Skip to main content

Health and Social Care Bill

Volume 736: debated on Tuesday 13 March 2012

Report (7th Day) (Continued)

Schedule 19 : The Health and Social Care Information Centre

Amendment 258A

Moved by

258A: Schedule 19, page 424, line 17, leave out “the exercise of its functions” and insert “any function exercisable by it to be exercised”

My Lords, I shall speak also to the other 41 amendments in this group, some of which, I stress, are minor, technical or consequential.

Part 9 establishes the information centre in primary legislation, setting out its powers in relation to the collection, analysis, publication or dissemination of information. Several noble Lords, as well as the British Medical Association and the NHS Future Forum, have expressed a keen interest in the need to ensure an appropriate balance between the protection of patient information and the use and sharing of information to improve patient care. For example, I recall that the noble Baroness, Lady Wheeler, stressed the need to provide,

“safeguards that are strong enough to protect patients”.—[Official Report, 21/12/11; col. 1802.]

She is, of course, absolutely right. We are sensitive to these concerns.

Your Lordships have already approved amendments that raise the threshold required for the board and CCGs to disclose personal information. Government Amendments 268, 280 to 282, 284, 285 and 287 to 289, which are supported by the BMA, further strengthen the protections in the Bill in relation to confidential personal information. Government Amendment 268 would in effect restrict the bodies that are able to request the centre to collect confidential personal information to the principal bodies—that is Monitor, NICE and the CQC—or any other body prescribed in regulations. It also restricts the making of such requests to a person to whom information may be lawfully disclosed—for example, because they have obtained consent or have a power in statute to require such disclosure—or where the information may be lawfully disclosed to the centre.

Government Amendment 272 limits the circumstances in which the information centre may require provision to it of confidential personal information. Government Amendments 280, 281, 282, 284, 285, 287 and 288 clarify when dissemination by the information centre of information which identifies or enables the identity of an individual to be ascertained would be permitted, and when the information centre may be directed to disseminate or not to disseminate information. Government Amendment 289 would require the information centre to publish a code of practice for health or social care bodies or anyone providing publicly funded health or social care on how to deal with person-identifiable or other confidential information.

We believe these amendments strike the right balance between appropriately protecting an individual’s confidential personal information and ensuring that the wider benefits of safely and securely sharing information, which include improvements in the quality of services and treatments, can be realised. There are also a number of minor and technical amendments to improve the drafting of the clauses and to ensure that they can be effectively exercised in practice.

Government Amendments 291A to 291D and 297A to 297D are intended to provide a further degree of future-proofing to ensure that the exact requirements for the future development and delivery of informatics systems to support the health and care sector can be met. Last week, my right honourable friend the Secretary of State for Health highlighted our approach for delivering informatics systems in the future. We intend that the board and the Secretary of State will be supported in the management of informatics systems and services by a lean delivery organisation that will take over from NHS Connecting for Health from April 2013. We are currently looking at where these delivery functions will sit, with the information centre as an option to house some or all of this work. These amendments would enable provision to be made so that the centre could exercise the functions of the Secretary of State or the board in relation to delivering these systems. The amendments will also help to future-proof the legislation so that the provisions can support a more flexible, agile approach to delivering informatics systems in the future. I beg to move.

My Lords, I welcome and support the government amendments in this group. In Committee, I stressed our strong support for placing the Health and Social Care Information Centre on a firmer statutory footing and replacing the current special health authority. The centre, male-midwived by my noble friend Lord Warner, as he put it, was set up by the Labour Government and has enjoyed a large measure of success, particularly in developing the bedrock quality improvement initiatives in the NHS. I stressed then that if we are able to get the patient confidentiality issues right, the UK has a huge opportunity to lead the world in health research.

The government amendments go a long way towards meeting the concerns expressed by me and other noble Lords on safeguarding patient confidentiality and the need to place a greater emphasis on obtaining consent from the patient when this information is collected or published. The information centre now has to obtain consent before it publishes information that could identify a person.

The new clause in Amendment 268, in particular, which establishes what type of information is confidential and how the information centre must deal with information, is a major step forward, as is the new clause outlined in Amendment 289 requiring the information centre to develop a code of conduct on confidential information.

The noble Earl quoted me from Committee stressing the need for safeguards that are strong enough to protect patients. As that is the first time that I have ever been quoted by the Government, I think I can legitimately claim credit for the subsequent amendments. The extra safeguards to protect patients—for example, detailing when the Secretary of State can request information and who can request the information centre to collect information, and ensuring that consent must be obtained where the information is deemed confidential—are all vital to ensure public and patient confidence that information will be properly acquired, stored, used and published.

We also strongly support Amendment 268, limiting the range of bodies that can request that the information centre collect personal or confidential information to principal bodies, such as Monitor, CQC or NICE, which are able to make a mandatory request because they have obtained consent and have the power under statute.

On the code of conduct, I hope that the noble Earl will assure us that there will be widespread consultation on the development of a code. I should also be grateful if he could reassure the House that the code will provide further detail about the proposed mechanisms that the centre will need to obtain the consent of patients. It is obviously important that we get this issue right. What will be the process for obtaining consent where people are unable to provide it—for example, patients who are unable to make decisions for themselves under the Mental Capacity Act 2006?

Finally, the Government’s Statement in the House on 6 December on UK life sciences announced their intention to share much more patient information with the private and independent sectors in an anonymised form to aid medical research and development. I believe that there are to be discussions with the BMA and other appropriate organisations on that matter to ensure strict safeguards that will instil public confidence. We particularly want to be clear how the Government will judge to which companies they will make that information available and what criteria they will use in those circumstances. I should be grateful if the Minister could update the House on progress on that issue.

My Lords, I am very grateful to the noble Baroness for her broad welcome for this group of amendments. She is absolutely right: they improve the provisions for patient confidentiality and, at the same time, the sharing of information where that is appropriate. I also welcome her endorsement of our approach to the information centre, which, as she rightly said, was set up under the previous Government and, we believe, has proved its worth in the mean while.

She asked a number of questions. On the first one, relating to consultation, yes, we will work with a range of groups in developing the code and will publish proposals in due course. On her other questions about the mechanisms for consent and obtaining consent from patients who are unable to give it because of mental incapacity, I hope that she will allow me to write a letter to save the time of the House but also because I want to get my answers absolutely correct, and I fear that I would leave important things out if I tried to answer her now.

My Lords, before the noble Earl sits down, what about the point relating to UK life sciences and the information given to the private and independent sectors?

Amendment 258A agreed.

Clause 253: Powers to direct Information Centre to establish information systems

Amendments 259 to 261

Moved by

259: Clause 253, page 243, line 26, leave out second “and” and insert “or”

260: Clause 253, page 243, line 30, leave out from beginning to second “it” and insert “the Secretary of State considers that the information which could be obtained by complying with the direction is information which”

261: Clause 253, page 243, line 38, leave out from “if” to “it” in line 39 and insert “the Board considers that the information which could be obtained by complying with the direction is information which”

Amendments 259 to 261 agreed.

