Penny Mordaunt (Portsmouth North) (Con):
I am a former director of the largest patient organisation in Europe, which provides services on the commissioning side and the provider side through advice and support. It is a charity that deals with long-term conditions. We had to follow extremely strict rules to ensure that there was no conflict of interests and we could not provide commissioning services to an area of the country if we
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were also on the provider side. Why does she think that that situation has not existed for this particular area of health care?
Nadine Dorries: Because, unfortunately, abortion provision and counselling is never scrutinised thoroughly or legislated on. No legislation happens in this place to deal with abortion. It is an issue that can never be debated. People shy away from debating abortion because of the uproar that results so things do not happen that perhaps should happen. If one is to have cosmetic surgery and it is deemed that it might have a psychological effect, one would be offered independent counselling. That does not happen with abortion.
BPAS and other organisations would say that they do not have to meet targets and that they have no financial concerns. However, BPAS has advertised for business development managers, whose primary function is to increase its market share—those are its own words in the advert. If an organisation advertises that it wants to increase the number of abortions, can we trust it to provide vulnerable women who walk through the door with the counselling that they need? On pensions mis-selling, this place has separated by law the people who provide and sell pensions from the people who advise on pensions.
Nadine Dorries: No, I am going to close. I thought long and hard about tabling this amendment. Like so many issues concerning abortion, it is a highly emotive area. There are those who believe that the right to an abortion is so sacred that, no matter what, it should never be touched, debated or reformed. There is not a single MP in this House who has not been asked by a constituent about their beliefs on this issue. I am sure that many prefer, understandably, to fudge a response, particularly when the reaction to discussing abortion can be so aggressive, as I have found to my cost.
The amendment is about one thing and one thing only: providing women with more choice. It would allow women who are at their most vulnerable greater access to support. It must be wrong that the abortion provider that is paid £60 million to carry out terminations also provides the counselling when a woman feels strong
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or brave enough to ask for it. If an organisation is paid that much for abortions, where is the incentive to reduce them?
I will move on to the tactics that have been used in this House to thwart the amendment. I wish to be very clear and will take no more interventions. I went to see the Prime Minister regarding this amendment and he was very encouraging. In fact, it was at the Prime Minister’s insistence that I inserted the word “independent”. I have attended a meeting at the Department of Health at which it was decided what process would be implemented to make this a reality.
Last weekend, the former MP for Oxford West and Abingdon, Evan Harris, who has spent most of the day in the office of the hon. Member for Cambridge (Dr Huppert)—he is still here, tabling his amendments—turned up on the airwaves expounding the theory that there is no evidence of a problem, that the amendment is unnecessary as nothing needs to be fixed, that the status quo should remain and that the abortion industry should be allowed to continue under the veil of secrecy that it has.
I received a message informing me that the former Member for Oxford West and Abingdon had approached the Deputy Prime Minister’s office and exerted pressure. In fact, he tweeted exactly that, saying that he had applied pressure on the Deputy Prime Minister, who had now forced the Prime Minister to make a climbdown. Basically, a Liberal Democrat—in fact, a former MP who lost his seat in this place—is blackmailing our Prime Minister and our Government. Our Prime Minister is being put in an impossible position regarding this amendment. Our health Bill has been held to ransom by a former Liberal Democrat MP, who has focused on this amendment.
Mr Speaker: Order. I apologise for interrupting the hon. Lady, but there is so much noise in the House that it is sometimes difficult to know whether somebody is seeking to intervene or standing for another purpose. Point of order, Mr Martin Horwood.
Martin Horwood: On a point of order, Mr Speaker. Is it in order for an hon. Member to accuse a former hon. Member of blackmail in the course of their speech? That is an accusation of a criminal offence.
Mr Speaker: I am grateful to the hon. Gentleman. My understanding at present is that there has been no breach of order. However, I would say to the hon. Member for Mid Bedfordshire (Nadine Dorries) and to the House that temperate language, moderation and good humour are the essential features referred to in “Erskine May”, and it is best if they inform our debates.
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I think our Prime Minister has been put in an impossible position. I want every Liberal Democrat Member to know that in the polling that was done, support for the amendment was 78% among the public, but it was highest among those who voted Liberal Democrat in the 2010 election, at 84%.
Nadine Dorries: It is time to make a decision not informed by the Liberal Democrats, and without being blackmailed by a Liberal Democrat or held to ransom by the Liberal Democrats. It is time to make a decision based on our conscience. I say to hon. Members: be prepared to stand by your view today for a long time, as it will be on everyone’s parliamentary record. In weighing up whether to support the amendment, Members should bear in mind the fact that 78% of the public support it. This is why we are here as Members of Parliament—to make difficult decisions such as this, not to be blackmailed or held to ransom. This is why we are MPs—because our constituents expect us to be brave. They expect us to stand up in the face of blackmail and be accountable.
Nadine Dorries: It does not happen very often in the House, but we have a conscience vote. It hardly ever happens, but we are all personally answerable for the decisions that we take. This decision is about nothing more than supporting an offer of counselling to vulnerable women who may need it and who may use it as a lifeline.
This is about being accountable for our views, which is what Parliament is all about. I do not see why we should shy away from putting our positions on the record. If Members want to stand in the way of a woman’s basic right to independent counselling, then they should vote against this proposal. However, if they want to ensure that a woman can have access to very basic support, they should vote for the amendment. It is up to them—support these reasonable measures to provide all women with independent counselling, or stand in the way of that basic support.
This vote is about women. I want every woman in this country to be able to look every MP in the eye and ask, “How did you vote for me and my daughters? What was the decision that you took?” Every MP will be accountable for that vote and that decision today.
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Ms Diane Abbott (Hackney North and Stoke Newington) (Lab): The decision to seek an abortion may be the most serious and difficult that many women face in their lives, and I think it deserves some seriousness and calm in this debate.
For nearly five decades, this House has been in agreement that abortion and matters related to it should be above mere party and partisan politics. For nearly five decades, there has been a settled pro-choice majority in this House and in the country, and for nearly five decades the House has believed that when Members of all parties have religious or ethical objections to abortion, their right to vote against it should be absolutely respected. However, this amendment is not about that. It is a shoddy, ill-conceived attempt to promote non-facts to make a non-case.
The case that the amendment is intended to make is that tens of thousands of women every year are either not getting counselling that they request, or are getting counselling that is so poor that only new legislation can remedy the situation. I might say, after many years in the House, that in matters of this kind, if legislation is the answer we have almost certainly asked the wrong question.
“A decision to terminate a pregnancy is never an easy one. In making these decisions, patients and doctors should ensure that the decision is supported by appropriate information and counselling about the options and implications.”
“Women should be given counselling according to their need—including post-abortion if she needs it. All women should be offered standalone counselling. The counselling should include: implications counselling (aims to enable the person concerned to understand the…course of action…); support counselling (aims to give emotional support in times of particular stress) and therapeutic counselling (aims to help people with the consequences of their decision and to help them resolve problems which may arise as a result)”.
“Counselling must be offered to women who request or appear to need help in deciding on the management of the pregnancy or who are having difficulty in coping emotionally”.
Yet the proposers of the amendment are asking us to believe, on the basis of purely anecdotal evidence, that tens of thousands of doctors, nurses and charity workers involved in the 190,000 abortions a year are wilfully ignoring both the law and the guidance of the British Medical Association and the Royal Colleges. They go further than that, arguing that tens of thousands of doctors, nurses and charity workers are merely in it for the money. They imply that those men and women are involved in some sort of grotesque piecework. It is almost as though they were paid per abortion. The
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proposers of the amendment, I might add, also seem to be arguing that thousands of women do not actually know what they are doing. It tells us something about the validity of their claims that they are obliged to smear tens of thousands of doctors and nurses to make any kind of case. No wonder that a journalist for
The Sunday Times
—no friend of the liberal left, but one who happens to have served as a lay member of the Royal College of Obstetricians and Gynaecologists—last weekend described the amendments as a “senseless and sinister bid” to cut abortions.
Mr Kevin Barron (Rother Valley) (Lab): I agree with my hon. Friend. Any evidence that we have heard has been anecdotal—we have heard of a 16-year-old’s journey and of e-mails that hon. Members have seen but that I have not. However, my hon. Friend makes a real point. The conclusion of the consultation might be that a termination takes place, but this is the only procedure in this country that requires the informed consent of two doctors. Government Members besmirch doctors by saying that such things happen daily, but that is not true. From my nine years on the General Medical Council, I recognise that we have good ethical guidelines for doctors. Nothing is done without the informed consent of two medical practitioners.
