The NHS is currently facing challenges that it has never faced before. Even though the Government have protected the NHS with real-terms funding increases, we do not underestimate how challenging it has been to continue to deliver high-quality care in the current climate. Demand for healthcare is rising and changing as the population ages and different diseases come to the fore. We are faced with an ageing population, as has been said, and one where increasing numbers of people are living with multiple chronic conditions. The big issues that the NHS must deal with now, such as dementia and lifestyle conditions such as obesity, cannot be addressed by the traditional model of a healthcare system which is focused on the acute sector.

I want to spend most of my speech considering the future of the NHS following the recent publication of the Five Year Forward View. This document, which was published jointly by NHS England and five other arm’s-length bodies, sets out a vision for how our health system will evolve over the next five years. It is a

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vision which the Government share. The Secretary of State and I have previously set out the four pillars of our response, which are worth recapping.

The first pillar is to ensure that we have an economy that is able to pay for the growing costs of our NHS and social care system. A strong NHS needs a strong economy. The success of our economy means that we were able to provide additional funding in the Autumn Statement, including £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. In all, NHS funding will be about £3 billion more next year compared with this year, and all that extra funding will be baselined for future years.

The NHS itself contributes to that strong economy in a number of ways, and we want to help it to develop its role. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. The NHS can also attract jobs to the UK by playing a pivotal role in our emerging life sciences industries. In the past three years, we have attracted £3.5 billion of investment and 11,000 jobs. This Government have set out our ambition to be the first country in the world to decode 100,000 research-ready whole genomes.

The second pillar of our plan is to change the models of care to be more suited for an ageing population. As I said earlier, we need to accommodate growing numbers of vulnerable older people who need support to live better at home with long-term conditions such as dementia, diabetes and arthritis. To do that, we need a greater focus on prevention, which will help people to stay healthy and not allow illnesses to deteriorate to the point where they need expensive hospital treatment.

This Government have already made good progress in improving out-of-hospital care. Last year, all those aged 75 and over were given a named GP responsible for their care—something that was abolished by the previous Government. From April, everyone will have a named GP. Already 3.5 million people benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is integrating the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health.

However, I recognise that there is more to do. NHS England has already invited applications from local areas for the £200 million of funding which has been made available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with their local partners, for the entire health and care needs of people in their area.

A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. Previously, the NHS has often been too slow to adopt and spread innovation. Sometimes this has been because the people buying healthcare have not had the information to see how much smart purchasing can

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contain costs. From this year, CCGs will have access to improved financial information, including per-patient costings. The best way to encourage investment in innovation is a stable financial environment. Following the next spending review, local authorities and CCGs will receive multi-year budgets. The NHS also needs to be better at controlling costs in areas such as procurement and agency staff as well as reducing litigation and other costs associated with poor care. We are working with NHS England and partner organisations to agree the level of savings in each area, which will allow more resources to be directed to patient care.

The final pillar of our plan is to continue to develop a culture of care in all parts of the NHS. We have made good progress since the Francis report. We have introduced a greater focus on patient care. There are 5,000 more nurses on our wards and 4.2 million NHS patients have been asked, for the first time, if they would recommend to others the care they received. We plan to go further over the next few months. We will set out how we will improve training and safety for new doctors and nurses, launch a national campaign to reduce sepsis, and, responding to recommendations made in the follow-up Francis report, tackle issues of whistleblowing and the ability to speak out easily about poor care.

Noble Lords have raised a number of other important issues in this debate. I shall endeavour to respond to as many as I have time to do. First, I shall talk about funding, a subject covered very thoughtfully by the noble Lord, Lord Turnberg, my noble friends Lord Horam and Lord Cormack, and the noble Lord, Lord Liddle, among others. The Five Year Forward View argued that a combination of growing demand and no further efficiencies would bring about a funding gap for the NHS of nearly £30 billion by 2020-21 against a flat real baseline. A 2% efficiency growth, rising to 3% over time, produces a remaining gap of £8 billion. But if the NHS can achieve 3% efficiency gains, the remaining challenge would reduce to around £4.4 billion in 2020-21. I will talk about the scope for efficiencies in a moment, but this is broadly the same real-terms funding increase that the Government have committed to the NHS over this Parliament.

