secretary of State's duty relating to education and training
(1) The Secretary of State has a duty to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size and competence to discharge his duties under this Act to ensure a comprehensive health service.
(2) In discharging this duty, the Secretary of State must establish a body known as Health Education England and this body will be responsible for the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries.
(3) The budget for this body and its functions should be calculated on the basis of a formula related to the total health service expenditure and initially should be no less than the level of expenditure on education and training at the time of Royal Assent."
Lord Warner: My Lords, I am grateful to everybody who has spoken in this debate. I particularly welcome the support given by the most reverend Primate and by the noble Lord, Lord Owen. I share the scepticism of the noble Lord, Lord Owen, about next-Session legislation and we would all do well to think carefully about his remarks.
I am still rather puzzled about why, if the Government are prepared to set up Health Education England as a special health authority, they cannot put it in the Bill along the lines of Amendment 47B. By all means doctor Amendment 47B. It was not the purpose of Amendment 47B to unreasonably tie the hands of the Government but I am still struggling with the question of why, if the Minister is prepared to produce a detailed paper before Report in which he agrees to set up a special health authority by next September, we cannot have a sensible cross-party discussion about setting up Health Education England in this Bill and giving the Government the necessary powers to make regulations to fill in the details.
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My ears pricked up on the subject of money when the noble Earl said that there would be a "robust analysis". I am willing to open a book on how far south of £4.9 billion the Government end up with on the robust analysis on education and training. I am available at all hours to discuss the odds a little further on this issue.
I will study the noble Earl's remarks carefully. I listened carefully to what he said. He has moved some way. Whether he has moved sufficiently far to stop us bringing forth an amendment on Report is in doubt.
Clause 6: The NHS Commissioning Board
The Lord Speaker (Baroness D'Souza): I must advise your Lordships that if Amendment 48 is agreed to I cannot call Amendments 49 to 51 by reasons of pre-emption.
48: Clause 6, page 3, leave out lines 27 to 34 and insert-
"(2) The Board has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act and subject to any directions issued by the Secretary of State.
(3) The Board must exercise the functions conferred on it by this Act in relation to clinical commissioning groups so as to secure that services are provided for those purposes in accordance with this Act.
(4) The Secretary of State may give a direction to the Board to discharge each of those functions, and in such manner and within such period or periods, as may be specified in the direction."
Lord Hunt of Kings Heath: My Lords, we come to a very important matter-the role and function of the national Commissioning Board. It is almost as important as the previous debate on the responsibilities of the Secretary of State.
In a telling intervention last week, the noble Lord, Lord Marks, spoke of the tension in the Bill between the proposed duty to promote autonomy on the one hand and the fulfilment of the Secretary of State's overall responsibility for securing the provision of services on the other. I suspect there is a similar tension built into the Bill in terms of the relationship between the Secretary of State and the national Commissioning Board.
At the heart of this debate have been concerns about the alleged micromanagement by the Secretary of State into the affairs of the National Health Service and specifically with regard to reconfiguration decisions. I sympathise with those in the NHS who can feel frustrated if hard-worked-through proposals are held up or rejected by Ministers or the service is constrained by too many interventions and targets from the centre. To think that this can simply be waved away in the new structure may prove to be optimistic. I suspect that a confusion of responsibilities between the Secretary of State and the national Commissioning Board and the plethora of organisations the Government have established or proposed to set up may well add to the burdens of the NHS.
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Why is there political intervention in the health service? Surely there is political intervention because the NHS is one of the most important services that the Government are called upon to deliver to the public. Surely there is political intervention because, in the end, the public require it. In our debate last Wednesday the noble Lord, Lord Mawhinney, said that the public, for whom the NHS exist and who pay the NHS bill, expect politicians to intervene on their behalf. Indeed, democracy may be a messy process but I prefer a messy process to rule by quango or even an unaccountable group of clinicians.
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