Ms Abbott: I would be more willing to give way were we not so far advanced in a debate that will last for only an hour and a half. I was not aware that so many Back Benchers wanted to contribute, because they have not hitherto tried to intervene.
Some colleagues have expressed their surprise that yet again we are discussing women’s reproductive rights in this House, but they should not be surprised. Abortion has never stood on its own as a technical issue; it is part of a century-long debate about women’s sexuality, womens’s rights and women’s freedoms. Sadly, for some people that is apparently still contested ground in 2011. Some even argue that the proposals are best seen as part of a wider push on the socially conservative agenda that has been so successful for right-wing politicians in America. Thankfully, in this country, that agenda has come up against a determination to keep such issues above party politics, the absence of a Fox News pumping out socially conservative propaganda 24 hours a day and British common sense.
I could say many things on the lack of an evidence base behind the amendments, but let me say this: women—both individual women and women in general—have been called in aid in this debate, and indeed they face very real problems in this society, here in 2011. They face spiralling unemployment as a direct consequence of the coalition’s policies and the sexualisation of our culture, which affects younger and younger female children—[
] I hope that hon. Members listen to this, because it is a point that many mothers and fathers will understand. Too many young women in communities up and down the country think that the only road to fame and fortune is to pump their bottom and their breasts full of silicone and tout themselves as
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some sort of media celebrity. Another issue is the number of very young women who have been badly parented, who have children too young and who, with all their good intentions, parent their own children badly in turn. Even in an era of financial constraint, those are the issues that this House should be addressing.
Nobody is saying that arrangements in relation to counselling cannot be improved. I believe that the hon. Member for Cambridge (Dr Huppert) has tabled a good amendment to that effect, which some of us hope finds favour in another place. However, the Bill and the amendment are not appropriate for a full and careful debate on abortion. The amendments deal with matters that are amply covered by existing law and regulations.
Dr Poulter: The hon. Lady is making an excellent speech and has outlined the fact that there is adequate provision for counselling in the status quo. Doctors, nurses and other medical professionals who must deal with such situations every day have adequate measures in place, as the Royal College of Obstetricians and Gynaecologists has outlined. They do not look only at the medical consultation, but at the whole patient, as we have heard. If that means that counselling is required, they will ensure that their patient gets it. Does she agree that this is not the place for the amendment, which serves no purpose, and that we need to get on and debate the Bill?
As hon. Members have heard, the amendments deal with matters that are amply covered by existing law and regulations that are well known to doctors and nurses. They deal with matters that must, at the end of the day, be between a woman and a doctor. I deprecate the extent to which amendment 1 is an attempt to import American sensationalism, confrontation and politicisation into these issues in a way that will be of no benefit to ordinary women.
There is no evidence base for the amendments, and on the basis of all the recent polls there is no substantive support for amendments of this nature. Legislation addressing the issues raised by Government Members is already in place. This House should have more respect for the medical profession and for the vulnerable women who put themselves forward for abortion in one of the most difficult periods in their lives, rather than support an amendment of this nature, which is spurious and baseless. I urge the House emphatically to reject the amendment.
The Parliamentary Under-Secretary of State for Health (Anne Milton): I feel that I need to start by saying that this debate is about women; it is not about hon. Members. It is about ensuring that women get the very best possible services that they not only need but deserve.
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There was much comment and speculation ahead of the debate, not all of it accurate or helpful. It might therefore be useful if I explain the Government’s approach to meeting the spirit of the amendments without primary legislation. I associate myself with my hon. Friend the Member for Bracknell (Dr Lee), who urged calm and balance. Today’s debate has not necessarily reflected either of those things.
The Bill gives new public health functions to local government. In some cases, the steps that local authorities must take will be prescribed in regulations, which include the provision of sexual health services and abortion services. That will be a duty of local authorities and not of clinical commissioning groups—some of the amendments in the group have caused confusion about that. We intend to specify in regulations that local authorities must ensure that part of what they commission is a choice of independent counselling.
Amendments 1 and 2 would fragment the service by splitting responsibility for the commissioning of counselling and for the commissioning of the rest of the service. If they and amendment 1221 were to be made, clinical commissioning groups and local authorities would have different but overlapping duties in relation to independent counselling, and the definition of “independent” would be different for each. We would have a fragmented service, which none of us wants. Most women go to their GP, which is not the same as a clinical commissioning group, or they self-refer to an abortion provider, so amendment 1221 would not work.
None the less, the amendments have highlighted some important issues. There are indeed no quality standards for abortion counselling, and women are not always offered the opportunity to have counselling. It is worth repeating that we want counselling to be provided by appropriately qualified people who offer non-judgmental, therapeutic support, and who act according to their professional judgment, in the best interests of their clients, without undue influence or regard to outside interests.
I know there has been considerable interest in exactly what “independent” should mean and in whether it must automatically mean independence from the abortion service provider in every possible way. That is not a simple question, and it is certainly not as simple a question as the amendments imply. There are permutations of financial, organisational and clinical independence to be considered. For example, would the amendments mean that a self-employed counsellor who had a contract with a charitable abortion provider for two days a week was independent on the other three days, or not?
Before we legislate, we want to think through all the implications—including financial and legal—of a definition. We also want to consult widely and publicly as part of our proposals to help us ensure that we really improve services for women at what we all know is an extremely difficult time in their lives. We need to consult the public; indeed, we need to consult the women about
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whom we are talking. We have heard passionate contributions this afternoon, and I want to harness and corral them to create the calm and balance that we all want to be established, so that we can consult and arrive at the best conclusions. I also stress that the regulations would be subject to affirmative resolution.
Whether women want to take up the offer of independent counselling will be a matter for them, but we are clear that the offer should be made. The hon. Member for Hackney North and Stoke Newington (Ms Abbott) mentioned the post-abortion period. That is a critical time on which there is little focus.
I hope that what I have said reassures my hon. Friend the Member for Cambridge (Dr Huppert), who I believe is trying to be helpful, but we do not support any of the amendments. We intend to ensure that the independent counselling offered to women follows the highest standards of good practice. My hon. Friend’s amendment 1252 is therefore unnecessary, as well as, we believe, unenforceable as currently drafted. It does not define “information or advice”, and crucially, it does not mention independent counselling. Counselling is different from advice and support. However, the Government support the spirit of the amendments, and we intend to present proposals for regulations after consultation. Not only is primary legislation unnecessary, but it would deprive Parliament of the opportunity to consider the detail of how the service will develop and evolve.
Amendment 1180 would oblige the Government to make regulations requiring NICE to produce guidance on abortion services. It would also oblige NICE to make specific recommendations in the guidance. That conflicts with other provisions in the same clause that prevent central interference in the substance of the NICE recommendations. Clearly that would seriously damage the independence of NICE and its reputation for evidence-based guidance. The second part of the amendment would require health or social care bodies, or private providers of abortion services, to comply with all recommendations made by NICE, which would effectively mean that NICE was setting essential requirements for abortion services, which is not its job or function. That is the role of the Care Quality Commission, and those standards and qualities are driven by good commissioning.
Andrew Selous: We all greatly appreciate the calm and measured way in which the Minister is responding. Is she aware that, in 2006-07, a Labour-dominated Science and Technology Committee recommended that those functions should be taken over by NICE?
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This does not, of course, mean that NICE has nothing to contribute. Hon. Members may know that it is currently considering a draft library of NHS quality standards, which includes a proposed topic on abortion services. We may have an opportunity to air the issue further at that point.
It is a very long time since I worked in a maternity unit, but I worked in one run by the Salvation Army, and I have seen many young women go through the trauma of an unplanned and unwanted pregnancy. Yes, we need to do a great deal more to prevent unwanted pregnancies from happening in the first place, but when faced with such a situation, young, and indeed older, women need help and support to make the decision that is right for them without interference from any vested interests. The amendments were tabled in a spirit of improving services for women, but they will not work. They will not deliver what my hon. Friend the Member for Mid Bedfordshire (Nadine Dorries) wants, or what I want. They will not work for women. I urge my hon. Friend to withdraw her amendment and to work with me to ensure that we secure the right services for women.
