[2nd Allocated Day]
Further consideration of Bill, as amended in the Public Bill Committee
Duties of consortia as to commissioning certain health services
I beg to move amendment 1, page 6, line 8, at end insert—
‘(c) after paragraph (f) insert a new paragraph as follows—
“(g) independent information, advice and counselling services for women requesting termination of pregnancy to the extent that the clinical commissioning group considers they will choose to use them.”.’.
With this it will be convenient to discuss the following:
Amendment 2, page 6, line 8, at end insert—
‘(2A) After subsection (1) insert a new subsection as follows—
(1A) In this section, information, advice and counselling is independent where it is provided by either—
(i) a private body that does not itself provide for the termination of pregnancies; or
(ii) a statutory body.”.’.
Amendment 1221, in clause 14, page 9, line 37, at end insert—
‘( ) After paragraph 8 insert—
“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.
(2) In this paragraph, information, advice and counselling are independent where they are provided by either—
(a) a private body that does not itself refer, provide or have any financial interest in providing for the termination of pregnancies; or
(b) a statutory body.’.
Amendment 1252, page 9, line 37, at end insert—
‘( ) After paragraph 8 insert—
“Provision of advice relating to unplanned pregnancy
8A The Secretary of State must ensure that all organisations offering information or advice in relation to unplanned pregnancy choices must follow current evidence-based guidance produced by a professional medical organisation specified by the Secretary of State.”.’.
Amendment 1180, in clause 240, page 226, line 31, at end insert—
‘(1) Regulations must require NICE to make recommendations with regard to the care of women seeking an induced termination of pregnancy, including the option of receiving independent information, advice and counselling about the procedure, its potential health implications and alternatives, including adoption.
(2) The regulations must require health or social care bodies or any private body that provides for the termination of pregnancies to comply with the recommendations made by NICE under subsection (1).’.
Four weeks ago I was not sure whether I would get to the point where I could speak in the Chamber today. This has been a long and hot-under-the-collar summer. Following my announcement of my intention to table the amendment, I have been threatened with being throttled, car-bombed, burned alive and a host of other distasteful and unpleasant ways in which I would meet my end.
I shall not go into detail about any of these responses to my amendment. Needless to say, some of them involved bodily functions to a graphic degree, and some of the scatological messages were unbelievable. I will not repeat the bile that has poured into my inbox every day. I do not think there is anything that I or my staff could be threatened with, or that we could read or be told now, that would elicit any shock from us. There is nothing worse that we could hear.
Before I go into the detail of the amendment, I shall talk about a significant and substantial shift as a result of the amendment. It has always been the tradition of the House that abortion issues have been discussed and debated in the Chamber and the media have commented on what happened, usually in a reasonable way. But the amendment has changed the game for ever. All Members in all parts of the House know, particularly from the 2008 debate, that we debate with passion. I would say that the 2008 debate was one of the best debates of the previous Parliament. However, we all remain courteous and friendly with each other following the debates. The usual parliamentary knock-about and the usual games take place—I shall say more about that in relation to the amendment in a moment—but the debate usually takes place here and the media comment on what happens here as it happens.
I have no greater opponent in the House on this issue than the right hon. and learned Member for Camberwell and Peckham (Ms Harman). In 2008 she was the whipper-in and the mover behind what happened in that debate, but I have no greater respect for almost any other woman in the House than I do for her. I hugely respect what she has achieved for women and humanity, and I know that she approaches the issue honourably, as I hope I do. It is incredibly sad, therefore, that my summer has been made so difficult not by Opposition Members, who have all been incredibly quiet, but by the nastiness and the response of the left-wing media and union-funded organisations.
The past four weeks have been incredibly difficult. The campaign against the amendment has been co-ordinated by an organisation known as Abortion Rights, which is funded by Unison and a number of other small unions. It also received membership contributions, but, as I was told in a meeting with the organisation, it is largely funded by the unions and Unison is the biggest contributor. [Interruption.] I am not saying that every penny is not accountable; I am just informing the House that the campaign has been funded by the unions. I do not think that there is a problem with that.
I will tell the hon. Lady exactly who funds my campaign—nobody. Neither I nor my office has received a single penny. Here, to me, is the disadvantage of the amendment. The unions can contact Members’ constituents and ask them to e-mail individual MPs, but I cannot afford to promote the amendment in that way. The press barons, whom the unions have fed with their response to the amendment, can pour what they want into the newspapers, but I cannot. What we have seen is an absolute divide.
I absolutely will—that is why I am here—but it is important to explain the context and the background to some of misinformation that Members have received in their inboxes. This is my opportunity to correct the misinformation MPs have been fed about the amendment.
The amendment has created a divide that was not present before, including in 2008. The Guardian and The Times and the union-funded Abortion Rights have mounted a campaign against the amendment. I must say that the core Conservative vote newspapers, The Daily Telegraph, the Daily Mail and so on, have been supportive, so this chasm and the politicisation of abortion has begun as a result of the amendment and as a result of the unions and the left-wing media.
There are lots of comments being made from a sedentary position, Mr Speaker, but The Times has actually fed that divide directly and repeated much of the information it has been given. I want to answer some of the accusations made about me in response to the amendment. I do not have the press barons’ money to mount and fund a campaign. I have not received a penny. In fact, I am broke. My office has not received a penny in funding.
I have also been accused of being a religious fundamentalist. Like 73% of the country, I am a member of the Church of England and have Christian beliefs, but I am not sure when that became a crime and prevented me from having an opinion. On Saturday, The Guardian printed a flow chart showing the conservative Christians who are supposed to be mounting a sphere of influence with the amendment. I did not know who 95% of the people mentioned were or the organisation they represent. If I followed Islam or Judaism, I wonder what the response would have been to such a flow chart in The Guardian. I found the chart absolutely reprehensible and disgusting.