Clause 254: Powers to request Information Centre to establish information systems

Amendments 262 to 267

Moved by

262: Clause 254, page 244, line 11, leave out second “and” and insert “or”

263: Clause 254, page 244, line 13, leave out from beginning to “it” in line 14 and insert “A request may be made under subsection (1) by a person only if the person considers that the information which could be obtained by complying with the request is information which”

264: Clause 254, page 244, line 20, leave out from “Chapter” to “it” in line 23 and insert “a request under subsection (1) is a mandatory request if—

(a) it is made by a principal body, and(b) the body considers that the information which could be obtained by complying with the request is information which”

265: Clause 254, page 244, line 41, leave out “relevant” and insert “principal”

266: Clause 254, page 244, line 42, after “to” insert—

“(i) the code of practice prepared and published by the Centre under section (Code of practice on confidential information), and(ii) ”

267: Clause 254, page 244, line 44, leave out ““relevant” and insert ““principal”

Amendments 262 to 267 agreed.

Amendment 268

Moved by

268: After Clause 254, insert the following new Clause—

“Requests for collection under section 254: confidential information

(1) A request under section 254 is a confidential collection request if it is a request for the Information Centre to establish and operate a system for the collection of information which is in a form which—

(a) identifies any individual to whom the information relates who is not an individual who provides health care or adult social care, or(b) enables the identity of such an individual to be ascertained.(2) A person may make a confidential collection request under section 254 only if the request—

(a) is a mandatory request,(b) relates to information which the person making the request (“R”) may require to be disclosed to R or to the Information Centre by the person holding it, or(c) relates to information which may otherwise be lawfully disclosed to the Information Centre or to R by the person holding it.”

Amendment 268 agreed.

Clause 256: Information systems: supplementary

Amendments 269 to 271

Moved by

269: Clause 256, page 245, line 32, leave out “that” and insert “any”

270: Clause 256, page 245, line 36, leave out “collected pursuant to” and insert “obtained by complying with”

271: Clause 256, page 245, line 37, leave out “or information derived from such information,”

Amendments 269 to 271 agreed.

Clause 257: Powers to require and request provision of information

Amendments 272 to 274

Moved by

272: Clause 257, page 246, line 9, at end insert—

“(2A) But the Information Centre may not impose a requirement under subsection (1)(a) for the purpose of complying with a confidential collection request falling within section (Requests for collection under section 254: confidential information)(2)(c).

(2B) In such a case, the Information Centre may, however, request any person mentioned in subsection (2) to provide it with any information which the Centre considers it necessary or expedient for the Centre to have for the purpose of complying with the request.”

273: Clause 257, page 246, line 16, at end insert—

“( ) If the Information Centre considers it appropriate to do so, the Centre may make a payment to any person mentioned in subsection (2)(b) who has provided information to the Centre pursuant to a request made under subsection (2B) in respect of the costs to that person of doing so.”

274: Clause 257, page 246, line 18, leave out “subsection (1)” and insert “this section”

Amendments 272 to 274 agreed.

Clause 258: Publication of information

Amendments 275 to 278

Moved by

275: Clause 258, page 246, line 32, leave out “collects pursuant to” and insert “obtains by complying with”

276: Clause 258, page 247, line 9, leave out “collected pursuant to” and insert “obtained by complying with”

277: Clause 258, page 247, line 10, leave out “collects pursuant to” and insert “obtains by complying with”

278: Clause 258, page 247, line 18, leave out “collects pursuant to” and insert “obtains by complying with”

Amendments 275 to 278 agreed.

Clause 259: Other dissemination of information

Amendments 279 to 287

Moved by

279: Clause 259, page 247, line 39, leave out “collects pursuant to” and insert “obtains by complying with”

280: Clause 259, page 247, line 46, after “and” insert “—

(i) the relevant person has consented to the dissemination, or(ii) ”

281: Clause 259, page 248, line 2, at end insert—

“( ) the information is in a form which identifies any individual to whom the information relates who is not a relevant person or enables the identity of such an individual to be ascertained and the individual has consented to the dissemination;”

282: Clause 259, page 248, line 11, at end insert—

“(3A) The Information Centre may also disseminate, in such form and manner and at such times as it considers appropriate, any information which it collects pursuant to a direction under section 253 or a request under section 254 (whether or not it falls within subsection (2)) to any person to whom the information could have been lawfully disclosed by the person from whom the Centre collected the information.

(3B) The Information Centre may also disclose information which it obtains by complying with a direction under section 253 or a request under section 254 (whether or not it falls within subsection (2)) if—

(a) the information has previously been lawfully disclosed to the public,(b) the disclosure is made in accordance with any court order,(c) the disclosure is necessary or expedient for the purposes of protecting the welfare of any individual,(d) the disclosure is made to any person in circumstances where it is necessary or expedient for the person to have the information for the purpose of exercising functions of that person conferred under or by virtue of any provision of this or any other Act,(e) the disclosure is made in connection with the investigation of a criminal offence (whether or not in the United Kingdom), or(f) the disclosure is made for the purpose of criminal proceedings (whether or not in the United Kingdom).(3C) Paragraphs (a), (b) and (f) of subsection (3B) have effect notwithstanding any rule of common law which would otherwise prohibit or restrict the disclosure.”

283: Clause 259, page 248, line 12, leave out subsections (4) and (5)

284: Clause 259, page 248, line 22, after “section” insert “or section (Dissemination: directions under section 253 and requests under section 254)”

285: Clause 259, page 248, line 23, leave out from “it)” to first “any” in line 24 and insert “under or by virtue of”

286: Clause 259, page 248, line 25, leave out subsection (7)

287: Clause 259, page 248, line 28, at end insert—

“( ) For the purposes of this section and section (Dissemination: directions under section 253 and requests under section 254) the provision by the Information Centre of information which it has obtained by complying with a direction under section 253 or a request under section 254 to the person who gave the direction or made the request is to be treated as dissemination by the Centre of that information to that person.”

Amendments 279 to 287 agreed.

Amendments 288 and 289

Moved by

288: After Clause 259, insert the following new Clause—

“Other dissemination: directions under section 253 and requests under section 254

(1) A direction under section 253 may require the Information Centre to disseminate information which it obtains by complying with the direction if the information falls within subsection (2).