I thought that I would be addressing the House about an amendment with my name on it, but, for reasons unknown to me, my name was dropped from it. What I wanted to say, however—and it is reinforced by the way in which the Minister has approached the matter—is that while I thought that the original amendment involved an issue that we should consider, I believe that the Minister has dealt with it. The hon. Member for Mid Bedfordshire (Nadine Dorries) and I embarked on this journey together, and my plea to her now is not to press the amendment. The Minister has provided us with an advance which I hope will signal a change in the temper of the abortion debate in the House.
This has been one of those debates in which people emphasise motives and rarely take voting records into account. I put my name to that amendment because in every vote on the subject that has taken place in the 30 years for which I have been in the House, I have voted against wrecking the Abortion Act, and I thought that there was an issue here that should be considered. However, I feel that the Minister has more than met the point, and she has widened the debate about what the inquiry will cover. I hope that the whole House will pay attention to her and to my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott). Presumably a report will be produced once the consultation has been completed, and perhaps we shall then be able to have a debate opened by Front Benchers in which Back Benchers’ speeches are time-limited.
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Despite what has happened today, I think it important for us to try to use this event to make it clear that we will have different debates about abortion in the House of Commons in future, for we should have such debates. We should be more concerned with facts, and less concerned with trying to put our sticky fingers into other people’s souls and pronouncing that they have failed.
Dr Huppert: I am delighted to have a chance to speak in the debate. It is tempting to respond to all the comments made by the hon. Member for Mid Bedfordshire (Nadine Dorries), but I shall avoid doing so. Instead, I shall make just two points.
“The hon. Lady has asserted many things to be facts that are not… Some of the things that she is saying are not borne out by the evidence.”—[Official Report, 20 May 2008; Vol. 476, c. 263.]
Dr Huppert: I am afraid that there will not be time to go through all that. The hon. Lady challenged me to comment on some evidence that she had provided, and then would not allow me to do so. The hon. Member for Totnes (Dr Wollaston) remarked on that.
“Where studies control for whether or not the pregnancy was planned or wanted, there is no evidence of elevated risk of mental health problems.”
Unfortunately, there is not sufficient time to cover all the other topics the hon. Lady would like to talk about. I congratulate her, however, as it takes a lot to unite Abortion Rights with the Society for the Protection of Unborn Children, both of which oppose her amendments. The SPUC has been very clear that it cannot ask MPs to support the amendments.
Let me move on, however, and ask whether there is actually a problem that we need to address: are there too many abortions? The best way to reduce the number of abortions is by empowering individuals, by providing better access to contraception and by providing better sex and relationships education at school to both boys and girls. Are there areas where we need better advice and counselling? Absolutely there are. People who have had a miscarriage do not get the counselling support that they desperately need. We should focus attention on that. For all the reasons that have been discussed, I urge the House to reject these amendments.
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I want to speak in favour of my amendment 1252, which proposes that evidence-based advice should be given. Although the Government will not support the amendment if it is put to a vote, I was pleased to hear that they accept the principle behind it, which is that we want that expert advice. I am not a medical doctor—I am not an obstetrician or gynaecologist—but they have clearly stated what they think the best advice is, and it should be followed. We should expect all groups giving advice to live up to this high standard. Women—all people—should get proper medical advice, and it should be the best advice available. They should not be misled, and they should not have made-up risks told to them. The Royal College of Obstetricians and Gynaecologists has excellent guidance from 2004, and all organisations should stick to it. I confirm that the British Pregnancy Advisory Service and Marie Stopes stick to that guidance, and so should all other groups.
I trust the Government when they say that they will stick to that advice—the best medical advice. I have some concerns about some of the Government’s other comments however, and I hope to have a chance to talk to the Minister in greater detail, although this debate has not been the forum in which to do that. I urge the House to stand up for what it believes in, to reject the presentation we heard earlier and to reject the amendments.
We have heard a number of points of view. I take on board the comments of the right hon. Member for Birkenhead (Mr Field) and I appreciate the response from the Minister. She is my friend, and she has gone out of her way to understand the issue and to bring this debate to a calm and reasoned conclusion.
This debate is not just about my amendment. There are many people who support it, as I have frequently stated. [Interruption.] I have no idea why whenever I stand the hon. Member for Rhondda (Chris Bryant) always feels the need to continue chatting; he should just be quiet.
I heard what the right hon. Member for Birkenhead said, and I have listened to the Minister. Unfortunately, I am being urged by many other people, not least those who have told their stories, to go to a vote, because there are people who want a line drawn in the sand here. I shall therefore press amendment 1221 to a Division.
“Provision of independent information, advice and counselling services for women requesting a termination of pregnancy
8A (1) A local authority must make available to women requesting termination of pregnancy from any clinical commissioning group the option of receiving independent information, advice and counselling.
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The House divided:
Ayes 118, Noes 368.
Amess, Mr David
Bacon, Mr Richard
Beith, rh Sir Alan
Bellingham, Mr Henry
Benton, Mr Joe
Brady, Mr Graham
Brazier, Mr Julian
Buckland, Mr Robert
Burrowes, Mr David
Cash, Mr William
Clappison, Mr James
Coffey, Dr Thérèse
de Bois, Nick
Dodds, rh Mr Nigel
Donaldson, rh Mr Jeffrey M.
Duncan Smith, rh Mr Iain
Evennett, Mr David
Fox, rh Dr Liam
Glindon, Mrs Mary
Goodwill, Mr Robert
Grant, Mrs Helen
Gray, Mr James
Grayling, rh Chris
Hayes, Mr John
Hollobone, Mr Philip
Howarth, Mr Gerald
Jackson, Mr Stewart
Leigh, Mr Edward
Lidington, rh Mr David
Main, Mrs Anne
McCrea, Dr William
McDonnell, Dr Alasdair
Newmark, Mr Brooks
Nuttall, Mr David
Paterson, rh Mr Owen
Redwood, rh Mr John
Robertson, Mr Laurence
Roy, Mr Frank
Scott, Mr Lee
Shepherd, Mr Richard
Streeter, Mr Gary
Swayne, rh Mr Desmond
Vaz, rh Keith
Walker, Mr Charles
Wallace, Mr Ben
Whittingdale, Mr John
Wilson, Mr Rob
Tellers for the Ayes:
Mr Brian Binley and
Mr Peter Bone
Abbott, Ms Diane
Ainsworth, rh Mr Bob
Alexander, rh Danny
Alexander, rh Mr Douglas
Allen, Mr Graham
Anderson, Mr David
Arbuthnot, rh Mr James
Bain, Mr William
Balls, rh Ed
Baron, Mr John
Barron, rh Mr Kevin
Beckett, rh Margaret
Begg, Dame Anne
Bell, Sir Stuart
Benn, rh Hilary
Beresford, Sir Paul
Betts, Mr Clive
Blears, rh Hazel
Blunkett, rh Mr David
Blunt, Mr Crispin
Brake, rh Tom
Brine, Mr Steve
Brown, rh Mr Gordon
Brown, rh Mr Nicholas
Brown, Mr Russell
Bruce, rh Malcolm
Buck, Ms Karen
Burnham, rh Andy
Burns, rh Mr Simon
Byrne, rh Mr Liam
Campbell, Mr Alan
Campbell, rh Sir Menzies
Campbell, Mr Ronnie
Carmichael, rh Mr Alistair
Chapman, Mrs Jenny
Clarke, rh Mr Kenneth
Clegg, rh Mr Nick
Clwyd, rh Ann
Cooper, rh Yvette
Crausby, Mr David
Cunningham, Mr Jim
Darling, rh Mr Alistair
Davey, Mr Edward
De Piero, Gloria
Dobson, rh Frank
Donohoe, Mr Brian H.
Doran, Mr Frank
Dorrell, rh Mr Stephen
Eagle, Ms Angela
Ellman, Mrs Louise
Field, rh Mr Frank
Flint, rh Caroline
Foster, rh Mr Don
Francis, Dr Hywel
Garnier, Mr Edward
Gauke, Mr David
Gillan, rh Mrs Cheryl
Gyimah, Mr Sam
Hague, rh Mr William
Hain, rh Mr Peter
Hamilton, Mr David
Hanson, rh Mr David
Harman, rh Ms Harriet
Harper, Mr Mark
Harris, Mr Tom
Haselhurst, rh Sir Alan
Havard, Mr Dai
Healey, rh John
Heath, Mr David
Hepburn, Mr Stephen
Hodge, rh Margaret
Hodgson, Mrs Sharon
Hughes, rh Simon
Huhne, rh Chris
Huppert, Dr Julian
Hurd, Mr Nick
James, Mrs Siân C.