I absolutely will not.
I want to mention some of the other lies that have been printed about me. I have been accused of wanting to reduce the number of abortions by introducing the amendment. That is absolutely not the objective. However, if any individual in the street was asked about the amendment and told that it might bring down the number of abortions, would they say, “Well, that’s a good thing,” or would they say, “We’re proud of the fact that 200,000 abortions a year are performed in the UK”? That is the highest number in western Europe. Would the individual in the street say that that is a good thing? No, they would say that it probably would be a good idea if something could help to bring that number down. I do not want to restrict access to abortion. The amendment is not about restricting access. I do not want to return to the days of Vera Drake-style back-street abortionists. That is not what the amendment is about. I am pro-choice, although I am presented as pro-life in every newspaper. The pro-life organisations are in fact e-mailing pro-life MPs to tell them not to vote for the amendment. I am pro-choice. Abortion is here to stay.
It is absolutely ridiculous that the amendment has been portrayed as something that would restrict access to abortion. The amendment is about medical practitioners making to a woman who presents at their surgery or organisation an offer of independent counselling, not compulsory counselling. Every single day I have read a headline stating that the amendment is intended to drive women into the arms of religious fundamentalists via compulsory counselling. That is absolutely not true. Any Member who rose and claimed that the amendment would make counselling compulsory would be being untruthful. It is nothing more than an offer. It is an offer made to some women who, when presenting at a GP’s practice, may have doubts, may be confused and may feel that they would like to accept. That is all it is—an offer. I find it very difficult to understand how anyone can object to a vulnerable woman being made an offer of counselling when she is suffering from a crisis pregnancy.
I thank the hon. Lady for giving way, and I commend her courage and perseverance. Does she share the concern of many in this House and outside about the businesslike and commercial decisions that are taken in relation to abortion and feel that, because one hour of counselling a week for everyone is not enough, it is wrong that a commercial industry has been made out of abortion? Does she agree that when abortion becomes a business, the feelings of people have been lost?
Well, that comment is probably the most fatuous we will hear in the debate, and probably the most disrespectful to women. I would like to know what the hon. Gentleman thinks about the report published last week in the British Journal of Psychiatry that women who have an abortion are twice as likely to suffer from mental health problems. Of course, I realise that the report he quotes from was probably written by men. I realise that the women who go through abortion and suffer as a result do not go back to the Royal College of Obstetricians and Gynaecologists to give feedback.
My hon. Friend was right to introduce her remarks to the House and highlight the unacceptable personal attacks that have been made against her, which denigrate an issue of vital importance and interest to the whole House. The House needs to rise above that in today’s debate. With regard to evidence of change, could she indicate what research she has done on how much face-to-face counselling takes place in organisations such as the British Pregnancy Advisory Service, for example?
Another piece of misinformation that has been put about is the idea that the amendment would prevent or delay the abortion process. Again, that is incredibly untrue. Counselling would be delivered within 24 to 48 hours, and the abortion process would take seven to 14 days to arrange. This amendment, this offer of counselling, is not for women who have made up their mind and—fantastic for them—want to go straight to the abortion clinic; it is for women who may be in distress. The counselling would be delivered within 24 to 48 hours, so there would be no delay whatever to the abortion process. In fact, many women who accepted the offer of counselling and proceeded to an abortion would proceed empowered, because they would have had the opportunity to talk through their situation with someone totally impartial—
I want to finish this point, and then I will give way.
The counsellor would be completely impartial, give no advice or direction and be entirely independent, so if the woman had been through the process and then continued to abortion, she would do so knowing that she had talked through her options with somebody.
I have spoken to organisations that provide counselling and have 80,000 registered counsellors throughout the UK. [Hon. Members: “Who?”] The British Association for Counselling and Psychotherapy. I asked, “If somebody required counselling, was at a GP’s practice and a telephone call was made, how long would it take to get a counsellor to a particular woman?” The answer was that counselling could be delivered in the GP’s practice, at another venue or in the woman’s home, and that it could be anything from immediate to within 48 hours.
Registered counsellors, who have e-mailed me regularly since the amendment was tabled, say that they would love to work—counselling is a growing industry—and to have the opportunity to work with women in that situation. Unfortunately, however, counselling is available on the NHS only via the abortion provider or via the hospital.
I am grateful to my courageous and honourable Friend for giving way. As 147 babies were terminated after 24 weeks in the past year—a 29% increase on the previous year—does she agree that such counselling should also include the fact that many of those terminated babies, who had minor disabilities such as cleft lips, cleft palates, half an ear or having only one ear, could have been dealt with through modern cosmetic reconstructive surgery?
I thank my hon. Friend for that comment. That is a different debate, but he highlights an important issue, and it is abhorrent that 147 babies were aborted for cleft palate, hare lip and minor cosmetic issues. I have a godson who had a club foot, and he was a wonderful young boy and is a wonderful young man. I find it quite amazing that anybody would choose to abort a baby because they had a club foot, but that is an issue for another day. The amendment does not cover it, but it is an important point.
Does my hon. Friend share my incredulity at those Opposition Members who maintain that an organisation such as BPAS—the British Pregnancy Advisory Service—can be independent in its counselling, when in its March 2011 report and financial statement it notes that
“an increase in procedures of 13 per cent against the background of falling national trends in 2010-11”
“a significant achievement”?
How can the opponents of the amendment maintain that there is no fiscal link and no conflict of interest?
That is precisely the next point in my speech; my hon. Friend must have been looking over my shoulder!
I now turn to the counselling provision available to women today. Many women do not want or need counselling. They find out that they are pregnant and know exactly what they want to do, but those are frequently the women who are supported—who have partners, family and friends who will support them through that awful situation. No woman wants to have an abortion, but many know that they have to, for various reasons, and this amendment is not about them. A mystery shopper, however, recently approached several abortion clinics posing as a young woman who was pregnant and unsure of what to do. Every time I mention BPAS there is a howl from Opposition Members, but I am going to mention it in this instance, because this is irrefutable evidence.