(2) Information falls within this subsection if—

(a) the information is required to be published under section 258;(b) the information is in a form which identifies any relevant person to whom the information relates or enables the identity of such a relevant person to be ascertained and—(i) the relevant person has consented to the dissemination, or(ii) the person giving the direction, after taking into account the public interest as well as the interests of the relevant person, considers that it is appropriate for the information to be disseminated;(c) the information is in a form which identifies any individual to whom the information relates who is not a relevant person or enables the identity of such an individual to be ascertained and the individual has consented to the dissemination;(d) the Centre is prohibited from publishing the information only by virtue of it falling within section 258(2)(c) and the person giving the direction considers it would be in the public interest for the information to be disseminated.(3) A direction under section 253 may require the Information Centre to exercise—

(a) the power conferred by section 259(3A) in relation to information which it collects pursuant to the direction, or(b) any other power it has under or by virtue of any other provision of this Act (other than section 259(1) or (3B)) or any other Act to disseminate information which it obtains by complying with the direction. (4) A request under section 254 may request the Information Centre to exercise—

(a) the power conferred by section 259(1) or (3A) in relation to information which it obtains by complying with the request, or(b) any other power it has to disseminate such information under or by virtue of any other provision of this or any other Act.(5) A direction under section 253 may require, and a request under section 254 may request, the Information Centre not to exercise the power conferred by section 259(1) or (3A) in relation to information which it obtains by complying with the direction or request.

(6) Section 254(3) does not apply in relation to anything included in a mandatory request by virtue of subsection (4) or (5).

(7) A requirement imposed on, or a request made to, the Information Centre in accordance with this section to disseminate information may include a requirement or request about the persons to whom the information is to be disseminated and the form, manner and timing of dissemination.”

289: After Clause 259, insert the following new Clause—

“Code of practice on confidential information

(1) The Information Centre must prepare and publish a code in respect of the practice to be followed in relation to the collection, analysis, publication and other dissemination of confidential information concerning, or connected with, the provision of health services or of adult social care in England.

(2) For the purposes of this section “confidential information” is—

(a) information which is in a form which identifies any individual to whom the information relates or enables the identity of such an individual to be ascertained, or(b) any other information in respect of which the person who holds it owes an obligation of confidence.(3) Before publishing the code, the Information Centre must consult—

(a) the Secretary of State,(b) the Board, and(c) such other persons as the Centre considers appropriate.(4) The Information Centre must not publish the code without the approval of—

(a) the Secretary of State, and(b) the Board, so far as the code relates to information concerning, or connected with, the provision of NHS services.(5) The Information Centre must keep the code under review and may revise it as it considers appropriate (and a reference in this section to the code includes a reference to any revised code).

(6) A health or social care body must have regard to the code in exercising functions in connection with the provision of health services or of adult social care in England.

(7) A person, other than a public body, who provides health services, or adult social care in England, pursuant to arrangements made with a public body exercising functions in connection with the provision of such services or care must, in providing those services or that care, have regard to the code.”

Amendments 288 and 289 agreed.

Clause 260: Information Register

Amendment 290

Moved by

290: Clause 260, page 248, line 31, leave out “collected” and insert “obtained”

Amendment 290 agreed.

Clause 266: Additional functions

Amendment 290A

Moved by

290A: Clause 266, page 251, line 8, leave out “it has”

Amendment 290A agreed.

Clause 268: Failure by Information Centre to discharge any of its functions

Amendment 291

Moved by

291: Clause 268, page 251, line 39, at end insert—

“( ) For the purposes of this section, a failure to discharge a function properly includes a failure to discharge it consistently with what the Secretary of State considers to be the interests of the health service in England or (as the case may be) with what otherwise appears to the Secretary of State to be the purpose for which it is conferred.”

Amendment 291 agreed.

Clause 270: Powers of Secretary of State or Board to give directions

Amendments 291A to 291D

Moved by

291A: Clause 270, page 252, line 16, at end insert—

“(d) requiring the Centre to exercise such systems delivery functions of the Secretary of State or (as the case may be) the Board as may be specified.”

291B: Clause 270, page 252, line 16, at end insert—

“( ) A function required to be exercised by a direction given by the Secretary of State or the Board by virtue of subsection (1) is subject to directions given by the Secretary of State or (as the case may be) the Board about the exercise of the function.”

291C: Clause 270, page 252, line 33, at end insert—

“( ) A power conferred on the Secretary of State under subsection (1)(d) must provide that a direction may include provision about payments by the Secretary of State to the Information Centre for things done in the exercise of the function in respect of which the direction is given.

( ) A power conferred on the Board under subsection (1)(d) must provide that a direction must permit the Information Centre to charge the Board a reasonable fee in respect of the cost of complying with the direction.

( ) A power conferred under subsection (1)(d) must provide that the giving of a direction does not prevent the Secretary of State or (as the case may be) the Board from exercising the function in respect of which the direction is given.”

291D: Clause 270, page 252, line 38, at end insert—

““systems delivery function”—

(a) in relation to the Secretary of State, means a function of the Secretary of State which is exercisable in relation to the development or operation of information or communications systems in connection with the provision of health services or of adult social care in England;(b) in relation to the Board, means a function of the Board which is exercisable in relation to the development or operation of information or communications systems in connection with the provision of NHS services.”

Amendments 291A to 291D agreed

Clause 277 : The National Patient Safety Agency

Amendment 292

Moved by

292: Clause 277, leave out Clause 277

My Lords, this returns us to a debate that we had in Committee on the future of the National Patient Safety Agency. I am a former chair of the National Patient Safety Agency, which was established following work by the former Chief Medical Officer, Liam Donaldson, looking at the experience of the airline industry, which over the years has developed a very effective system of learning from mistakes.

In the airline industry, airline pilots have the confidence to report near misses and other incidents because that is done on the basis of no recriminations. The evidence from those reports is put together to help the airline industry to become safer and it has been outstandingly successful over the years. That was the intention of the National Patient Safety Agency. It undertakes many roles but the core role is the national reporting and learning system which is aimed at carrying out the same process as in the airline industry.

I understand that, as the years go by, more and more incident reports are made by staff in the National Health Service from which patterns are learnt. The NPSA then issues various bulletins and safety warnings so that the health service learns from mistakes. With the abolition of the NPSA, what will happen to the national reporting and learning system? No doubt the noble Earl will be able to inform us of where they have got to. I understood that last year there were discussions about a transfer of operational management to Imperial College Healthcare NHS Trust. The point is that it comes under the auspices of the NHS Commissioning Board.

The issue here is whether that is sensible, given that the NHS Commissioning Board is a management body overseeing the National Health Service, where, in this system, you want to encourage staff to feel that they can report untoward incidents without any fear of repercussions. I would like to hear from the noble Earl, Lord Howe, how we will be assured of the independence of the process by which the reporting system and analysis are undertaken, and whether he considers that there might be ways in which it could be taken out of the umbrella of the NHS Commissioning Board. I, for one, would have thought that it might have a chilling effect on the willingness of NHS staff to report incidents in the future. I beg to move.