Johnson, rh Alan
Jones, Mr Kevan
Jowell, rh Tessa
Khan, rh Sadiq
Laing, Mrs Eleanor
Lammy, rh Mr David
Lansley, rh Mr Andrew
Lee, Dr Phillip
Leech, Mr John
Lewis, Mr Ivan
Lewis, Dr Julian
Liddell-Grainger, Mr Ian
Llwyd, rh Mr Elfyn
Love, Mr Andrew
McCann, Mr Michael
McFadden, rh Mr Pat
McGuire, rh Mrs Anne
McIntosh, Miss Anne
McKenzie, Mr Iain
Meacher, rh Mr Michael
Meale, Sir Alan
Michael, rh Alun
Miliband, rh David
Miliband, rh Edward
Moon, Mrs Madeleine
Moore, rh Michael
Morris, Anne Marie
Morris, Grahame M.
Mudie, Mr George
Murphy, rh Mr Jim
O'Brien, Mr Stephen
Offord, Mr Matthew
Osborne, rh Mr George
Pickles, rh Mr Eric
Poulter, Dr Daniel
Randall, rh Mr John
Raynsford, rh Mr Nick
Reed, Mr Jamie
Reid, Mr Alan
Riordan, Mrs Linda
Robinson, Mr Geoffrey
Ruddock, rh Joan
Sanders, Mr Adrian
Sheerman, Mr Barry
Simpson, Mr Keith
Slaughter, Mr Andy
Smith, rh Mr Andrew
Smith, Miss Chloe
Soames, rh Nicholas
Spellar, rh Mr John
Spencer, Mr Mark
Stanley, rh Sir John
Straw, rh Mr Jack
Stuart, Ms Gisela
Swire, rh Mr Hugo
Syms, Mr Robert
Tapsell, rh Sir Peter
Thomas, Mr Gareth
Timms, rh Stephen
Umunna, Mr Chuka
Vara, Mr Shailesh
Villiers, rh Mrs Theresa
Walter, Mr Robert
Watson, Mr Tom
Watts, Mr Dave
Whitehead, Dr Alan
Wicks, rh Malcolm
Willetts, rh Mr David
Williams, Mr Mark
Winnick, Mr David
Winterton, rh Ms Rosie
Wollaston, Dr Sarah
Wright, Mr Iain
Young, rh Sir George
Tellers for the Noes:
Diana Johnson and
Question accordingly negatived
7 Sep 2011 : Column 389
7 Sep 2011 : Column 390
7 Sep 2011 : Column 391
7 Sep 2011 : Column 392
(5) Section 115 of the Health and Social Care (Community Health and Standards) Act 2003 (health care and social services complaints regulations: supplementary) applies in relation to regulations under this section as it applies in relation to regulations under subsection (1) of section 113 of that Act.
‘(1) Regulations may impose requirements on the National Health Service Commissioning Board and clinical commissioning groups for the purpose of ensuring that they are open and transparent in their decisions in commissioning health services for the purpose of the NHS.
7 Sep 2011 : Column 393
(2) The Board must ensure that the total national limit on clinical commissioning groups expenditure on administrative costs in any year from April 2014 does not exceed 55 per cent. of the total spent on administrative costs by primary care trusts in the financial year 2009-10.”’.
For the purposes of improving the quality of patient care, the Secretary of State has a duty to maintain a comprehensive, multi-professional education and training system for health professionals and to ensure the continued professional development of all staff delivering NHS services.”’.
‘For the purposes of improving the quality of patient care, all providers of services for the purposes of the health service have a duty to contribute towards the maintenance of a comprehensive, multi-professional education and training system for health professionals and to ensure the continued professional development of all their staff delivering health services.’.
(2) Regulations may provide that for the purposes of this section a clinical commissioning group also has responsibility (whether generally or in relation to a prescribed service or facility) for persons who—
(3) The power conferred by section 3(1B)(b) must be exercised so as to provide that, in relation to the provision of services or facilities for emergency care, a clinical commissioning group has responsibility for every person present in its area.
‘(1) The Secretary of State may direct the NHS Commissioning Board, or a clinical commissioning group, to exercise any of his functions relating to the health service which are specified in the directions.
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‘The Care Quality Commission, in exercising its functions, must have regard to the need to avoid existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research or case-load, becoming viable or unstable due to an unplanned reduction in income or caseload.’.
‘The Secretary of State must issue directions to clinical commissioning groups which will ensure that commissioning work is predominantly retained as a function by staff directly employed by the clinical commissioning group.’.
(2) The Chief Environmental Health Officer for England shall give advice to and report to the Chief Medical Officer for England on all such aspects of environmental and public health as are relevant to the public health functions referred to in section 2A of the National Health Service 2006 Act and the duties referred to in section 2B of that Act.
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Amendment 1169, in clause 3, page 2, line 38, leave out from ‘State’ to end of line 40 and insert ‘, so far as is consistent with the interests of the health service, must exercise the functions conferred by this Act so as to secure—
‘(2) The Secretary of State must publish and lay before Parliament an annual report detailing the progress which has been achieved in discharging this duty, and the means by which the Secretary of State intends to fulfil this function in the following year.’.
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In carrying out its duties in respect of the commissioning of services the Board must in the exercise of its functions have regard to the interdependency of services and the impact that the arrangements for the provision for one service may have on the financial and clinical sustainability of other services.’.
The Board must not exercise its functions, in particular in respect of section 13I (Duty as to patient choice) or 13K (Duty to promote innovation) in a way which could lead to existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research, becoming unviable or unstable due to an unplanned reduction in income or case-load.’.
‘Duty to reduce bureaucracy
132ZA Duty to reduce bureaucracy
(2) For that purpose the Board must exercise its duties under 14A and 14C to ensure that at no time there exist more clinical commissioning groups than there were primary care trusts on 1 April 2011.’.
Amendment 1218, in clause 22, page 27, line 17, at end insert ‘provided that the members of a clinical commissioning group cannot consist entirely or mainly of persons who are providers of primary medical services under section 83(2).’.
‘(c) shall be co-terminus with the social services local authority, unless it is notified by the relevant health and wellbeing board, and the local authority, that they approve an area which is not co-terminus.’.
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In carrying out its duties in respect of the commissioning of services each clinical commissioning group must in the exercise of its functions have regard to the interdependency of services and the impact that the arrangements for the provision for one service may have on the financial and clinical sustainability of other services.’.
(2) The Secretary of State must issue guidance on how conflicts of interest and personal and prejudicial interests should be dealt with by clinical commissioning groups as part of their decision making.’.
Each clinical commissioning group must not exercise its functions, in respect of section 14U (Duty as to patient choice) or 14W (Duty to promote innovation) in a way which could lead to existing NHS services, including but not restricted to, emergency care, intensive care, chronic and complex care, teaching, training and research, becoming unviable or unstable due to an unplanned reduction in income or case-load.’.
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(4) A clinical commissioning group shall exercise the powers specified in section 7(2)(f) only after consulting (to the extent that it appears to it to be practical) any person who appears to it to have an interest through its own previous research in the ideas or intellectual property in question as to whether it should exercise them and, if so, as to any financial arrangements.
(5) A clinical commissioning group shall demonstrate in its annual report under section 14Z3 how the exercise of its power conferred by subsection (1) has not interfered to a significant extent with the performance by the group of its functions.
(6) Income raised by a clinical commissioning group as a result of the exercise of powers under this section shall be specified in its annual accounts, referred to in its annual report under section 14Z13, and paid annually to the Secretary of State.’.
‘(6A) If the opinion of a Health and Wellbeing Board given to the clinical commissioning group under subsection (5) is that the Health and Wellbeing Board does not consider that the draft takes proper account of each joint health and wellbeing strategy referred to in that subsection, and if the clinical commissioning group does not so consider it, the group shall inform the Health and Wellbeing Board, whereupon it may report to the Secretary of State that it does not consider that such a plan takes proper account of any such strategy and the Secretary of State may require the clinical commissioning group to carry out such further consultation with the Health and Wellbeing Board as he considers appropriate, or may make a final decision on the plan and require the Commissioning Board or the clinical commissioning group to take such action, or desist from taking such action, as he may direct.’.
‘(3) If in the Board’s opinion, having considered any opinion submitted to it by a Health and Wellbeing Board under 14Z12(1)(a), the plan published by the clinical commissioning group does not take proper account of each joint health and wellbeing strategy published by the Health and Wellbeing Board which relates to the period (or any part of the period) to which the plan relates, the Board must instruct the clinical commissioning group to revise its plans under 14Z10(1).’.