The individual posed at a central London clinic as a 26-year-old pregnant woman who did not know what to do, and she asked for counselling. I shall come on to the difference between counselling and consultation, but she said that she did not know what to do, because she had been given the immediate consultation, was not sure whether to go through with the pregnancy, and therefore wanted an abortion. She was told that, at that very busy clinic in central London, one hour of counselling was available at one set time per week. I believe that when she revealed her identity she was offered another hour.
In fairness to BPAS, it says that it has flexibility in the system and can offer more hours. Why did it not do so? If it has flexibility, how much is there?
I am very grateful—[Interruption.] The hon. Lady says something from a sedentary position. I wholly deprecate the fact that she has had threats made, but it is inappropriate to bring forward this amendment to this Bill, because if we are going to consider abortion we should be considering the whole issue in the round, not just appending something to this kind of Bill. As she knows, I disagree with her, but she will also know that the whole point of counselling, in any circumstance, is to allow a person to come to the right decision for themselves. That is precisely what BPAS, Marie Stopes and others provide, because any counsellor who does not do that is not worth their salt.
I would love to hear how the hon. Gentleman knows that that is what happens in Marie Stopes and BPAS. He always speaks on such issues as someone with huge experience, but I am highlighting at this moment what happens. If he thinks that one hour per week, at a set time at a busy London clinic, for the entire throughput of women having abortions, is enough counselling, so be it; that is his opinion.
I should like to make this point before I take any more interventions, because I also want to defend BPAS. I do not want it to look as if I am attacking the organisation, because it and, probably more so, Marie Stopes, do what they do—the clinical procedure of carrying out abortion—incredibly well. The service that they provide for the NHS is absolutely vital, and I do not want to see Marie Stopes or BPAS disappear or to diminish their roles. They have a job to do, and they do it well. Their job is the provision of clinical abortions, and I want that to continue.
Will my hon. Friend confirm that it is still safe for those of us who do not have concerns about the counselling that BPAS and Marie Stopes offer to support her amendment, because it does not prevent BPAS and Marie Stopes from offering counselling? I, for one, have no such concerns, yet I am prepared to vote for her amendment, because it does not prevent those organisations from offering advice. Will she confirm that?
My hon. Friend is not totally correct, because the whole purpose of the amendment is to separate out the financial situation. I shall come on to that in a moment. I disagree with my hon. Friend, and if she listens to the rest of the debate she will understand why. I do not believe that the place where an abortion was carried out is the right place for someone suffering from post-abortion distress to receive their counselling—a situation that many women suffering from post-abortion distress have told me about.
I am grateful to my hon. Friend and parliamentary neighbour. May I for a second take the debate from the general to the particular? I think that she is on to something. I mentioned a 23-year-old constituent of mine who, having been to an abortion clinic, then went to a clinic such as my hon. Friend advocates. It was then her decision: she decided to change her mind, and today has a beautiful three-month-old daughter. She is pleased that she had the opportunity for that counselling, which no one forced her to take. That is why I think my hon. Friend is on to something.
Marie Stopes International said in the briefing that it sent to all MPs that only 2% to 2.5% of women who go through the abortion counselling process opt to keep the child. Does my hon. Friend agree that that may indicate an incredibly poor success rate among counselling services?
I will give way in a minute.
There is a huge disparity between the figures that show both where a woman received her counselling and her decision. In 2008, BPAS announced that the proportion of women who came to it and decided not to proceed with an abortion was as high as 20%. Unfortunately, freedom of information requests asking for the figures and the contracts with PCTs show that that is not true: the real figure is 8%, and sometimes even lower in some PCTs. I am not sure why an abortion organisation would say that its figures for women who do not proceed to an abortion are higher than they actually are.
I want to finish this point, and then I will give way. I know that the hon. Member for Stretford and Urmston (Kate Green) wants to intervene, and I will take an intervention from the hon. Member for Luton South (Gavin Shuker) first, in a moment.
There is a huge disparity in the figures, and the freedom of information request shows an even bigger disparity. Marie Stopes had told me—I hope I get this right—that the proportion of women who go to the organisation and do not proceed to termination is about 15%, although I do not know what freedom of information requests would show about those figures. The fact is that abortion providers are saying that 20% or 15% of women do not proceed to abortion, although freedom of information requests show that the figure is 8%, as was shown in the press this week. I have no idea why there is that disparity, or why they would say that the figure is 20% when it is not.
The hon. Lady has rightly probed the relationship between counselling and abortion on behalf of those of us who feel uncomfortable about that relationship. However, does she agree that 90 minutes does not seem like a long time for us to debate the implications of what is going on? The Bill is substantively about the nature of the NHS, and not about abortion provision. In that light, I urge her to consider whether it is appropriate to divide the House on this issue.
I am not going to take any interventions for a few minutes. I would like to go back to the fact that only one hour of counselling is available in a busy London clinic. I ask Members, just for a moment, to put themselves in the shoes of a 16-year-old girl who turns up at that clinic and does not know what to do. She is pregnant and panicking. Some of her friends tell her to have an abortion and some tell her not to. She does not want to tell her parents because she is scared of doing so. Her boyfriend is saying to her, “You’ve got to have an abortion and get rid of it.” That is a mish-mash of the four or five stories a day that we hear in my office.
The girl starts vomiting in the morning and carries on all day. She feels sick and ill and cannot think straight. She is not sleeping because she is scared stiff. She has not gone to school for more than a week because she thinks that people there will be able to tell that she is pregnant. She is out of her mind with worry. She turns up at a clinic and is told, “Sorry, that one appointment’s been taken. You’ll have to go to Richmond.” The girl does not even know where Richmond is, and she has never even been to hospital without having her mum with her.