The funding announced in the Autumn Statement fully delivers the investment required to make the Five Year Forward View a reality in 2015-16 and provides funding to start delivering the changes required by the Five Year Forward View to deliver a sustainable NHS in future years. As I have said, this new funding will be baselined for future years. As has happened over this Parliament, real increases in funding will be required to complete this transformation and ensure a sustainable NHS in the future but the NHS will also be required to make significant efficiencies. Of course, I cannot go further than that at the moment because the detailed funding package for 2016-17 onwards will be announced at the next spending review, whichever party is in government. It is worth pointing out that all the £1.5 billion of investment in NHS front-line patient care in 2015, stemming from the Autumn Statement, will go to improving local NHS services and will help the NHS to meet rising demand. On top of that, we are introducing a £200 million transformation fund. The fund will kick-start the work needed to

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develop new ways of caring for patients which do a better job of joining up GPs, community services and hospitals.

In part of her speech, the noble Baroness, Lady Jay, focused on competition. I am sure she will remember that greater competition in the NHS was introduced through deliberate policies from 2003, such as the independent sector treatment centres and choice of any willing provider. Rules were put in place in 2007 to manage this competition. We as a government continued that approach of managed competition, overseen, however, by an expert health regulator in the shape of Monitor. I would just say that this has hardly led to a giant expansion of private provision. Commissioner spending on healthcare from private sector providers equates to about 6.1% of total NHS revenue expenditure, which is only 1.2% more of the NHS budget than in 2010. Much of the increase is accounted for by social enterprises and charities, which I know the party opposite supports.

The key here is that it is not politicians who take these commissioning decisions but clinicians. As the noble Baroness conceded, there has not been a change in the Secretary of State’s core duty. He is responsible for promoting a comprehensive health service. This remains consistent with the wording of the original 1946 Act. At the same time, what the Act also did was right. The Health and Social Care Act puts clinicians in charge of decision-making about patients rather than politicians or administrators. That involves a strengthening of local accountability and decision-making through clinical commissioning groups and local health and well-being boards. Local authorities are once again responsible for public health, as my noble friend Lady Barker reminded us. We have also restored a culture of care to the health service so that doctors are primarily accountable to their patients, not top-down- targets or bureaucrats. I simply say to the noble Baroness, Lady Jay, and the noble Lords, Lord Morris and Lord Hunt, that any future Government would reverse those measures at their peril.

The noble Lord, Lord Turnberg, said that the NHS should become a much more preventive service and we fully agree with that. Action is needed to address the common risk factors for the big killer diseases. To give one example, the NHS health check provides an opportunity to review an individual’s health against some of the risk factors that he listed. Last year, more people than ever before received a free NHS health check. Since it was introduced, 7.5 million offers have been made and more than 3.7 million NHS health checks have been received, offering a real opportunity to reduce avoidable deaths and disability and to tackle health inequalities.

My noble friend Lord Balfe spoke about GPs and, in particular, GP access. We are introducing a number of measures to ensure that people who need to see a GP do so at a time to suit them. We have invested through the Prime Minister’s Challenge Fund £50 million this year to help more than 1,100 practices to develop new ways of improving GP access. We have committed to invest another £100 million into the scheme next year and we will extend seven-day opening to every patient in the country by 2020. From January, practices will also be allowed to register people outside their

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local area, making it easier for hard-working people to register near their place of work or somewhere else that is convenient to them. Despite a decrease in head count, there has been a 1.2% increase in full-time equivalent GPs since 2012 and the number of practice nurses and other practice staff has also grown, representing in total a real capacity increase.

The noble Lord, Lord Rea, focused on alcohol, an important issue. We are committed to reducing alcohol-related harm and have already banned alcohol sales below the level of duty plus VAT, meaning that it will no longer be legal to sell a can of ordinary lager for less than around 40p. Alcohol consumption per head has fallen, I am pleased to say, in recent years. Reduced affordability of alcohol, influenced by tax rises up to 2013, has been a factor in this. Alcohol minimum unit pricing is still being considered as a possible way forward but no decision has been taken.

The noble Baronesses, Lady Masham and Lady Wilkins, turned our attention to spinal injury services. The NHS England spinal cord injuries service specification clearly sets out what providers must have in place to offer evidence-based safe and effective services. It sets a core requirement that each specialised SCI centre can demonstrate that it has a minimum of 20 beds dedicated exclusively for the treatment and rehabilitation of SCI patients. The overall bed complement for England is being reviewed through a demand and capacity project led by the Spinal Cord Injury Clinical Reference Group. That group aims to produce a report in 2015-16.

The noble Baroness, Lady Wilkins, argued for a strategic view of spinal injury services. As she knows, NHS England commissions specialised rehabilitation services as defined by the service specification, which sets out what providers must have in place to offer safe and effective specialised rehabilitation services. The clinical reference group is currently completing a review of those services. It will involve establishing nationally what the current demand is for rehabilitation services, which must be the first point of reference.