(1) If the Health and Well-being Board is of the opinion under section 14Z12(1) that a plan published by the CCG under section 14Z9(6) or 14Z10(2) and which is submitted to it in accordance with section 14Z9(6) and 14Z10(3) or 14Z11(4) or (8), does not take proper account of any relevant joint health and wellbeing strategy it may refer the matter to the Secretary of State for a decision.
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(4) The time specified in subsection (3) must be after such time as the Secretary of State is satisfied that the workforce education and training functions of strategic health authorities are being fulfilled by another body.’.
(b) direct payments can only be made in respect of services which NICE has specified are services that can be provided by the health service, having particular regard to safety, efficacy and cost-effectiveness.’.
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11A In section 12C (Direct payments pilot schemes) omit subsection (8).’.
Paul Burstow: I rise to support the Government’s amendments and to explain the Government’s thinking on the amendments tabled by Opposition Members and other Members in the House. This large group of amendments covers a range of key clauses that enable us to deliver on a number of key tenets of the Bill: first, an NHS led by clinicians; secondly, an NHS with quality at its heart; thirdly, an NHS that is open and collaborative; and, fourthly, an NHS with clear, stronger political accountability. It is on the last point that I would like to start my remarks today.
The role of the Secretary of State has been the subject of great debate, especially in recent weeks. It is right that we should have this debate and it is a very important issue, especially given its particular complexity, but let us ensure that the debate is based on the facts. Too often, opinions have been offered and accusations made without full knowledge of what the Bill does and does not do.
Let me start by clearly setting out what the Bill does not do. First, it is absolutely not the Government’s intention in this Bill to allow the Secretary of State to wash his hands of the NHS. The Government believe in a comprehensive, tax-funded NHS that is free at the point of use, based on need and not ability to pay. Nothing in this Bill will change that. Secondly, I want to reassure hon. Members that there is no question but that the vast bulk of NHS-funded health care will continue to be delivered by NHS bodies that are bound by law and their constitutions to remain as public sector bodies and to fulfil a primary duty of providing services to the NHS. Indeed, the Bill contains a new provision—for the first time—specifically to prevent any future Secretary of State or NHS bodies from acting to promote the private sector over the public sector.
Let me turn to what the Bill does. It ensures not only that the Secretary of State will remain politically and legally accountable for a comprehensive health service but that he will retain the capacity to intervene where necessary to ensure that a service is provided.
Let me start with the accountability of the Secretary of State. Not only does the Secretary of State retain a raft of specific duties that mean he cannot wash his hands of the NHS but the Bill retains the legal requirements that services should be free of charge except where already specified. It now includes requirements, too, on securing continuous improvement in the quality of services, on promoting research and the use of evidence learned from research and, for the first time ever, on the need to have regard to the need to reduce health inequalities.
Helen Jones (Warrington North) (Lab): Will the Minister explain to the House why, rather than providing a duty to act to reduce health inequalities, the Bill requires bodies only to have regard to health inequalities? It is quite possible to have regard to them and to do nothing to reduce them.
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Paul Burstow: There is a clear duty on the boards to act, too, and I ask the hon. Lady why the Labour Government, in 13 years, chose not to do anything about that matter. There was never a legal duty of any sort in the past and we now have clear duties on all the bodies and on the Secretary of State. Of course, I shall come on to talk about the mandate, which has a role to play, too.
Andrew George (St Ives) (LD): I merely wish to seek clarity from my hon. Friend on some of the briefings that his Department has been putting out about the duty to provide, to which he has referred already. Those briefings indicate that there was somehow no provision in the National Health Service Act 1946 for a duty on the Secretary of State to provide. I wanted my hon. Friend to acknowledge that section 1(1) states
“and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act.”
“purpose to provide or secure”.
Paul Burstow: I am grateful to my hon. Friend for that intervention. If he listens carefully to what I am saying, he will hear that I am developing an argument that will go towards answering that question. Rather than trying to answer it in a very small way now, I would rather answer it in a comprehensive way through reference to what I had planned to say to the House.
As I was saying, hon. Members should ask themselves how the Secretary of State would be able to wash their hands of the NHS while simultaneously being legally required to deliver on all the duties I have just outlined. Crucially, the Secretary of State also retains the duty to promote a comprehensive health service, which dates from the Act that founded the NHS in 1946 and has been unchanged by this Bill. The Secretary of State will also have the duty to secure that services are provided for that comprehensive health service and will have failed in that duty if they are not.
The Secretary of State also has the ability—the obligation, in fact—to set goals and priorities for the NHS through the mandate. That will set out what the Secretary of State wants the NHS to deliver, which will be updated every year. It will be widely consulted on and Parliament will scrutinise it, for the first time ever giving Parliament a detailed say in what the NHS is tasked to deliver.
The Secretary of State has further powers in addition to the mandate to impose standing rules by which the NHS commissioning board and the clinical commissioning groups must operate, which will be subject to scrutiny and control by Parliament—a power Parliament does not currently have. What is changing, however, is the Secretary of State’s relationship with the NHS in terms of the role of Ministers in the commissioning and provision of services to the NHS. The Government believe that it should not be the job of Ministers to provide directly or commission NHS services, either. It should be the role of front-line professionals, who should have the freedom to focus on driving up quality of care,
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free from interference by Ministers in operational decisions—something that all parties in this House have said that they want to see.
We understand that all Government legislation has a responsibility to foresee the unforeseeable, to ask questions about the worst-case scenario and to ensure that the answers stand up to scrutiny. That is why this Bill contains a number of back-stop provisions to make it absolutely certain that any future Secretary of State will not be able to turn a blind eye to failings of service provision, so we have ensured that the Secretary of State has the power to step in if the board, or Monitor, is failing to deliver on its duties, including any duties imposed on the board through the mandate.
Owen Smith (Pontypridd) (Lab): In the event where there is not an emergency, will the Minister confirm that under the new provisions the Secretary of State will not have the power, as he has, to direct a commissioning group to do what he thinks is appropriate for the people in that area?
Paul Burstow: No, he will not have powers of direction. Of course, powers of direction are not subject to any form of parliamentary scrutiny and can be issued by a Secretary of State by fiat. In future, this House, through regulations, will be able to look at and agree—or not—standing rules that in most effects will have the ability to direct clinical commissioning groups and the NHS commissioning board on a wide range of matters. I direct the hon. Gentleman to clause 17, which sets those out at great length.
Simon Hughes: I am listening very carefully and, as my hon. Friend knows, we have had conversations and a wider debate about this issue. I understand what he is saying about the specific power of the Secretary of State both to act and to direct if things are failing, but does he accept that some of us would still like to be persuaded that the best way of enunciating the fundamental duty at the beginning of the legislation is not to say that the principal job is to secure the provision of the services of the NHS but to write in that it is to provide them? The back-stop encompassing statement, as it were, would mean that we could be sure that the duty rested with the office holder of the role of Secretary of State in England at any one time.
Paul Burstow: I am grateful to my right hon. Friend for having given me the opportunity to talk about this at some length, and I want to give him some reassurance. However, it is hardly a back-stop to have in clause 1 something that is not what the Secretary of State on a day-to-day basis actually does. It is a back-stop to say that when things fail, the Secretary of State should be able to exercise those functions to make sure that things are put right. I would like to say a bit more about that now.
I want it to be clear that we do not envisage the Secretary of State having to intervene other than in exceptional circumstances. Nevertheless, the measures are the legislative back-stops in the Bill and it is right that they are there to protect the comprehensive nature of our NHS and to provide reassurance. To answer my
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right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) directly, there are a number of ways in which the Secretary of State could secure the provision of services. In particular, he could impose requirements on the NHS commissioning board and clinical commissioning groups using both the mandate and the standing rules. He could establish, and has the powers to do so, a special health authority, and could direct it to carry out any NHS function. That power has been used in the past to establish NHS Direct—a service-providing organisation. Also, he could intervene, including by replacing the management and directing them in the event of a significant failure. Those measures are the belt and braces in the Bill to make absolutely sure that the NHS and the public are protected from all eventualities. We have ensured that the Secretary of State’s powers are sufficient to ensure that a comprehensive NHS is provided, including through the public sector, rather than simply relying on existing providers and the market.