I would like hon. Members to think about what it is like for that 16-year-old girl, and what they have against a GP or somebody else offering that girl an hour’s counselling so that she can talk through the issues and reach the right conclusion for her, non-advised.
As I said, I do not want to look as if I am knocking abortion providers. As a nurse, I assisted with many terminations. I do not want to look as if I feel that there is no place for abortion provision. I am pro-choice and do not want to return to those other days.
The central point of disagreement for many people is the implication in the amendment that the abortion providers—BPAS has a presence in my constituency—are incapable of providing impartial independent counselling to those who come to them. The manager and staff at the centre in my constituency have said that they find insulting the idea that when they are giving counselling they are somehow seeking to persuade those who come to them to have an abortion, when that is not the case. In fact, when I visited BPAS recently a couple of young ladies had come to the centre intending to go through with an abortion but subsequently decided not to because of the counselling that they received.
All I can say is that we will look at the freedom of information figures that have come from the clinic in the hon. Gentleman’s constituency. If what he says is the case, that must have been the year’s allocation for that clinic, because the FOI request information that we have received does not show that.
No, I will carry on for a bit longer.
I want to talk about the difference between consultation and counselling. I doubt very much whether the constituents of the hon. Member for Streatham had counselling; I think they probably had consultation. There is a big difference. Every woman who turns up at an abortion clinic has a consultation, but that is about the medical process—the side effects and what is going to happen. Every e-mail that we receive from women on this subject involves a consultation. This is how the law stands today; my hon. Friend the Member for Broxtowe (Anna Soubry) might want to listen to this, as most of the way through she has been nodding in agreement with the adverse comments.
When a woman turns up at an abortion clinic, the clinic does not offer counselling. It does offer consultation, but the woman has to ask for counselling; it is not offered. She has to ask—or the doctor in the clinic has to see that a woman is in a particular position, or be alarmed enough by her state to offer counselling. I want to make the point very clear: counselling is not offered, but has to be asked for. [Interruption.] Someone says from a sedentary position that it is, but if it is, the centre is operating outside the guidelines, because counselling is not offered.
I am sure that many abortion providers do their level best to give advice, but that is not the point being made. Surely in any field of endeavour it is not appropriate for the provider of a service to give the so-called independent advice. That is the key point—and, frankly, the only point.
As I have said to many people, I will come on to the financial situation and the reasons for it.
To recap, the amendment proposes that abortion clinics make an offer of counselling, which they do not make because under the guidelines they have no provision to make it—the woman has to ask for it.
Last week, The British Journal of Psychiatry reported that women who abort are twice as likely to suffer from mental health problems.
I do not want to ban abortion—I want it to continue—but should we not be taking better care of our young girls and women? Should we not be offering them something better? How do women get to the position of suffering mental health problems as a result of abortion?
The hon. Lady will be aware of facts and figures that indicate that a number of people who have had abortions regret it afterwards. Does she feel that if the consultation process is done correctly and the information is shown to the person who wishes to have the abortion, they would perhaps then decide that the child they are carrying could develop into a young lady and have life? Does she feel that the consultation process is clearly where the issue has to be addressed and that the emphasis has to be on the counselling, not on the abortion?
The hon. Gentleman makes a point that is pertinent to his own beliefs. What I believe about counselling is that no advice should be given, that there should be no direction, and that it should be completely impartial. It should be an influence-free zone—a bubble—where a woman can sit and talk through the issues with somebody who is not guiding her. That is what counselling should be.
Every single day I receive e-mails from women who do not want other women to experience what they have experienced—who do not want their daughters to go through what they have gone through. I receive e-mails from staff who are working in, or have worked in, abortion clinics. I am in dialogue with some very senior members of staff of a number of organisations and abortion clinics across the UK—
No, I will not give way again.
Those members of staff are themselves not necessarily happy with the guidelines and the way in which they are forced to operate. I speak to people at abortion clinics across the UK who would like the guidelines to change because they do not necessarily feel that women receive the counselling that they should receive because it is not offered but has to be asked for.
I hope that the quality of counselling is determined by the professional bodies by which the counsellor is accredited—they determine the standard of counselling. It does not matter whether counselling is for an abortion, for cosmetic surgery, or for anything else—it has a defined manner in which it is delivered, which is that advice is not given, that influence is not asserted, and that it is totally impartial. Any counsellor who is trained as such and accredited by a professional body delivers counselling in that manner.
Let me return to the mental health issue and the e-mails that I receive on a daily basis. One of the problems—
My hon. Friend has twice quoted the Royal College of Psychiatrists and asserted that there is a much higher rate of mental illness after termination of pregnancy, but the RCP has made it clear—any Member can look online at the draft of its very comprehensive evidence review—that we have to compare like with like. In other words, we have to make a comparison with rates of mental illness after unwanted pregnancy. Looking at the rates after unwanted pregnancy, we see that there is no difference between the rate of mental illness after termination of pregnancy and live birth. Indeed, the biggest predictor of mental ill health after a termination of pregnancy is whether somebody was suffering with problems beforehand.
The hon. Lady makes the assumption that I want women to continue with unwanted pregnancies. That is not the case. I have made the point that abortion is here to stay for any woman who wants an abortion. The amendment simply proposes that any woman who feels that she wants or needs counselling can be offered it—that is all. I find it very difficult to understand why the hon. Lady would feel that anybody in a crisis pregnancy should not be offered counselling. Why should they not?
The hon. Member for Cambridge (Dr Huppert), who is currently fulfilling his role as Dr Evan Harris’s vicar on earth, expressed the view that everything is fine at the moment. Does my hon. Friend share my concern that it is routine for primary care trusts absolutely to refuse to reveal the financial relationship they have—for instance, with Marie Stopes or BPAS—on the basis of commercial confidence, and that it takes freedom of information requests to get that information? The system is clearly not working, and if we want transparency and openness, things have to change.