My noble friend Lord Horam spoke about bed blocking and asked whether some of the delayed discharges could be resolved by discharge to mental health trusts or housing associations, and whether local areas could do more than they are doing. I would simply say to him that these things have to be dealt with locally; we cannot hope to do it centrally. The Health and Social Care Act 2012 gives local clinicians more power and responsibility to develop the right solutions for their local areas. Hospital trusts are already forming effective partnerships to ensure that patients get the support they need to be discharged from hospital quickly, and I can tell him that NHS England and others are supporting them to do this.

My noble friend Lady Barker focused part of her speech on mental health. I fully agree with her that public services should reflect the importance of mental health, putting it on a par with physical health, as we have argued so often. Parity of esteem between mental and physical health is now enshrined in legislation. For the first time, we have introduced waiting time standards for mental health, ensuring that NHS England and local partners properly prioritise access to mental health services, and we have made mental health part

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of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.

The noble Lord, Lord Kakkar, in his wide-ranging speech, covered a number of key issues. I turn first to efficiency savings. There is no doubt that the NHS needs to be better at controlling costs in areas such as the procurement of medicines and clinical equipment, and indeed non-clinical equipment, energy and fuel, agency staff, the collection of fees from international visitors, and reducing litigation and other costs associated with poor care. Gains can also be made in ways of working, such as by getting paramedic teams to treat more patients at home rather than bringing them to hospital; creating more regional centres of excellence for specialist treatments such as stroke and heart disease; bringing more services out of hospital and into the community by, for instance, having specialist consultants in GP surgeries; offering more patients better access to GPs, including evening and weekend appointments and Skype consultations; and joining up health and social care services such as through the Better Care Fund. Working with NHS England, the department has announced plans in all these areas. We will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations with agreed plans to eliminate waste, thus allowing more resources to be directed to patient care.

The noble Lord, Lord Hunt, asked me about the cancer drugs fund. Of course, the policy behind this is to give patients access to the drugs they need, but I would qualify that by saying that those drugs need to be clinically effective. That is the reason why NHS England is doing the sifting process that is currently in train. The payments from industry that he referred to were never going to be hypothecated; they form part of NHS England’s general budget. Having said that, NHS England does have the freedom to apply the money as it sees fit, whether that is for drugs, radiotherapy, or indeed any other investment that it deems to be clinically effective.

Moving back to the noble Lord, Lord Kakkar, who asked me about innovation, the appropriate use of technology-enabled care services such as telehealth and telecare can support patients in managing their long-term conditions more effectively and enable people with social care needs to live independently for longer. We are making progress in this area, and I will be happy to bring him up to date by letter on that. As regards the new NHS Innovation Accelerator programme announced yesterday, I agree with him that that is very good news. It invites leading healthcare pioneers from around the world to bring their tried and tested innovations to the NHS. Again, I can expand on that by letter.

Where are we with the personalised medicine agenda, informatics and the UK Biobank? I can say to him, as I can to my noble friend Lady Thomas, that we are determined to make Britain the best place in the world to discover and develop 21st century medicines. By harnessing the UK’s unique strengths in research, the NHS, medical charities and a vibrant life sciences

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cluster of innovative companies, we are sure that we can accelerate access to new treatments and attract major new investment and growth.

I will need to leave the other questions to the letter that I have promised to send round to all noble Lords who have spoken. However, suffice it to say for now that in recognising that the NHS faces some definite challenges as we strive to increase both the efficiency and quality of care, we also have a clear plan for how we are going to tackle this. The progress that we want to make will only be made possible by people: those who work in the NHS and those who rely on it. We need to free people up to make decisions about the NHS, creating models of care that suit local needs while upholding a world-class standard. I am confident that we can do that together.

5.30 pm

Lord Turnberg: My Lords, I thank all noble Lords for their wide-ranging and well informed contributions. I have learnt a lot. I clearly cannot comment on every noble Lord’s contribution, but I particularly wanted to say how pleased I was to hear from the noble Baroness, Lady Wilkins, who is back in her place and in fine voice.

Clearly, we were never going to solve all the problems of the NHS today, but I believe that this debate has been a useful contribution as we ease our way into the next election. The next Government will have to level with the public, who are very supportive of the NHS, and grapple with the issue of how we might cope with the conundrum of paying for a service that becomes more complex as every day goes by.

Of course we should become more efficient, but I am reminded that Aneurin Bevan, when the NHS began, thought that as we cured and prevented more diseases the service would get cheaper. However, every year it seems to have got more expensive, and as we cure one disease, another disease pops up. It is an unfortunate fact that the mortality rate among humans is almost 100%—exactly 100%. On that happy note, once again I thank all noble Lords for their contributions and look forward to the next Government’s actions as a result.