The position is clear: we are giving the NHS more freedoms and autonomy—something that many of us in the House have for many years argued should take place—and we are increasing its accountability. We are making watertight the obligations to provide a comprehensive health service that is free to all, based on need and not ability to pay.
Paul Burstow: The power to establish NHS trusts is contained in previous legislation. The Bill provides for, in due course, the repeal of the provision to establish NHS trusts. As we indicated in our response to the NHS Future Forum, that will not take place for several years to come. Regardless of that, however, the Secretary of State will retain the power to establish special health authorities that can exercise a provider function.
Rosie Cooper (West Lancashire) (Lab): The Minister just said that the Secretary of State will have the power directly to remove the management of hospitals or provider organisations. Will that apply both to NHS and private providers? Will the Secretary of State’s reach go that far?
Paul Burstow: We discussed yesterday at some length the role of Monitor and its powers through the licensing regime, which will apply not just to NHS public sector providers but to private and voluntary sector providers. The powers there are extensive and I recommend that the hon. Lady should look at the debate we had yesterday.
Another issue that comes up is the duty of autonomy. Amendment 1197, which was tabled by my hon. Friend the Member for St Ives—not all of Cornwall—(Andrew George), seeks to remove clause 4, entitled “The Secretary of State’s duty as to promoting autonomy”. This clause was highlighted by the legal team advising 38 Degrees about the changes to the role and functions of the Secretary of State. The specific purpose of the autonomy duty is to free front-line professionals to focus on improving outcomes for patients rather than looking up to Whitehall. It does not undermine the overarching duty to promote a comprehensive health service, nor enable Ministers to abdicate responsibility for the NHS.
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It is our view that the legal opinion published by 38 Degrees overstates the effect of clause 4. The opinion suggests that the court will expect the Secretary of State to demonstrate that any steps he took that interfered with the autonomy were “really needed”, or “essential”, and that no other course of action could be followed. This is not the Government’s intention and we do not believe that that is the effect of the clause. It would be sufficient for the Secretary of State to demonstrate that he had reasonable grounds for concluding that a course of action was the most effective way to act in the interests of the health service and fulfil a duty imposed on him by, for example, clause 1 or a new section 1A in the Bill.
I understand, however, and I am aware that despite the provisions in the Bill there are still concerns about the role of the Secretary of State. It is understandable, when we are talking about the future of our most treasured national institution, that people should express their concerns and not be willing to tolerate even a sliver of doubt about the safety of the NHS in the future. We are determined to eliminate the doubt that has grown in people’s minds and we are certain that clause 1 is watertight in framing the legal responsibilities of the Secretary of State.
There seems to be some doubt in hon. Members’ minds about whether other parts of the Bill could in some way prejudice those responsibilities, in particular because of the establishment of autonomous bodies that act under their own legal powers and mandate rather than under the direction of the Secretary of State. For example, some have claimed that the Secretary of State might be able to hide behind clause 4 and take a hands-off approach even if services were in crisis, but that certainly is not our intention. We are therefore willing to listen to the concerns that have been raised and, if necessary, to offer clarification or make amendments to put beyond legal doubt the fact that the Secretary of State remains responsible and accountable for the comprehensive health service that we all want to see.
Simon Hughes: I am very grateful and I will not keep the Minister long. I have listened very carefully, as colleagues will have done, to my hon. Friend’s extremely reassuring comments. If he and the Secretary of State are committed to working on some wording that will alleviate concerns at the beginning of the Bill, I know that my colleagues and I will be very happy to work with him.
Paul Burstow: I am grateful to my right hon. Friend. I can say no more than I have said and I think I have said what is necessary to make the Government’s intentions clear. Of course, I will now give way to my hon. Friend the Member for St Ives, who has been so diligent in tabling so many amendments.
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Andrew George: I am grateful to my hon. Friend for giving way and for his appreciation of the efforts I am making. I, too, appreciate his comments on the Government’s intentions. It has not been my argument at any stage to suggest that the Government’s intentions are dishonourable. He has mentioned the possibility of tabling amendments, but may I have some reassurance that this is a genuine and serious issue—that we need to have policy, but also, clearly, the restraint of the Secretary of State at the same time?
I have heard my hon. Friend’s comments and I think he needs to look again at what I have said. I have been very clear that we are listening and that, if necessary, we will offer clarifications or further amendments, and I am very happy, as is the Secretary of State, to carry on those discussions.
There are a number of amendments regarding other duties on the Secretary of State that I believe would not improve the drafting of the Bill. Amendments 1240, 1241, 1169 and 1183 seek to revise the duties of quality and inequality. I know that the amendments are well meant, but they would make the duties undeliverable. The Secretary of State cannot improve quality and reduce inequalities in isolation, and the duties have to reflect that. Amendment 1194 is unnecessary as the Bill already recognises the need to promote research and the use of research evidence, and creates, for the first time, responsibilities for taking a whole-system approach to achieving this. Amendments 1184 to 1193, 1195, 1196 and 1198 seek to change the extent of similar duties on the board and the clinical commissioning groups. Each of the board’s and clinical groups’ duties has been drafted to ensure that the duty is suitably strong, realistic and appropriate.
Let me address the role of the Secretary of State in relation to another issue that has been misunderstood—charging. I want to be very clear that nothing in the Bill enables the board or clinical commissioning groups to charge for services provided as part of the comprehensive health service. Services will remain free at the point of need, except where legislation specifically allows for charges to be made—for example, prescription charges and charges for dentistry. The Government have also committed not to introduce any new charges.
Amendment 48, tabled by the hon. Member for Brighton, Pavilion (Caroline Lucas), who is not in her place at the moment, would prevent charges from being imposed for any service provided by the NHS. It has always been possible for Ministers to provide for charges for certain health services. There are limited provisions for charging even in the original NHS legislation introduced by Nye Bevan and the Labour Government of 1946. Under the current system, there are extensive exemptions: about 60% of the English population do not pay prescription charges, but—it is an important but—NHS charging raises over £1 billion a year of revenue that is ploughed back into services for patients,
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and it does make an important contribution to the overall affordability of the NHS. Therefore, I cannot accept the amendment.
The hon. Member for Brighton, Pavilion also tabled several amendments on direct payments. The amendments are unnecessary and too restrictive. Amendment 1247 would restrict direct payments to being spent on services approved by the National Institute for Health and Clinical Excellence. The great opportunity of personal budgets is that they allow people in areas where less medicalised services are provided to have much greater control over aspects of their care—those community-based services that are so important in maintaining the quality of life for many people with long-term conditions.
Finally, amendment 1248 would remove the power to extend direct payments nationally following the pilots, which are continuing. The Health Act 2009 provided that direct payments could be extended with the active agreement of Parliament using the affirmative procedure, and that seems a perfectly reasonable way of having a parliamentary check over the outcomes of the pilots that will be reported to the House next year. Amendment 1247 would prevent direct payments from being used for private health care or health insurance. The amendment is unnecessary. NHS funds could never be used to pay people’s private health insurance premiums.
I shall now turn to education and training. We have already committed to introduce at a later stage in the Bill’s proceedings an explicit duty for the Secretary of State to maintain a system for professional education and training. Work is ongoing and an amendment will be tabled in the House of Lords. That will be more effective and more precise than the long-term measure of simply blocking the abolition of strategic health authorities, so amendments 7 and 47 will not do.
Our vision of a modern NHS has clinical commissioning at its very heart. We want clinicians, GPs, nurses and other health care professionals to have the autonomy to commission innovative new services, and to have the true responsibility that the previous Government denied them. That involves striking the right balance between freedoms for clinical commissioning groups and their essential responsibilities to other parts of the health care service.
We made many changes in response to the recommendations of the NHS Future Forum report. We always wanted clinical commissioning groups to have a robust set of governance arrangements, to involve a wide range of other professionals and to be transparent in how they conducted their business, and we have now further strengthened those parts of the Bill so that they are very much improved.
As I said at the start of my remarks, I should like to speak briefly to a number of amendments, as I am conscious that many other hon. Members wish to speak. First, I will address some amendments that are very similar, if not identical, to those that we had the opportunity to debate at least once, and possibly twice, during the first stage of the Committee and in the re-committed Committee.
Amendment 1181, which is like amendments 45 and 46, seeks to restrict clinical commissioning groups’ powers to raise additional income. As was explained in Committee, those amendments are unnecessary. The Secretary of State has already published guidance, which can be
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easily updated, specifically on the powers to generate income, which applies to current NHS bodies, including primary care trusts.