My hon. Friend is absolutely right. Not only that, but the accounts of BPAS and Marie Stopes, which are revealed via the Charity Commission, can sometimes be three years out of date—we do not get to see them until three years later. That is amazing when one considers that the Charity Commission is paid £60 million of taxpayers’ money each year.
This, for me, is about the women who have contacted me and asked me to propose this amendment on their behalf, and I have to dedicate some of this speech to them. Every day I receive e-mails and speak to people—
I constantly speak to people at a high level across the abortion industry, and they always tell me that no woman goes through those doors wanting to be there. All women’s stories are the same; there is a theme that runs through every single one. The individual circumstances may be different, but the stories all start in the same way and with the same questions: “Will I lose my job or won’t I lose my job?”; “Will he leave me or won’t he leave me?”; “Will my parents kick me out or won’t they kick me out?” The questions are all the same; there are no surprises. Many women say that once they are referred—
Perhaps this is not about this particular debate on the amendment, but I have to say that some of us in this House have the conviction that the emphasis seems to be on the right of the woman and that it is about time we spoke about the right of the unborn child. They have rights too.
No, I want to continue for a bit longer.
The diagnosis of pregnancy happens very quickly. One can buy a pregnancy testing kit for £1. It is possible that the reason some women suffer distress following an abortion is that they can be tested before they have even missed their first period. For some women, that is fantastic and they go straight for an abortion when they find out. For others, however, it all happens so quickly that they can be aborted by the time they are seven or eight weeks pregnant, and then afterwards, when the pressure has gone and the coercion has disappeared, they realise—
May I just finish this point? When those women would have been 10 weeks pregnant, two or three weeks after the abortion, they realise that they could have worked it out and that they could have got there somehow. That is when the problems are beginning to kick in. That is why an increasing number of women are becoming very anxious about the fact that they do not receive pre-abortion counselling. That is why I receive so many e-mails and why other organisations receive them.
I want to place it on the record that as somebody who wants a reduction in the time limit on abortions provided in this country; who wants independent counselling to be provided; who has seen many patients who have had mental health problems post-abortion, such as self-harming and depression over 10 years; and who has been present at a termination and watched an eye go past in a tube, with a cursory reference made to it by the consultant, unfortunately I am frustrated by the way in which the amendment has been tabled. The hon. Member for Rhondda (Chris Bryant) made the point that abortion as an issue should be talked about in the round. As a consequence, I cannot support the amendment, but that does not mean that I do not support the principles and the desire to make abortion as infrequent in our society as possible.
I thank my hon. Friend for his candour. However, I inform him that opportunities to debate abortion in this House do not come very often. In fact, the last time it happened was in 2008 when I had to table an amendment to another Bill, which was controversial. The same criticism was made that the amendment should not have been tabled to that Bill. The fact is that the Government do not make provision for abortion to be discussed in this House. Therefore, it either has to be attached to a Bill like this or it does not happen at all, unless one is drawn first in the ballot for private Members’ Bills.
Yes, but my point is that this is such an emotive subject—we can tell from the responses on both sides of the House that people feel passionately about this—that the debate needs to be calm and considered and the language both here and in the media must not be inflammatory or incendiary, because if it is, it polarises the debate and those of us who want to see progress towards abortion not being so prevalent in society get terribly frustrated.
I wonder whether my hon. Friend will clarify something. It is my understanding that if she chooses to press any of her amendments to the vote, it will be amendment 1221. I wonder if that might be more acceptable to my hon. Friend the Member for Bracknell (Dr Lee) than amendment 1, which he may have been speaking about.
The amendments are grouped, but when I spoke to the Table Office last night, I was told that I would speak to amendment 1 and that amendment 1 would be pressed to the vote. I hope that the Clerks will clarify that. [Interruption.] I will take advice from the Clerks, but when I spoke to the Clerk last night, I was told that it was amendment 1. [Interruption.] My hon. Friend the Member for South West Bedfordshire (Andrew Selous) is going to find out for me now.
On the offer, the amendment would provide space and time to talk and think for women who are feeling confused—that is all.
I now come to the financial arrangements between abortion clinics and counselling providers. If anybody in this House were to take out a mortgage today, the person who sold them the mortgage would have to refer them elsewhere for independent advice. If it was a husband and a wife, I believe that they would have to go to separate advisers, because they cannot both take advice about taking out the mortgage from the same person. I wonder why we feel it is appropriate that organisations that take £60 million a year of taxpayers’ money and are paid to carry out abortions give advice on the procedure.
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 were also on the provider side. Why does she think that that situation has not existed for this particular area of health care?
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.
No, I would like to continue on the financial incentives.
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.
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 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.
The interesting thing is that ComRes polling shows that 78% of the public support the amendment.
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.
Thank you, Mr Speaker.
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%.
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.
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.
How many times do I have to say no to my hon. Friend?
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.
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.
I am afraid that we are an hour into an hour-and-a-half debate, and I am anxious to allow time for other Members to speak.
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.
The amendment is the opposite of evidence-based policy making. We know that the British Medical Association advises its members:
“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.”
We know that the Royal College of Obstetricians and Gynaecologists guidance on abortion states:
“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)”.
We know that Department of Health regulations state:
“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”.
We also know that all the clinics that have been discussed in the debate are inspected and regulated.
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 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.
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.
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—[Interruption.] 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 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.
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?
I am grateful to the hon. Gentleman, who is, of course, a practising doctor who knows a great deal more about these matters than many of us in the House.
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.
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.
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.
How do the Government intend to meet the spirit of the amendments?
I need to make a little progress.
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 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 am afraid that time is against me.
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.
I will not, I am afraid. I must make progress.
The amendment would not, incidentally, require local authority commissioners of abortion services to comply with NICE recommendations.