My Lords, I support my noble friend’s amendment. As a Minister, I, too, had responsibility for the NPSA and I was responsible when we introduced the reporting system. It is easy to forget how difficult it was to secure agreement across the NHS to that reporting system. There was a great deal of nervousness about it and it has certainly taken time to build up the confidence, across the country, that ensures that most service providers are now engaged with reporting these incidents. If we put that reporting system under a powerful body that is responsible for commissioning, there is a real danger about maintaining the support for the level of reporting that we have achieved. There is a risk that, without a few more safeguards in the arrangements, we may see a dropping off in the reporting of those incidents. Providers will be nervous about how commissioners will interpret the reporting of those incidents. That is the nub of the issue. I think we have a real problem about how we can carry on building on the good work done by the NPSA on that reporting system and ensuring that we continue to give confidence to the NHS to report these incidents in the service of the greater good. I am interested to hear what the Minister has to say about protecting the gains that we have made so far in this area.

My Lords, I speak in support of what has been said by the noble Lord, Lord Warner. There is real anxiety that people will be frightened to admit to and report errors, if they feel that that could threaten, in any way, the contracting of the service that they are working in. Who in the new system will be responsible for rolling out training that has come from the cataloguing and analysis of problems, and how will the lessons learnt in devolved nations be fed into the system for the UK as a whole. Indeed, how will lessons learnt in England be fed out to the devolved nations?

My Lords, I speak as somebody who has been involved with the National Patient Safety Agency for longer than the noble Lord, Lord Warner, as a Minister, or the noble Lord, Lord Hunt, as its chairman, as I chaired it for four years. What is important is that the National Patient Safety Agency, as it is currently, has been unable to be effective. It has not been effective because it is not mandatory to adopt, implement or use the learning produced from the reports it receives from all healthcare providers on systems failures that may cause harm to patients. I hope that the Minister will reassure us that whatever the new arrangements are, the learning produced from systems failures will be implemented, or will be expected to be implemented.

I do not know whether the Commissioning Board is the ideal place for it—I understand that it is taking over the group that looked after the analysis of the reports. Therefore, it will be its task to disseminate all the learning that comes from it. The actual collection of information or data will be outsourced on a contractual basis to Imperial College. Perhaps the Minister will comment on that. The important issues are that the information on systems failure is collected and that the lessons learnt are available to all those who commission and provide healthcare. They must be implemented.

My Lords, I hope it goes without saying—I think that all noble Lords would agree—that patient safety has to be the key priority for all those working in the health service. We cannot allow it to be an add-on or an afterthought. For that reason, the Bill puts safety at the heart of the NHS, not at arm’s length. Currently, the National Patient Safety Agency’s core function is to improve the safety of NHS care by promoting a culture of reporting and learning from adverse events. It does that, as the noble Lord, Lord Hunt, rightly mentioned, through its national reporting and learning system. As noble Lords are aware, it is our intention that Clause 22, or new Section 13Q, will give the NHS Commissioning Board responsibility for this function, including the collection of information about patient safety incidents, the analysis of that information and the sharing of the resulting learning with providers of NHS care—those who contract with clinical commissioning groups or directly with the board.

The noble Lord, Lord Hunt, asked whether it was sensible to do as we propose. Safety is, of course, a key domain of quality and we believe that the board, as the body legally responsible for ensuring continuous quality improvement in the NHS, will be best placed to drive a powerful safety agenda through the NHS. The board will use its leadership, expertise and oversight of the system, including oversight of the national reporting and learning system, to lead continuous quality and safety improvement. Its unique perspective would allow it to ensure that appropriate levers are used to drive safety improvement across the system, based on the needs of the NHS. Embedding safety across the system is vital to increase the pace of development, and it is the intention that the patient safety function will be conferred on the shadow body—the NHS Commissioning Board authority—in June of this year.

It is intended that the operational management of the NPSA’s national reporting and learning system will transfer on a temporary basis to Imperial College Healthcare NHS Trust on 1 April 2012. From April, Imperial College will manage the team responsible for the existing NRLS function for a temporary period of two years. During the two-year period a full tendering process will be developed by the NHS Commissioning Board that is intended to identify the future specification of requirements for a national system to capture and analyse patient safety incident data.

Within the board there will be a patient safety team of around 40 staff led by the director of patient safety and bringing together policy, insight, advice and guidance. The arm’s-length bodies review recommended the abolition of the National Patient Safety Agency. It made clear that the agency’s functions, while necessary within a system supporting wider quality and safety improvement, did not need to be performed at arm’s length. For me, one of the key arguments for making this change is that the National Patient Safety Agency did not have the authority or position to exploit fully the information gained from the national reporting and learning system. In contrast, the board will have the necessary authority and be positioned at the very heart of the system, and therefore be better placed to lead and drive improvements.

The noble Lords, Lord Hunt and Lord Warner, questioned whether the board was actually the right body. I understand the noble Lords’ concerns regarding the independence of the NRLS, but I feel as well that the board will prove to do an excellent job. In particular, it is worth remembering the board’s specific duty with regard to this in new Section 13Q.

As regards conflicts of interest, the NPSA is not being placed within the Commissioning Board as an ALB organisation; it is being abolished. We are putting safety at the heart of the NHS. The NHS Commissioning Board will assume responsibility for securing some functions of the patient safety division of the NPSA relating to reporting and learning from patient safety incidents so that we can embed patient safety into the health service through commissioning and the contracts that commissioners agree with providers. If incident reports suggest that commissioning is the problem, this would be picked up by the system.

The noble Baroness, Lady Finlay, asked me what the proposals will mean in the context of the devolved Administrations. There is provision in the Bill for the NHS Commissioning Board to make information on reporting and learning available to others as it deems appropriate. Such information may be shared with devolved Administrations, and the board will have powers to enter into agreements with them to provide services.

The noble Lord, Lord Patel, asked who would be responsible for making the information available and acted upon. The board will have responsibility for provision of all appropriate guidance and advice. It is for the board to determine how best to ensure that this information is made available, particularly in the NHS. Clinical commissioning groups must have regard to that advice and ensure, through their contracts with providers or otherwise, that appropriate steps are taken to reduce risks and secure the safety of patients. The board would have to ensure that the advice and guidance that it provides is effective. The Bill also provides the board with the ability to deliver any of these functions through those that it considers best placed to maximise safety.

Patients rightly expect that any service provided through NHS funding will be safe, and making the board responsible for the key functions on safety will place responsibility for the safety of care where it should be—at the centre of the NHS. In saying that, however, I pay tribute to the positive contribution made by the National Patient Safety Agency and to make clear that its abolition is not at all to belittle its functions. It is, rather, a consequence of ensuring that vital functions are carried out in the best place in the new system. I believe that this is at the heart of the NHS—with the board—rather than at arm’s length.

I hope that I have sufficiently reassured the noble Lord, Lord Hunt, and that he will feel able to withdraw his amendment.