Amendments 37 and 38 are on conflicts of interest. We have listened to the concerns that were expressed in the listening exercise and made changes, so the Bill already requires clinical commissioning groups to make provision for dealing with conflicts of interest.
Amendments 31 and 32 would prevent any property currently held by PCTs or strategic health authorities from being transferred to any provider that is not a public authority. As we said in Committee, we have no intention of giving away NHS property to private companies. That will not be the case and, given the safeguards that are in place, it cannot happen.
Several amendments have sought to probe accountability within clinical commissioning groups. I repeat what we said in Committee. A clinical commissioning group is not able to delegate its statutory responsibilities for carrying out its functions. It cannot palm them off or pass them on to others. Amendment 1245 would limit representation on CCG committees and sub-committees, preventing those clinical commissioning groups from inviting other professionals and experts to participate—something that we were told during the listening exercise was widely welcomed and wanted.
Amendment 1249 restricts the use of sub-committees—an essential part of any organisation with a wide range of functions. Similarly, amendment 1234 would prevent GPs or their employees from working on behalf of a clinical commissioning group, which would be a severe constraint on those groups’ ability to function. Amendment 1244 would prevent a clinical commissioning group from delegating its functions to anyone other than its employees. That would make it very difficult for those groups to carry out their statutory functions effectively.
New clause 20, tabled by my hon. Friend the Member for St Ives, similarly would restrict the support that clinical commissioning groups can draw on. We want to allow those groups to access the best support and advice available—to be able to work with local authorities, third sector organisations and charities, research organisations and the independent sector. I mentioned in Committee several times, and it is worth repeating, that the support organisation established by the Neurological Alliance is proving of invaluable assistance to commissioners, and amendments such as new clause 20 would prevent it from doing the work it does for the clinical commissioning groups. I can follow the intention behind the amendments, but I hope my reassurances about the final responsibility—the statutory responsibility—for decision making in clinical commissioning groups resting with their members and the governing body are clear.
There is a raft of amendments dealing with the relationship between local authorities and commissioning groups. We want that to be a dynamic relationship, with constant dialogue and collaboration, which is precisely why the Bill proposes the establishment of health and wellbeing boards. Amendments 1202, 1171 and 1250 would introduce a new, centrally imposed procedural requirement on health and wellbeing boards and clinical commissioning groups. Clinical commissioning groups will have a duty to have regard to the relevant joint health and well-being strategy.
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Where commissioning plans vary significantly from the joint strategy, the group will need to justify or consider amending its plans. Health and wellbeing boards also have the power to refer their views and concerns to the NHS commissioning board when they feel that the plans have not had proper regard to the joint health and well-being strategy. That indicates to the NHS commissioning board that the health and wellbeing board believes the CCG is actively failing to fulfil its duties. Anything further would undermine the important balance that needs to be struck in what is fundamentally a partnership relationship between two organisations that have separate sets of sovereignties and responsibilities.
The importance of that partnership approach highlights why it would be impossible to create an obligation on clinical commissioning groups to act alone to secure integration of services. How can one body decide to integrate with another against the wishes of the other? A duty cannot be imposed on one side unless the relationships exist that will allow that to take place. That can be achieved only by both parties working together, and for that reason amendments 1230 and 1231 do not contribute to that relationship’s working well.
Amendment 1211 seeks to make the clinical commissioning groups coterminous with local authorities. We have accepted the NHS Future Forum’s recommendation that the boundaries of local clinical commissioning groups should not normally cross those of local authorities, with any departure needing to be clearly justified as part of the establishment process set out in the Bill.
Amendment 1213 would prevent a clinical commissioning group that had received a reward under the quality premium from using that money without first securing the agreement of the local health and wellbeing boards. That would severely limit the CCG’s freedom to spend its quality payment as it saw fit. Health and wellbeing boards will shape commissioning priorities through the joint health and well-being strategy, by being consulted by the CCG on their commissioning plans. Under the duties set out in proposed new section 14Z14 of the National Health Service Act 2006, the NHS commissioning board must also consult each relevant health and wellbeing board in making its annual performance assessment of those CCGs.
Rosie Cooper: Great play keeps being made about consultation. I do not hear any play being made about the right to be heard or a right of veto, or whatever. CCGs can ask the health and wellbeing boards what they think; health and wellbeing boards might make a recommendation, but there is no obligation for anyone to listen.
Paul Burstow: The hon. Lady is completely wrong when she says that there is no obligation. There are clear duties in the Bill for health and wellbeing boards’ views, and their preparation of joint strategies on health and well-being and joint strategic needs assessments, to be legally binding documents, in the sense that CCGs must have regard to them. They are not pieces of paper that can be just tossed aside and dismissed. They are very important documents in the emerging system.
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Steve McCabe (Birmingham, Selly Oak) (Lab): A number of us are trying to understand what will trigger some kind of higher-level arbitration if it becomes abundantly clear to a significant group of people in a local community that the health and wellbeing board’s view is not being properly considered by the CCG. At that point, when there is a clear conflict, how will that conflict be exposed so that the Secretary of State or someone else clearly arbitrates so that there is fairness, not lip service? A lot of people are anxious about that.
Paul Burstow: That anxiety was expressed in Committee by some Opposition Members. As a result of the NHS Future Forum’s recommendations, we have put in place further checks to ensure that those concerns are allayed. Not least of those—as well as our view that the health and wellbeing boards should have on them a majority of elected councillors—is that they will have clear rights of membership from the local healthwatch, which will be listening to the wider community and will represent those wider concerns. They will have the views and expertise of the director of public health, the director of adult social services and the director of children’s services. If they feel that the strategy that they have all agreed is not being honoured in the commissioning strategy, they can ultimately refer that matter to the NHS commissioning board, and that can lead to changes being made.
Helen Jones: Many of us are concerned that we will not know properly what is going on in CCGs, because there is no requirement for them to be subject to the Public Bodies (Admission to Meetings) Act 1960 and to meet in public. They can decide whether to meet in public. How on earth is accountability to be maintained if those bodies can decide in private—[Hon. Members: “No, they can’t.] Yes, they can. They can decide in private how they will consider input from the health and wellbeing boards, and what they will do about it. Where is the line of public accountability?
Paul Burstow: I fear that, unfortunately, the hon. Lady might well have dusted down an old copy of the Bill, before the Future Forum made its recommendations and we made amendments to make it absolutely clear that a CCG’s governing board must meet in public. That is the decision-making body. Moreover, we also require those boards to set out in detail and publish all their decision-making arrangements—unlike PCTs, whose decisions could be made in private and no one would know.
Let me move on to health and wellbeing boards influencing commissioning decisions. Other people have questioned why we should have a quality premium at all. Indeed, amendment 1199 would remove the NHS commissioning board’s ability to reward CCGs financially for the quality of services—I emphasise that—and the outcomes that they secure, or reductions in health inequalities, which is something that all hon. Members across the House want to be promoted. That is the basis on which we want things to move forward, and high-quality services should be recognised and rewarded.
With amendments made in the second Bill Committee, we made it absolutely clear that such payments will provide an incentive to CCGs to focus on improving quality and outcomes. We will work with patients and professional groups to draft the regulations to reinforce that clear undertaking, which was made as a result of listening.
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Andrew George: I am grateful to the Minister for giving way to me, as he is referring to my amendment. I think that I understand what the Government are trying to achieve here, but in order to assess properly what quality and outcomes are, that assessment must not be pre-empted. The purpose of my amendment is to ensure that good quality and outcomes are not rewarded too early after treatment, before people can make a proper assessment and know the long-term impact of a new procedure.
Paul Burstow: My hon. Friend makes a fair point—one that, I think, we would agree with entirely. That is why the Government published, for the first time ever, an outcomes framework for the NHS that is all about considering how clinical care leads to the sort of longer-term outcomes that he seeks, so I hope that that addresses his comments. That will be built into the way in which we go forward with drafting the regulations to reinforce that approach.
On the stability of services, my hon. Friend has tabled amendments 1203 and 1204 and new clause 18, which link very closely to Opposition amendments 42 and 43 on the interdependency of services. My right hon. Friend the Secretary of State spoke to two similar amendments that my hon. Friend moved yesterday. We agree with hon. Members about the need to secure continued access to services for patients. We have introduced substantial new proposals to improve on our previous plans. However, I repeat what my right hon. Friend said yesterday: this is not about securing access to the same services in perpetuity. That has never been the case, and it should not be the case. Services evolve, and we must allow new providers—whether NHS, social enterprise or private sector—to come in where they can deliver high-quality care for patients.