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.
I hope that hon. Members are reassured by our proposals and by my personal involvement in the issue.
The hon. Member for Rhondda (Chris Bryant) is clearly not reassured, but perhaps he will let me finish.
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 will be brief, because I know that others wish to speak.
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.
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.
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.
First, let me quote something that was said by the right hon. Member for Bristol South (Dawn Primarolo) before she became Deputy Speaker. She said of the hon. Member for Mid Bedfordshire:
“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.]
I think that that is extremely true.
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.
The Royal College of Psychiatrists has clearly done a much better systematic review than the one the hon. Member for Mid Bedfordshire looked at. It shows:
“Where studies control for whether or not the pregnancy was planned or wanted, there is no evidence of elevated risk of mental health problems.”
As I have said, that is a much more detailed review.
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.
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.
First, I should point out that the hon. Member for Cambridge (Dr Huppert) was referring to an older study.
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.
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Other Services Etc. Provided As Part Of The Health Service
Amendment proposed: 1221, page 9, line 37, at end insert—
‘( ) After paragraph 8 insert—
“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.
(2) In this paragraph, information, advice and counselling are independent where they are provided by either—
(a) a private body that does not itself refer, provide or have any financial interest in providing for the termination of pregnancies; or
(b) a statutory body.’.—(Nadine Dorries.)
Question put, That the amendment be made.
New Clause 1
Complaints about exercise of public health functions by local authorities
‘In Part 3 of the National Health Service Act 2006 (local authorities and the NHS) after section 73B insert—
“73C Complaints about exercise of public health functions by local authorities
(1) Regulations may make provision about the handling and consideration of complaints made under the regulations about —
(a) the exercise by a local authority of any of its public health functions;
(b) the exercise by a local authority of its functions by virtue of section 6C;
(c) anything done by a local authority in pursuance of arrangements made under section 7A;
(d) the exercise by a local authority of any of its other functions—
(i) which relate to public health, and
(ii) for which its director of public health has responsibility;
(e) the provision of services by another person in pursuance of arrangements made by a local authority in the exercise of any function mentioned in paragraphs (a) to (d).
(2) The regulations may provide for a complaint to be considered by one or more of the following—
(a) the local authority in respect of whose functions the complaint is made;
(b) an independent panel established under the regulations;
(c) any other person or body.
(3) The regulations may provide for a complaint or any matter raised by a complaint—
(a) to be referred to a Local Commissioner under Part 3 of the Local Government Act 1974 for the Commissioner to consider whether to investigate the complaint or matter under that Part;
(b) to be referred to any other person or body for that person or body to consider whether to take any action otherwise than under the regulations.
(4) Where the regulations make provision under subsection (3)(a) they may also provide for the complaint to be treated as satisfying sections 26A and 26B of the Act of 1974.
(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.
(6) In this section, “local authority” has the same meaning as in section 2B.”’.—(Paul Burstow.)
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.
With this it will be convenient to discuss the following:
New clause 10—Requirements as to transparency—
‘(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.
(2) Regulations under this section may in particular impose requirements relating to—
(a) the imposition of minimum waiting times for patients,
(b) the imposition of clinical thresholds that a patient must reach before being eligible for treatment.
(3) The regulations may provide for the requirements imposed, or such of them as are prescribed, not to apply in relation to arrangements of a prescribed description.’.
New clause 11—Financial duties on clinical commissioning groups: administrative costs—
‘After section 223K of the National Health Service Act 2006 insert—
“223L Financial duties on clinical commissioning groups: administrative costs
(1) The Board must direct clinical commissioning groups to ensure that their expenditure on administrative costs does not exceed a prescribed percentage of their resource.
(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.”’.
New clause 12—Secretary of State’s duty as to education and training—
‘After section 1F of the National Health Service Act 2006 insert—
“1G Secretary of State’s duty as to education and training
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.”’.
New clause 13—Providers’ duty as to education and training—
‘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.’.
New clause 14—Duties of clinical commissioning groups as to persons for whom they are responsible—
‘After section 3B of the National Health Service Act 2006 insert—
“3C Duties of clinical commissioning groups as to persons for whom they are responsible
(1) A clinical commissioning group has responsibility for persons who usually reside in the clinical commissioning group’s area.
(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—
(a) were provided with primary medical services by a person who is or was a member of the clinical commissioning group,
(b) have a prescribed connection with the clinical commissioning group’s area, or
(c) are provided with primary medical services by a member of the clinical commissioning group.
(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.
(4) Regulations may provide that section 3(1A) does not apply—
(a) in relation to persons of a prescribed description (which may include a description framed by reference to the primary medical services with which the persons are provided);
(b) in prescribed circumstances.
(5) The duty in subsection (1) does not apply in relation to a service or facility if the Board has a duty to arrange for its provision.”.’.
New clause 16—Distribution of health service functions—
‘(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.
(2) The functions which may be specified in directions include functions under enactments relating to mental health and care homes.’.
New clause 17—Secretary of State’s directions to health service bodies—
‘(1) The Secretary of State may give directions to any of the bodies mentioned in subsection (2) about its exercise of any functions.
(2) The bodies are—
(a) the NHS Commissioning Board; and
(b) clinical commissioning groups.
(3) Nothing in provisions made by or under this or any other Act affects the generality of subsection (1).’.
New clause 18—Care Quality Commission: duty as regards stability of existing NHS services—
‘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.’.
New clause 20—Clinical commissioning group commissioning work: public function—
‘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.’.
New clause 23—Chief environmental health officer for England—
‘(1) The Secretary of State shall appoint a Chief Environmental Health Officer for England.
(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.
(3) The Secretary of State shall report to Parliament annually on the work of the Chief Environmental Health Officer for England.’.
Amendment 1222, in clause 1, page 2, line 2, leave out ‘promote’ and insert ‘provide or secure a’.