My Lords, I must say I am very uneasy because I think that the arm’s-length bodies review completely missed the point. It was my understanding that the NPSA itself was not charged with improving safety. The whole point about setting it up was to have an independent body to which people in the NHS could report adverse incidents. Information would then be used in different ways, first in the issuing of safety bulletins and reports on a pattern of safety incidents, which would improve safety in the health service. It was always the expectation that responsibility for safety rested with the health service and the regulator, CQC.

It is a fundamental confusion of roles to suggest that the body that collects this information should also be responsible for performance-managing safety. The moment you mix them up, people will be inhibited from reporting safety incidents. That is our key concern on this. Putting the reporting mechanism under the auspices of the Commissioning Board, albeit to be contracted out, will have a chilling impact on people who report. I think the architecture is wrong. I suspect incidents will fall in future. It would have been best to keep the roles separate and independent. I think I will test the opinion of the House on this.

Amendment 292A

Moved by

292A: Before Clause 280, insert the following new Clause—

“Human Rights Act 1988: provision of certain personal care and health care services to be public function

(1) A person who is commissioned to provide—

(a) personal care to an individual living in their own home, or(b) a health care service,shall be taken to be exercising a function of a public nature in providing such a service.(2) In subsection (1)(a) “personal care” in relation to England has the same meaning as in paragraph 2 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and in relation to Scotland has the same meaning as “personal care and personal support” as defined in section 2(28) of the Regulation of Care (Scotland) Act 2001 and section 1(1)(c) and Schedule 1 to the Community Care and Health (Scotland) Act 2001.

(3) In subsection (1)(a) and (b) “functions of a public nature” has the same meaning as in section 6(3) of the Human Rights Act 1998 (acts of public authorities).”

My Lords, if I am a very frail, vulnerable, sick person in need of support or care, and I go into a residential home, my human rights will be protected. In this case, that means the right to dignity, respect, and privacy if I am having intimate care. If I have exactly the same needs and exactly the same services provided for me in my own home, my human rights are not protected. But I am the same person. My human rights now depend on whether I am down the road in a residential home or have the same services in my own home. That cannot be right. This amendment is designed to close the loophole in the law that allows this. It means that if a public body has arranged or contracted the service, it is a public function within the meaning of Section 6(3)(b) of the Human Rights Act, so it brings certainty that I will get my human rights protected. These are not controversial rights—it is just decent care.

We know that almost half a million older people receive essential care in their own homes, commissioned by their local authority in England, excluding the other devolved areas. Approximately 84 per cent of these people lack the protection of the Human Rights Act because their care is provided, as we now know, by private or third sector organisations. We received compelling evidence of the extent of human rights breaches in home care settings in the findings of the Equality and Human Rights Commission’s formal inquiry into the human rights of older people receiving home care. As the lead commissioner on ageing, I was part of that inquiry.

This amendment is supported by many organisations. Among them are Age UK, the British Institute for Human Rights, Disability Rights UK, the Equality and Diversity Forum, Justice, Liberty, Mencap, the Scottish Human Rights Commission and the Northern Ireland Human Rights Commission. In its report Implementation of the Right of Disabled People to Independent Living, published on 1 March 2012, the Joint Committee on Human Rights recommended that the Health and Social Care Bill should be amended in this way.

My understanding, however, is that while the Government have no argument with the view that the Human Rights Act should apply to private and third sector organisations providing publicly commissioned home care, it seems that they consider that the law provides this coverage already and that this amendment is therefore unnecessary. I share the commission’s view that private providers of services, under arrangements made with the relevant statutory bodies under the NHS Act as amended by the Bill, will not necessarily continue to be carrying out a function of a public nature. The Equality and Human Rights Commission feels that the Department of Health’s analysis of current case law is a bit overoptimistic. Were this question to be determined by a court, the outcome could not be predicted with any certainty.

I want to thank the Minister for giving a huge amount of his time and consideration to these issues. I know that he is wholeheartedly in support of the principles behind my amendment. It is plain that he has an undoubted commitment to avoiding human rights abuses in health and care settings. However, the fact remains that any relevant assurances that he might give us, while very welcome, must fall short of providing the urgent legal clarity about the scope of the Act that I believe to be very important. They would not provide service users with clear legal redress for human rights abuses or breaches, or give providers an immediate legal incentive to apply human rights standards to service delivery.

I am not suggesting that legislative provisions are the only guarantee of human rights protection, but I would argue that they are an important part of the solution. I recognise that, going forward, the Government’s policy agenda could—and, I hope, will—provide opportunities to embed more effectively a human rights approach in health and social care. Seeking change in service culture and practice of services is very important. However, while these policy opportunities are very worthy of consideration, closing this legal loophole would put down a clear legal benchmark that would positively help to build cultural change in the health and social care sector. Such policies that the Government now have, however well-intentioned, are not a substitute for clear legal obligations under the Human Rights Act. Those would give individuals the right of redress against service providers for human rights breaches.

The Government might also have reservations that making express reference to human rights in a health context could cast doubt on other areas beyond health or social care where public services are provided by private bodies. However, I do not agree that a reference solely in health and social care would cast such doubts on other policy areas. Thinking about the operation of such a reference in reverse, it would be difficult to see how a specific reference in justice or education legislation could reasonably affect social care or healthcare.

In closing, I must reiterate that I feel that the law is not certain. In my view, the current legal position is evidently unsatisfactory. There may good arguments to support the view that providers should consider themselves bound by the Act and the duty. There are also legal arguments against that position. There is no way to predict what view a court might adopt. Support for this amendment will clarify beyond doubt the fact that a person commissioned to provide home-based social care or healthcare is performing a public function with the responsibilities that are within such a function and within the meaning of the Human Rights Act and the Equality Act. I hope that the Minister will find it possible to support this amendment. I beg to move.

My Lords, I wish to support Amendment 292A, tabled by my noble friend Lady Greengross. As I am sure your Lordships will appreciate, I approach this issue from the perspective of people with a learning disability and would argue that the provisions of the Human Rights Act should be universally applied and not dependent as to whether an individual receives personal care in a residential setting or in their own home. Such a disparity is both unfair and unjustified, and it is right that we take the necessary steps to clarify matters.

For example, let me remind your Lordships of the appalling abuse highlighted by the BBC’s “Panorama” programme in May of last year. Winterbourne View, near Bristol, was a privately owned assessment and treatment centre where residents with a learning disability were subject to an horrendous culture of ongoing bullying combined with physical and psychological abuse.

I make reference to the abuse at Winterbourne View because, following an amendment in 2008 to the then Health and Social Care Bill, which is now the Act, the law was changed to ensure that care homes in the private and third sectors, when providing care that is publicly commissioned, were within the scope of the Human Rights Act. This was the correct step to take and ensures that all legislation, regulations and guidance regarding personal care which is publicly commissioned and provided for in residential settings is underpinned by the tenets of the Human Rights Act.