I shall turn now to excessive prescription and a number of issues that arise from several amendments, which would tilt the balance in a way that would turn the system much more into a command-and-control one than many hon. Members have argued that we should have for many a year. Amendment 1218 would break a fundamental principle at the heart of our proposals: that the membership of CCGs should consist solely of GPs, and that we should encourage, rather than prescribe, how they involve other professionals.
Amendments 1237 and 1238 would remove the Secretary of State’s power to make transfer schemes for property, staff, rights and liabilities, thus making it less flexible to make transfers from, for example, a PCT to a CCG. I am well aware that many people feel that the ability to transfer staff in that way is an essential part of managing a smooth transition. Therefore, to deny the Secretary of State the ability to do that seems very odd. Amendment 1167 is unnecessary for the same reason. CCGs are different entities from PCTs, with different
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structures, duties and functions. It does not make sense to set a limit on the number of CCGs by comparison with PCTs.
Opposition amendment 5 would delete clause 10, but Opposition new clause 14 would reinstate it, so it is a sort of hokey-cokey set of proposals, whereby a provision would be taken out and then put back in again. As the Bill includes a power to make regulations to take account of people in specific circumstances, new clause 14 and amendment 1178, which is consequential on it, are unnecessary.
New clause 11 would require the NHS commissioning board to limit the administration spend of CCGs individually and collectively by comparison to 2009-10. In other words, it would set an arbitrary starting line and effectively lock the budgets that way. An absurd shackling of the NHS commissioning board or CCGs in that way belies common sense and sound financial governance.
Amendment 1206 runs the inherent risks, as discussed in Committee, of trying to prescribe the setting allocations in legislation. I understand the concern expressed by my hon. Friend the Member for St Ives (Andrew George), and the White Paper made it clear that we want to ensure that access in every part of the country is fair and equitable. We will want to ensure that that is achieved, and I am happy to continue to discuss those issues with my hon. Friends.
Amendment 1167 is unnecessary for the same reason. CCGs are different entities from PCTs, with different structures, duties and functions, and it would not make sense to set limits in such a way. The additional statutory provisions set out in new clause 10 are also unnecessary. Imposition of a minimum waiting time would not take account of the clinical needs of individual patients, and it is for clinicians to plan care on the basis of the clinical needs of patients and their right to access the best service.
We are considering how best to prevent PCTs from imposing clinically inappropriate blanket minimum waiting times, but there are already sufficient powers in the Bill to address the issue when it comes to CCGs.
Amendment 41 is also about consultation and transparency. We have already changed the Bill to enhance the duty on CCGs to involve and consult the public, but the commissioners must have sufficient flexibility to be proportionate in how they involve patients and service users. CCGs will not be able to use that flexibility to underplay their duty to involve the public.
I want to discuss a section of the Bill that I know concerns some of my hon. Friends and which perhaps was not much discussed in Committee—public health. A number of amendments are relevant here. New clause 23 would create the role of a chief environmental health officer. The chief medical officer, however, is already able to provide the very advice that the new clause would establish a new role to provide. The chief medical officer can provide independent advice on environmental health issues. At a time of financial stringency, the new clause would create a layer of wasteful bureaucracy.
Amendments 1253 to 1260 relate to the role of directors of public health. Our position is that they should be employed by the local authority to support local government in the new role that the Bill confers on local authorities in respect of public health.
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Fiona O'Donnell (East Lothian) (Lab): The Minister and the Government are fond of pausing with this Bill. I want to offer him the opportunity to pause as he comes near to the end of this long list of amendments and apologise to the many health organisations and patients organisations across the country for the anxiety and concern that he and his Ministers have caused.
Paul Burstow: I am sure that as people read the transcript of the debate they will wonder why that intervention came at this point, other than to make a cheap party point. It is one that many Members of the House will know has set the tone for much of the Labour party’s contribution to debate on the Bill.
I was about to discuss an important issue, which is how we improve the health of our nation through our public health services. Returning to amendments 1253 to 1260 and the role of director of public health, we are having discussions about how best to ensure that the director of public health has an appropriate status within the local authority. There is concern about who directors report to and are accountable to. We intend to return to that matter once the consultations are concluded to make that absolutely clear, and to address those concerns.
Mr Stephen Dorrell (Charnwood) (Con): Will my hon. Friend repeat the statements that were made in a Select Committee hearing about the status of directors of public health? Is it the Government’s view that, at the very least, they should encourage—and preferably make mandatory—the status of a director of public health as a senior officer of the local authority, not reporting through any other senior officer of the authority?
Paul Burstow: My right hon. Friend is right to remind the House of the clarifying statement that was made before his Select Committee. That is what we want to encourage. We are listening to the results of the consultation exercise at the moment. Such people should be officers who report to the council and to the chief executive. Those are the issues that we are considering, and we will return to the matter.
Amendment 1254 would require the local authority to obtain the agreement of the Secretary of State before dismissing its director of public health. Our view is that as the local authority is the employer, it is not appropriate for the Secretary of State to intervene directly. The Bill already requires local authorities to consult the Secretary of State before dismissing a director of public health, so there is a safeguard already built into the legislation.
Amendment 1256 would require the director of public health to be suitably qualified. It is important to be clear that, as the Bill sets out, the director of public health must be jointly appointed by the Secretary of State, who can ensure that only appropriately qualified individuals are appointed. The amendment is therefore unnecessary.
Amendments 1255, 1258, 1259 and 1260 would either replace references to the Secretary of State with references to Public Health England or confer new duties on Public Health England. In legal terms, Public Health England and the Secretary of State are the same thing, and Public Health England will not be provided for in primary legislation. It will be an Executive agency, which makes amendments 1255 and 1260 superfluous.
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Amendments 1258 and 1259 would effectively require the director of public health to be employed by the Secretary of State. There is, I believe, widespread support for conferring new public health functions on local government in this area. As there is widespread support for that, it follows that local government should have the appropriate expertise and resources, rather than what my right hon. Friend the Member for Charnwood (Mr Dorrell) described, and rather than having to rely on central Government or agency support.
Amendments 1242 and 1243 would extend co-operation duties for local authorities when exercising public health functions. Local authorities already have a number of co-operation duties relating to health and wellbeing, and new health and wellbeing boards will encourage integration of health and social care. The amendments would simply complicate matters unnecessarily.
Amendments 1172 and 1173 would give the Secretary of State a duty to make arrangements for facilitating haematopoietic stem cell transplantation. That is unnecessary, because of the continuing functions of the Secretary of State, which we consider very important indeed. Those are provided for under proposed new paragraph 7C of schedule 1 to the National Health Service Act 2006. The amendments are therefore unnecessary. I hope that that reassures my hon. Friend the Member for Enfield North (Nick de Bois), who tabled them.
We are also making a range of technical amendments to these clauses, with which I will not detain the House. If Members wish to have further information about those matters, I should point out that they were the subject of detailed briefings published last week to accompany the amendments.
Owen Smith: I am grateful to the Minister for his contribution. Questions about the Bill just keep coming. That is how I feel on rising to speak. We have had eight months of debate on it. So far, more than 1,500 amendments have been tabled and we have learned today that more are coming, which was news to us at least. We have two—soon to be three—versions of the Bill, as well as a very real issue between Ministers and the Opposition over how it ought to be interpreted and what tone we ought to take when debating it. I would like to address some of those questions and talk about the tone. I also want to outline how we are interpreting the Bill and state that we feel very sincerely that the Government are misrepresenting what is in it.
By way of illustration, I shall pick up on a few things that the Minister said, which I feel either raise further questions or misrepresent what is in the Bill. I want to discuss in particular the issue that was debated by him and my hon. Friend the Member for Warrington North (Helen Jones)—whether, under the aegis of the Bill, the meetings of CCGs are to be held in public. He was very clear about that. In fact, he was so clear that he had his Liberal Democrat friends bouncing up and down, shouting, “Must, must! They must meet in public. Haven’t you read the Bill?” He went on to suggest that my hon. Friend had perhaps read an earlier iteration of the Bill. I know her well enough to know that she does her homework and she will indeed have read the second version of the Bill. There have been so many that it is quite easy to lose track. She will also have read schedule 2 of that Bill, which states—I will quote directly; I will not just make it up, like the Minister—