Amendment 1223, page 2, line 3, leave out from ‘must’ to ‘improvement’ in line 4 and insert ‘provide or secure a comprehensive Health Service designed to promote’.
Amendment 1239, page 2, line 4, after ‘improvement’, insert ‘and to ensure improvement’.
Amendment 1176, page 2, line 7, leave out subsection (2) and insert—
‘(2) The Secretary of State must for that purpose provide or secure the provision of services in accordance with this Act.’.
Amendment 1224, page 2, line 8, leave out ‘secure that services are provided’ and insert ‘provide or secure, either directly or indirectly, services’.
Amendment 48, page 2, Leave out lines 10 to 12 and insert—
‘(3) The services so provided must be free of charge.’.
Amendment 1174, page 2, line 10, after ‘services’, insert ‘so’.
Amendment 1175, page 2, line 10, leave out ‘as part of the health service in England’.
Amendment 1177, page 2, line 12, at end insert—
‘(4) For the purposes of this Act “the health service in England” is defined as those services provided under section 3 of this Act.’.
Amendment 1240, in clause 2, page 2, line 17, leave out ‘with a view to securing’ and insert ‘so as to ensure’.
Amendment 1241, page 2, line 23, leave out ‘with a view to securing’ and insert ‘so as to ensure’.
Amendment 1212, page 2, line 33, at end insert—
‘(5) In discharging the duty under subsection (1) the Secretary of State retains the power to create a new NHS trust or provider organisation.’.
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—
(a) that inequalities between the people of England with respect to the benefits that they can obtain from the Health service are reduced, and
(b) a continuous reduction of inequalities between the people of England with respect to the outcomes achieved for them.
‘(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.’.
Amendment 1183, page 2, line 38, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to reducing’.
Amendment 1197, page 3, line 1, leave out Clause 4.
Amendment 1194, in clause 5, page 3, line 16, leave out ‘have regard to the need to’.
Amendment 1242, in clause 9, page 5, line 32, at end insert—
‘(h) promoting co-operation between each of the authority’s relevant partners.’.
Amendment 1243, page 5, line 35, at end insert—
‘(4A) For the purposes of this section each of the following is a relevant partner of a local authority—
(a) where the authority is a county council for an area for which there is also a district council, the district council;
(b) the police authority and the chief officer of police for a police area any part of which falls within the area of the local authority;
(c) a local probation board for an area any part of which falls within the area of the local authority;
(d) a youth offending team for an area any part of which falls within the area of the local authority;
(e) a clinical commissioning group for an area any part of which falls within the area of the local authority.
(4B) The relevant partners of a local authority must co-operate with the local authority in the making of arrangements under this section.’.
Amendment 5, page 5, line 43, leave out Clause 10.
Amendment 1178, in clause 11, page 7, line 15, leave out from ‘Subsections’ to ‘apply’ and insert ‘(1), (3) and (4) of section 3C’.
Government amendment 49.
Amendment 1172, in clause 14, page 9, line 35, after ‘blood’, insert ‘, haematopoietic stem cells’.
Amendment 1173, page 9, line 37, after ‘tissue’, insert ‘, haematopoietic stem cell’.
Government amendments 50, 51 and 54.
Amendment 42, in clause 20, page 16, line 34, at end insert—
13DA Duty of the Board as to commissioning of services
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.’.
Amendment 1198, page 17, leave out lines 12 to 19.
Amendment 1184, page 17, line 21, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to’.
Amendment 1185, page 17, line 23, leave out ‘reduce’ and insert ‘reducing’.
Amendment 1186, page 17, line 25, leave out ‘reduce’ and insert ‘reducing’.
Amendment 1187, page 17, line 36, leave out ‘act with a view to enabling’ and insert ‘have regard to the need to enable’.
Amendment 1188, page 18, line 4, after ‘functions’, insert ‘have regard to the need to’.
Amendment 1195, page 18, line 17, leave out ‘have regard to the need to’.
Government amendment 60.
Amendment 1203, page 19, line 28, at end insert—
13OA Duty as regards stability of existing NHS 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.’.
Amendment 46, page 22, line 12, at end insert—
‘(1A) The Secretary of State must publish guidance to the Board, to which the Board must have regard, about the exercise of its powers under subsection (1).’.
Amendment 1167, page 24, line 16, at end insert—
‘Duty to reduce bureaucracy
132ZA Duty to reduce bureaucracy
‘(1) The Board must exercise its powers so as to reduce administrative costs in the NHS.
(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.’.
Government amendments 67 and 68.
Amendment 1206, page 26, line 41, at end insert—
223E1 Financial duties of the Board: needs-based allotments
(1) The Board must make allotments to clinical commissioning groups based solely on the need of the population served by each commissioning group.
(2) The Secretary of State may give directions as to how the needs set within subsection (1) are determined.’.
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).’.
Amendment 1211, page 27, line 22, at end insert—
‘(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.’.
Government amendments 70 and 71.
Amendment 43, in clause 23, page 34, line 20, at end insert—
14PA Duty of clinical commissioning groups as to commissioning of services
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.’.
Amendment 1189, page 35, line 2, leave out ‘have regard to the need to reduce’ and insert ‘act with a view to’.
Amendment 1190, page 35, line 3, leave out ‘reduce’ and insert ‘reducing’.
Amendment 1191, page 35, line 5, leave out ‘reduce’ and insert ‘reducing’.
Amendment 1192, page 35, line 22, leave out ‘act with a view to enabling’ and insert ‘have regard to the need to enable’.
Amendment 1193, page 35, line 36, after ‘functions’, insert ‘have regard to the need to’.
Amendment 1196, in clause 20, page 36, line 3, leave out ‘have regard to the need to’.
Amendment 1230, in clause 23, page 36, line 7, leave out from ‘consortium’ to ‘that’ in line 8 and insert ‘has a duty to secure’.