For those who face the ongoing consequences of prejudice and discrimination every day of their lives—such as people with a learning disability—the Human Rights Act can have benefits that go well beyond the preconceptions of those who are eager to dismiss it as a dangerous irrelevance. However, while the individuals concerned who suffered abuse in Winterbourne View or any other residential setting are able to turn to the Human Rights Act in seeking recourse for what occurred, if a similar type of abuse happened while they were receiving publicly funded personal care within the parameters of their own home, it may be assumed by victims, local authorities and others that they would not be able to do so due to the lack of clarity. This is self-evidently a completely unacceptable state of affairs and we should not be willing to tolerate such an absurd inconsistency. I would also add that if the CQC had the resources to undertake a greater number of unannounced inspections in all residential settings, it would be easier to identify abuse at an even earlier stage.

When applying the Human Rights Act the principle question must be, “To what extent has an individual’s human rights been violated?”. It should not be, “Under what type of roof did the alleged abuse take place?”. In my view, abuse is abuse is abuse, and it is as simple as that. Respecting an individual’s human rights should be universally applied and not subject to arbitrary levels of determination, such as the situation in which we currently find ourselves.

The Government claim that the loophole does not exist and so there is no need for the matter to be clarified in the way that the amendment requires. What is not in doubt is that, under the current circumstances, it is explicit under statute that when receiving publicly funded personal care services in residential settings, an individual’s human rights can be upheld via the Human Rights Act. However, when that care is received in their own homes, the situation is much more ambiguous and less certain. Therefore, I remain hopeful that the support of Ministers for this amendment will be willingly and freely given.

My Lords, I have put my name to this amendment because it seems very clear to me that we do need legislation to clarify the uncertain state of the law relating to the provision of health and social care services commissioned from the private and voluntary sectors. We know how we got to this point. Despite the intention of the then Government that responsibility under the Human Rights Act should generally follow the outsourcing of state functions, in the case of YL v Birmingham City Council the House of Lords held that a private company providing residential care under a contract with a local authority was not carrying out a public function for the purposes of the Human Rights Act. This human rights loophole was closed by Section 145 of the Health and Social Care Act 2008, but only for residential care services. The YL case did not directly deal with the question of health or home care services contracted out by the NHS or local authorities, so neither did the Health and Social Care Act 2008 in seeking to undo the YL decision. Thus there remains a lacuna in the law which needs to be addressed.

During the debates on this Bill in Committee, and in a subsequent letter to Peers, the noble Earl, Lord Howe, raised no objections to the Human Rights Act applying to home care provided by private and third sector organisations. Indeed, his letter maintained that publicly commissioned home care is already covered by the Act.

Similar considerations apply in relation to healthcare, because the current Health and Social Care Bill will mean more independent providers being commissioned to provide NHS services. In correspondence with the Joint Committee on Human Rights, the Government raised no policy objections to the Human Rights Act extending to outsourced NHS services. Indeed, here too the Government have indicated that providing outsourced NHS services already qualifies as a public function under the Human Rights Act, so there is no need for the law to be clarified.

The Equality and Human Rights Commission, after exhaustive legal analysis, has concluded that the matter is by no means so clear-cut. I have a detailed legal briefing here, but your Lordships will be relieved to hear that I do not intend to read it out.

There speaks a lawyer. Suffice it to say that everything about the matter is extremely complex and open to question, interpretation or qualification. The YL case took many by surprise. It was hardly clear-cut—the Law Lords were split three to two. They used a factor-based approach to determining whether an organisation other than a public authority is performing functions of a public nature. However, it is fair to say that each and every one of the factors employed is hedged about with qualifications.

In support of its view on outsourced NHS services, the Department of Health cites the Weaver case, where the Court of Appeal decided—once more by a majority—that a registered social landlord was performing a public function when allocating and managing social housing. However, some legal commentators thought that this was a surprising decision too, because it sits oddly with the YL case. This again emphasises the ambiguity of the case law and indicates that the outcome of future cases cannot easily be predicted. Indeed, an opinion obtained by the EHRC from senior counsel suggests that the reverse is the case. After detailed legal analysis of the statutory framework and case law, counsel concluded that each aspect of the Law Lords’ negative reasoning regarding residential care in the YL case applies equally to the provision by private care providers of home care services.

We do not have to take a view on whether the commission is right and the Government wrong. If the Government have no problem with the policy position which it is sought to reinforce, it is enough that there is a doubt. Why not put the matter beyond doubt and avoid all the uncertainties of the case law by putting this amendment in the Bill? The Government say that they would not wish to cast doubt on other areas beyond health where public services are provided by private bodies by making express provision in this area, but all this amendment is seeking to do is to finish plugging the gap opened up by the YL decision and not completely addressed by the Health and Social Care Act 2008.

At that time it was not so clear that there was a human rights problem in relation to non-residential services, but following a welter of reports from the Health Service Ombudsman, the CQC, the Patients Association and the EHRC, we now know that there is. The Equality and Human Rights Commission’s inquiry into older people and human rights in home care revealed disturbing evidence of older people being exposed to ill treatment that raised human rights concerns. There has also been shocking evidence of serious breaches of the human rights of older people receiving NHS care. The JCHR advised the Government two years ago that they should take the first legislative opportunity to clarify matters in relation to health services. Knowing what we now know, there should not be any further delay in clarifying the scope of the Human Rights Act in relation to health and social care services. The Government really have no excuse for not acting.

My Lords, I declare an interest as a member the British Institute of Human Rights advisory board, and I apologise for my failing voice. I simply want to add to the very eloquent testimony we have heard so far that surely common sense suggests that an organisation which carries out a public service function that is mandated by a public body and takes public money for that function should be bound by the responsibilities of public service. If it is not, fellow citizens whose rights are abused—and as we have heard from the noble Lord, Lord Low, and others, this is not uncommon, particularly in old-age care—will have a lesser right of redress. Furthermore, and almost more importantly for the prevention of abuse, providers of this level of care will have little incentive to train individual carers in those notions of dignity and respect that we call human rights.

We have the Government’s response on the record in a letter to the noble Lord, Lord Lester, on 27 February, that all providers of publicly funded health and social care services should consider themselves bound by the Human Rights Act. The Government think that a court would find that the provision of publicly funded personal care at home is a function of a public nature. This is not the same as being legally binding and, perhaps more importantly, the references to “personal care only”—that is to say the all-important Article 8 right to private and family life—are not in the picture at all. So I hope that the Government will accept this amendment.

My Lords, in my view, the Human Rights Act applies already to the matters raised in this amendment. The reason for that is fairly straightforward. As your Lordships know, when the Human Rights Act was passed, many functions previously exercised by public authorities were by that time exercised by private individuals and companies. Therefore, the Human Rights Act contained the provision that public authorities should include those in respect of whom certain of their functions are functions of a public nature. That was deliberately adopted to deal with the situation where the public service was in fact given by a private individual or a private company that was not itself a public authority. For the purpose of enforcing the Human Rights Act, bodies that had as any of their functions a public function were responsible in respect of it as if they were a public body.