Motion agreed.

Insurance Bill [HL]


5.31 pm

Clause 4: Knowledge of insured

Amendment 1

Moved by Lord Newby

1: Clause 4, page 3, line 16, leave out from “(whether” to “the” in line 17

Lord Newby (LD): My Lords, in moving Amendment 1, I shall also speak to Amendment 2. In the amended Bill, Clause 4(6) provides that, for the purposes of the duty of fair presentation of the risk, the insured “ought to know” what should have been revealed by a “reasonable search of information” available to it.

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Some of the evidence we heard in Committee made the case for the Bill explicitly confirming that the “reasonable” search may extend to persons covered by the insurance contract but who are not the insured in the sense of being a contracting party. Noble Lords will recall that my noble friend Lady Noakes and the noble and learned Lord, Lord Woolf, put forward amendments to this clause in Committee stating that the reasonable search may extend to persons who could benefit from the contract. The Government were unable to agree with the specific wording of those amendments, and they were subsequently withdrawn.

However, we agreed to take the issue away and consider whether amendments needed to be made to ensure that the intended scope of the clause is clear. The Government consider that such clarification would benefit the Bill, and Amendments 1 and 2 seek to address this issue. As we discussed in Committee, what is a reasonable search of information will depend on the type of cover an insured seeks and the type of entity it is. It is important that Clause 4(6) expresses a broad principle that is flexible enough to take account of the wide variety of insurance policies and types of cover which are bought in the non-consumer context.

Amendment 2 clarifies that “information” which an insured ought to know may include information held by a person other than the insured, specifically mentioning that this may include,

“a person for whom cover is provided by the contract of insurance”.

This makes clear that persons benefiting from the contract could come within the scope of the insured’s reasonable search. I believe that this was at the heart of the amendments put forward by my noble friend Lady Noakes and the noble and learned Lord, Lord Woolf, and I hope that they are content with the drafting we have produced on this in Amendment 2. These amendments will improve the Bill, and I hope that the House can support them. I beg to move.

Lord Woolf (CB): My Lords, in accord with the approach adopted by the Minister throughout the discussions on this Bill, I would like to acknowledge the help that he gave, which was something that I and the noble Baroness, Lady Noakes, were looking for.

Amendment 1 agreed.

Amendment 2

Moved by Lord Newby

2: Clause 4, page 3, line 18, at end insert—

“( ) In subsection (6) “information” includes information held within the insured’s organisation or by any other person (such as the insured’s agent or a person for whom cover is provided by the contract of insurance).”

Amendment 2 agreed.

Amendment 3

Moved by Lord Newby

3: After Clause 10, insert the following new Clause—

“Terms not relevant to the actual loss

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(1) This section applies to a term (express or implied) of a contract of insurance, other than a term defining the risk as a whole, if compliance with it would tend to reduce the risk of one or more of the following—

(a) loss of a particular kind,

(b) loss at a particular location,

(c) loss at a particular time.

(2) If a loss occurs, and the term has not been complied with, the insurer may not rely on the non-compliance to exclude, limit or discharge its liability under the contract for the loss if the insured satisfies subsection (3).

(3) The insured satisfies this subsection if it shows that the non-compliance with the term could not have increased the risk of the loss which actually occurred in the circumstances in which it occurred.

(4) This section may apply in addition to section 10.”

Lord Newby: My Lords, Amendment 3 is, with a few slight amendments, the text which the noble and learned Lord, Lord Woolf, put forward in Committee concerning terms not relevant to the actual loss. It is intended to prevent an insurer from relying on a policyholder’s non-compliance with a warranty or other contract term in order to avoid liability for an insurance claim for loss of an entirely different kind.

From the outset, the policy aim behind this amendment has been generally well supported. There were some concerns about the drafting of the clause, which meant that it did not achieve a sufficient consensus of support such that it could be introduced as part of an uncontroversial Bill. The text of this amendment was proposed and consulted on by the Law Commission after the introduction of the Bill as a drafting solution which, it was hoped, would be suitable for this non-controversial parliamentary procedure.

I am very pleased that the written and oral evidence put to the committee, together with the backing of the committee members themselves, has demonstrated a strong body of support for this formulation. As such, the Government consider it suitable to be included in this Bill. It complements the existing Clause 10, which makes changes to an insurer’s remedy for breach of warranty. I beg to move.

Amendment 3 agreed.