Amendment 1231, page 36, line 16, leave out from ‘consortium’ to ‘that’ in line 17 and insert ‘has a duty to secure’.
Amendment 37, page 36, line 36, at end insert—
14YA Duty as to conflicts of interest
(1) Each clinical commissioning group must exercise its functions so as to ensure that any conflicts of interest, and personal and prejudicial interests are dealt with.
(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.’.
Amendment 1204, page 36, line 36, at end insert—
14YA Duty as regards stability of existing NHS services
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.’.
Amendment 41, page 36, line 43, leave out from second ‘are’ to end of line 44 and insert ‘fully consulted—’.
Amendment 45, page 38, line 22, at end insert—
‘(1A) The Secretary of State must publish guidance to commissioning consortia about its exercise of powers under subsection (1), to which each commissioning consortia must have regard.’.
Amendment 1181, page 38, line 26, at end insert—
‘(3) For the avoidance of doubt it is hereby declared that nothing in this section authorises a clinical commissioning group—
(a) to disregard any enactment or rule of law, including but not limited to section 1(3), or to override any person’s contractual or proprietary rights; or
(b) to charge for anything the group does in the exercise of its powers under this section which relates to any accommodation, service or facility of a type to which section 3(1) applies; or
(c) to charge for anything in relation to the exercise of its functions under section 3 or 3A.
(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.’.
Amendment 1250, page 41, line 38, at end insert—
‘(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.’.
Amendment 1171, page 42, line 23, at end insert—
‘(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).’.
Amendment 1202, page 42, line 23, at end insert—
14Z12A Power of Referral of Commissioning plans to the Secretary of State
(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.
(2) Regulations under this section may provide for the mechanism by which such referrals are made.’.
Amendment 38, page 43, line 9, at end insert—
‘(ab) section 14YA’.
Amendment 1199, in clause 24, page 49, line 35, leave out from beginning to end of line 37 on page 50.
Amendment 1213, page 50, line 27, at end insert ‘and must consult with local Health and Wellbeing Boards prior to any decision on this matter with a view to securing their agreement.’.
Amendment 1255, in clause 27, page 53, line 5, leave out ‘the Secretary of State’ and insert ‘Public Health England’.
Amendment 1256, page 53, line 6, leave out ‘an’ and insert ‘a suitably qualified’.
Amendment 1257, page 53, line 20, after ‘authority’, insert ‘, reporting to the Chief Executive of that authority,’.
Amendment 1253, page 53, line 21, at end insert ‘, and will be accountable to—
(a) the local authority, and
(b) the Secretary of State for Health.’.
Amendment 1258, page 53, line 21, at end insert—
‘(2A) The individual so appointed is to be employed by Public Health England, which shall have responsibility for their professional qualification and development.’.
Amendment 1259, page 53, line 30, after ‘authority’, insert ‘or Public Health England’.
Amendment 1254, page 53, line 42, leave out ‘consult’ and insert ‘obtain the agreement of’.
Amendment 1260, page 53, line 42, leave out ‘the Secretary of State’ and insert ‘Public Health England’.
Amendment 7, in clause 29, page 54, line 30, at end insert—
‘(3) This section comes into force on a date to be specified by order by the Secretary of State.
(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.’.
Amendment 1237, page 256, line 31, leave out Clause 299.
Amendment 1238, page 257, line 29, leave out Clause 300.
Amendment 47, in clause 304, page 261, line 19, at end insert—
‘(1A) Section 29 comes into force in accordance with sections 29(3) and (4).’.
Amendment 1245, in schedule 2, page 269, line 21, leave out from ‘consortium’ to end of line 24.
Amendment 1244, page 269, leave out lines 25 to 29 and insert—
‘(3) The arrangement must include provision for the functions of the clinical commissioning group to be exercised by, and only by, its employees on its behalf.’.
Amendment 1249, page 269, leave out line 29.
Amendment 1234, page 269, line 29, at end insert—
‘(4) Nothing in paragraph (3) shall authorise the inclusion of any provision for any of such functions to be exercised by—
(a) any of the clinical commissioning group’s members who hold or benefit from contracts to provide primary medical services under section 83(2); or
(b) individuals who have been employees of such members; or
(c) by a governing body, committee or sub-committee which consists entirely or mainly of such members.’.
Government amendments 292 to 299.
Amendment 1170, in schedule 4, page 278, leave out lines 35 and 36 and insert—
‘(a) omit “Strategic Health Authorities” and insert after “(a)”— “the National Health Service Commissioning Board”, and
(b) omit “Primary Care Trusts” and insert after “(b)” — “Clinical Commissioning Groups”.’.
Amendment 1247, page 281, line 10, at end insert—
‘(2A) Regulations made under this section must specify that—
(a) direct payments can not be made in respect of the whole or part of a course of private health care or in respect of insurance premiums which have the purpose of providing healthcare, and
(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.’.
Amendment 1248, page 281, line 23, at end insert—
11A In section 12C (Direct payments pilot schemes) omit subsection (8).’.
Amendment 31, in schedule 23, page 417, leave out lines 18 to 21.
Amendment 32, page 418, line 34, leave out lines 5 to 8.
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.
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.
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.
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.”
Equally, the National Health Service Act 1977 contains the same reference to the
“purpose to provide or secure”.
The requirement to provide or secure is repeated throughout all the Health Acts.
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, 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.
Finally, in the event of a significant emergency such as a pandemic, the Secretary of State will have powers to direct any commissioner or provider of NHS services.
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?
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.
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.
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 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.
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.
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?
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.
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.
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.
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.
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 am grateful for your protection, Mr Deputy Speaker. I will take that as advice in relation to further interventions.
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, 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 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.
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.
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.
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.
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.
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.
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?
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.
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.
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 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.
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.
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.
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?
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.