The case of YL has been referred to. That was not a health case but a case under the National Assistance Act where the local authority had put the lady into a private home. A majority of the House of Lords held that that was not a public function in respect of the private home. It was of course a public function in respect of the local authority, Birmingham City Council, but not in respect of the private home. The Government of the day decided to reverse that decision, not because they thought that the principles of the Human Rights Act should be altered but because they believed that the outcome in that case was wrong. That is what has happened in relation to that type of case, leaving untouched the general principles settled in the Human Rights Act itself.

At the time, the then Government decided to have a consultation on whether the Human Rights Act needed to be amended in some way to deal with these situations. The result of that consultation, so far as I understand, was that nothing needed to be done. The Government put forward an amendment in respect of the YL decision, whose introduction in this House was, I think, in the hands of the noble Baroness, Lady Thornton. In accordance with what the Government thought about the matter she said:

“Therefore, it remains the Government’s view that, in general, the provision of publicly arranged health and social care should be considered a function of a public nature. The Government will therefore continue to treat those exercising such functions as being subject to the Human Rights Act”—

and ever since that has been the position. She went on:

“I reiterate one important point from the letters. It remains the Government’s firm view that independent providers of NHS care under the National Health Service Act are, as the law currently stands, exercising a function of a public nature”.—[Official Report, 22/05/08; col. GC 632.]

That is to say that independent providers operating under the health service were carrying out a function of a public nature, and therefore the protection of the Human Rights Act applied.

In YL, Lord Bingham of Cornhill, who was one of the minority, expressed the matter in this way: he thought the answer to the question in that case was clear. Unfortunately, not everybody sitting in the case thought the same, but that was his answer. He said:

“When the 1998 Act was passed, it was very well known that a number of functions formerly carried out by public authorities were now carried out by private bodies. Section 6(3)(b) of the 1998 Act was clearly drafted with this well-known fact in mind. The performance by private body A by arrangement with public body B, and perhaps at the expense of B, of what would undoubtedly be a public function if carried out by B is, in my opinion, precisely the case”,

which here is covered,

“by Section 6(3)(b)”.

In his opinion, that was the case in YL. Parliament has gone along with that in the amendment and has said that the minority in the YL case were correct. In particular, it has been affirmed that this applies to the Public Health Act.

Some of the situations that have been mentioned by those who support the amendment have occurred in private residential homes. That does not mean that the Act does not apply; it means that for some reason the Act was not observed in these homes. Sadly, that can happen anywhere in relation to the Human Rights Act. It does not mean that it does not apply; it just means that it has not been carried out.

This amendment is supposed to clarify the law. Your Lordships will notice that its heading states that it applies to certain parts of the health service: it is not in any way a universal provision. The heading states:

“Human Rights Act 1998: provision of certain personal care and health care services to be public function”.

It refers to certain services, not all. I submit that that applies to all in the light of the statute as I have explained it.

As I say, the amendment seeks to clarify the law and close a loophole. Unfortunately, when you start to investigate particular cases of this kind, you are apt to get into areas of risk. What happens if a lady who is getting personal care is staying with her daughter and is not in her own private home? This amendment would not apply to that situation. This is a very difficult area. Those who originally framed the Human Rights Act bore that in mind, and the Act was very carefully framed by the Labour Government of that day. My noble and learned friend Lord Irvine of Lairg was extremely careful in selecting the language that was used. As I said, in 2008, when the amendment was made in respect of the National Assistance Act, the position in relation to the health service was very clearly restated. I submit that this amendment is unnecessary, undesirable and risks not covering the whole of the National Health Service provision, as, indeed, it does not attempt to do.

My Lords, it is a privilege to act as junior counsel to a leader as distinguished as the noble and learned Lord, Lord Mackay of Clashfern. His speech makes it unnecessary for me to speak for long. I respectfully agree with everything that he has said but wish to add a few further points. I am very sorry to disappoint so many of my friends from civil society and their representatives whose eloquent speeches we have heard today. However, I do not think that there is a loophole and, if there were, I do not think that this amendment would remove uncertainty; it would, in fact, increase it.

I am particularly glad to say this in the presence of the noble Lord, Lord Wills. He will remember that he was Minister when I was trying, as a GOAT in the Brown Government—noble Lords will know what that means—to persuade his colleagues that we should do something about the YL problem by way of further legislation. Unfortunately, the previous Government were unable to muster support for that and the present coalition Government have given that general problem to the Commission on a Bill of Rights, on which I serve, as one of the issues to consider in the context of whether there should be a Bill of Rights for the United Kingdom. Therefore, the general problem is on the agenda of that commission. When it reports by the end of this year, the Government can then take stock of what to do about it.

As the noble Lord, Lord Low, indicated in his completely accurate account of some of the background, the origin of the problem lies in the majority decision of the Law Lords in the YL case. I believe that the majority in that case asked themselves the wrong question. Instead of asking how to apply the test in Section 6 of the Human Rights Act to cover private care homes, they said to themselves—and made clear—that it was somehow unfair to place greater obligations upon public sector bodies than private sector bodies. I think that was completely the wrong question and they were very bold in deciding not to follow Lord Bingham and the noble and learned Baroness, Lady Hale, whose speeches I found completely convincing in logic but also, more importantly, completely in harmony with the intentions of the legislation when it was enacted in 1998.

In the wake of that, as the noble and learned Lord, Lord Mackay, has said, regulations were passed to deal with the particular problem. However, the general problem of what to do about YL goes way beyond the health service and health service providers. It is the problem of the reach of the Human Rights Act in imposing obligations on bodies that are private in form but provide services of a public nature. The problem is how to define what is meant by that. The framers of the Human Rights Act—as the noble Lord, Lord Warner, will remember because he was one of the key advisers in the making of the Act—decided that, rather than having lists and dealing with specific examples, there should be general language that would be flexible and capable of being interpreted by the courts on a case-by-case basis. It is most unfortunate that that failed by the majority decision in YL.

This is a very important problem that goes way beyond this Bill and will need to be addressed by Parliament at some point. My first difficulty with the amendment is the point that has been raised by the noble and learned Lord, Lord Mackay, which is the reference to,

“certain personal care and health care services”.

I do not know what that means. What are the certain ones and what are those that are not covered by that? The other difficulty is that the amendment refers to something called a “health care service”. I do not know what that means, because “health care service” is defined nowhere in this vast Bill. So the amendment has, in seeking to remove ambiguities, created two further ambiguities that would, if the amendment were to be passed, have to be determined by the courts in addition to the proper interpretation of YL.