Clause 12: Remedies for fraudulent claims: group insurance

Amendment 4

Moved by Lord Newby

4: Clause 12, page 6, line 32, leave out subsection (1) and insert—

“(1) This section applies where—

(a) a contract of insurance is entered into with an insurer by a person (“A”),

(b) the contract provides cover for one or more other persons who are not parties to the contract (“the Cs”), whether or not it also provides cover of any kind for A or another insured party, and

(c) a fraudulent claim is made under the contract by or on behalf of one of the Cs (“CF”).”

Lord Newby: My Lords, I shall speak also to Amendments 5 to 9 and manuscript Amendment 10A, which has been tabled in substitution for Amendment 10. The amendments respond to representations made to the committee that Clause 12 on fraudulent claims in

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consumer group insurance should be extended to group insurance contracts in the non-consumer context. My noble friend Lady Noakes tabled amendments on this point in Committee. The Government supported this change in principle but were unable to support the specific amendments suggested by my noble friend. As such, her amendments were withdrawn on the basis that the issue would be taken away and considered further.

We have now had the opportunity to consider the amendments needed to the Bill in order to effect this change. Clause 12 currently provides that where a member of a group consumer insurance contract makes a fraudulent claim, the insurer has a remedy against the fraudulent group member but the remaining members of the group policy are protected. Amendments 4 and 5 extend the application of Clause 12 to the non-consumer context, and indeed in respect of contracts that cover both consumers and non-consumers as group members under the same policy. Amendments 6 and 7 correct a small error in Clause 12(3) that was spotted when drafting the main amendment to the clause.

Amendments 8, 9 and 10A deal with contracting out. In the consumer context, an insurer will not be able to put a consumer group member in a worse position than they would be in under Clause 12. In the non-consumer context, an insurer will have to comply with the transparency requirements if they wish to put a group member in a worse position. These provisions are consistent with the contracting-out provisions generally, and are a necessary consequence of extending Clause 12 to non-consumers. I should explain that the only difference between Amendment 10A and Amendment 10, which it replaces, is that the various cross-references to other sections have been corrected.

I believe that these amendments fully address the desire of the committee, particularly my noble friend Lady Noakes, and a number of the committee’s witnesses to extend the application of Clause 12 to the non-consumer context. These are uncontroversial amendments and I hope therefore that noble Lords can support them. I beg to move.

Lord Young of Norwood Green (Lab): My Lords, I thought it would be appropriate for us to say that we support these amendments. It is a good example of Parliament working to improve a valuable service industry, enhancing its position globally. That is important because the UK is a world leader in this. It is not a subject that I profess a great deal of knowledge about but I cannot help having a slight ironic feeling. My late father, who was a very successful insurance agent, would have been pleased to hear my contribution, brief though it is.

Amendment 4 agreed.

Amendments 5 to 7

Moved by Lord Newby

5: Clause 12, page 6, line 42, leave out “consumer”

6: Clause 12, page 7, line 7, after first “the” insert “first”

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7: Clause 12, page 7, line 10, at end insert—

“( ) the second reference to “the insured” in subsection (1)(b) is to A or CF,”

Amendments 5 to 7 agreed.

Clause 14: Contracting out: consumer insurance contracts

Amendment 8

Moved by Lord Newby

8: Clause 14, page 8, line 3, leave out paragraph (b)

Amendment 8 agreed.

Clause 15: Contracting out: non-consumer insurance contracts

Amendment 9

Moved by Lord Newby

9: Clause 15, page 8, line 18, leave out subsection (3)

Amendment 9 agreed.

Amendment 10A (in substitution for Amendment 10)

Moved by Lord Newby

10A:After Clause 16, insert the following new Clause—

“Contracting out: group insurance contracts

(1) This section applies to a contract of insurance referred to in section 12(1)(a); and in this section—

“A” and “the Cs” have the same meaning as in section 12,

“consumer C” means an individual who is one of the Cs, where the cover provided by the contract for that individual would have been a consumer insurance contract if entered into by that person rather than by A, and

“non-consumer C” means any of the Cs who is not a consumer C.

(2) A term of the contract of insurance, or any other contract, which puts a consumer C in a worse position as respects any matter dealt with in section 12 than that individual would be in by virtue of that section is to that extent of no effect.

(3) A term of the contract of insurance, or any other contract, which puts a non-consumer C in a worse position as respects any matter dealt with in section 12 than that person would be in by virtue of that section is to that extent of no effect, unless the requirements of section 16 have been met in relation to the term.

(4) Section 16 applies in relation to such a term as it applies to a term mentioned in section 15(2), with references to the insured being read as references to A rather than the non-consumer C.

(5) In this section references to a contract include a variation.

(6) This section does not apply in relation to a contract for the settlement of a claim arising under a contract of insurance to which this section applies.”

Amendment 10A agreed.

House adjourned at 5.42 pm.