In the YL case, the then Government argued strongly for the interpretation that Lord Bingham and the noble and learned Baroness, Lady Hale, gave. Both the previous and present Governments have said that they believe that the minority view in YL is the correct view. We now need to translate their general position when this commission has, in due course, considered it properly, which it has not yet had the chance to do. Can the Minister give a clear Pepper v Hart statement? I say that in trepidation because the noble and learned Lord, Lord Mackay of Clashfern, was the dissenter in Pepper v Hart. He thought that it was quite wrong for judges or others to be looking at what Ministers said in parliamentary debates, and there is a great deal to be said for that point of view. Nevertheless, it is the law. Rather than seeking to put an amendment which is too specific, too narrowly confined and itself contains two ambiguities on to the statute book, we could treat the Pepper v Hart statement as giving further guidance to the courts if and when the problem should arise in this particular context. I believe that to be quite sufficient. If we were to pass the amendment, we would create the very legal uncertainty that the noble Baroness, Lady Greengross, and the noble Lords, Lord Low and Lord Rix, rightly said should not be a feature of our legal system.

For all those reasons, I very much hope that the mover and supporters of the amendment will be satisfied if the Minister can give an unequivocal statement.

My Lords, in supporting the amendment, I hope that it might be helpful to your Lordships’ House if I were to provide more background from the previous Government, for whom I shared ministerial responsibility in this area, as the noble Lord, Lord Lester, alluded to. I am privileged to follow him on this, because I have found so often in our past relationships that we share many common objectives but do not always agree on the best way of getting to them.

As we have heard, the problem that the amendment seeks to address arose unexpectedly from a decision in the House of Lords, narrowly decided by a majority of three to two, which removed from vulnerable people basic protections that until then had been widely assumed to be entrenched. The arguments for addressing this problem have been compellingly outlined by other noble Lords who have spoken in this debate. These arguments were clear to the previous Government. As the Minister responsible for human rights, I felt that the YL decision did not reflect what Parliament had intended. I will not go into that because the noble and learned Lord, Lord Mackay, has set out cogently exactly why that is the case. I felt that it would be necessary to legislate to put that beyond dispute.

However, as always, it was necessary within government to agree on the scope of any change and to find an appropriate legislative vehicle. As your Lordships well know, this can often take some considerable time. In 2008, the Health and Social Care Bill, as it then was, was the first opportunity that the previous Government could find to make some progress in putting right the consequences of the YL case. I will come back to this, but here I agree with the noble Lord, Lord Lester, that this was only a start and did not address the more fundamental problem that the case had thrown up. The change in the 2008 Act was narrow in scope. As we have heard, the changes were limited to residential care services. They did not address the status of health services or home care services that were contracted out by the NHS or local authorities, and contracting out is only likely to increase under the legislation being brought in by this Government. The previous Government ran out of time in making a settled decision on how best to go further. Sadly the noble Lord, Lord Lester, had decided to stop being a GOAT, even before that process was concluded.

Therefore, in the light of all this and the YL judgment, I am not sure why the noble Earl seems to believe that all care from all providers is now covered beyond dispute by the Human Rights Act. I should be grateful if the Minister could set out in detail why he believes that advice to the opposite effect—including, as I understand it, from counsel to the HRC—is wrong. Why is that advice wrong?

The Government also appear to be concerned that accepting the amendment might cause legal uncertainty in other areas outside health and social care. I understand these arguments. I heard them many times when I was in government, but such bureaucratic caution could be extended to arguing against ever legislating for anything. However, in this particular case, if the Government are seriously worried, I suggest to the noble Earl that they may be too late. The 2008 Act has already opened that door. The Government’s suggestion that all these services are already covered, whatever the legal status of that commitment by the Government, has opened the door still wider. The Minister would therefore be unwise to rely on their line of argument, if that is what he is tempted to do in resisting the amendment.

Can the noble Lord explain what is meant by “certain personal care”, which is unclear, and what is meant by a “health care service”, which is not defined in the Bill? He is saying that we need it clarified. I do not understand how that can be done.

I am very sorry; the microphone was not working for the beginning of that. If the noble Lord was asking a specific question that he actually wants me to answer, I would be very grateful if he could repeat it.

I am asking whether the noble Lord has any answer to my point and that of the noble and learned Lord, Lord Mackay, about how the references to certain personal care and a healthcare service, which is not defined anywhere in the Bill, will resolve uncertainty rather than create greater uncertainty.

I understand that fundamental point. That does not argue against the Minister rejecting this amendment in principle. If he believes that that point in itself will create uncertainty, it is very open to the Government to redraft the amendment and specify it more precisely. I would be very content to support this amendment if the Minister said precisely that—that he would accept the amendment, subject to revising and clarifying that particular point. There will always be some areas of ambiguity in any legislation. That is why the courts exist and that is how the noble and learned Lords in this place have made their careers. That does not concern me very much. I would be perfectly content if the Minister stood up and said he was content to accept an amendment along these lines, subject to clarifying what the noble Lord and the noble and learned Lord have already identified as an issue.

I also understand that the Government are worried that they may be pre-empting the role of the Care Quality Commission and that this amendment may be unnecessary because of the protections that have been offered by that. Of course it has a role to play but that role should never substitute for the fundamental protections offered to the individual by human rights legislation.

As we have already heard, there is a serious problem of flagrant human rights abuses of older people. They need the protections offered by the Human Rights Act, but it is not just a question of the sort of brutal abuses that we have already heard described today. There are protections against those anyway, but I ask the Minister to consider this: the protection of the Human Rights Act offers fundamental dignity and respect to elderly and often very vulnerable people. I think here of the case of an elderly couple who had been together for 60 years or so but were about to be separated by a local authority. From memory, one of them had dementia and the local authority wanted to provide care for that partner in a specialist facility for dementia care, while the other partner went into more mainstream residential care. They had no protection against that. They were not being refused care. They certainly were not being abused in any of the ways that we have heard about already, but they wanted to spend their remaining years together. The Human Rights Act was the only protection that they had. The case was taken to court. They won and were able to spend their last years together. That is the sort of dignity and respect that elderly, vulnerable people are owed. That is the protection that the Human Rights Act offers them, and that is what this amendment seeks to extend.

Even then, there is a further benefit from extending the protection of the Human Rights Act in the way that this amendment wants to do. Important work that was carried out for the EHRC two or three years ago by the noble Baroness, Lady O’Loan, and Professor Klug at the EHRC showed how basic human rights principles of dignity and respect can help transform the culture of public service delivery. The Government could signal the importance that they attach to this by accepting this amendment today.

Throughout the long passage of this Bill, the Minister has been notable for his willingness to listen to and engage with argument and, where he has felt able, to change course. I hope that he will not now seek refuge by pushing this off to the forthcoming White Paper on social care. If media whispers are to be believed, No. 10 does not want that to see the light of day any time soon. Even if it appears, there is no guarantee that this issue will be satisfactorily addressed. Even if it is, it could then be years and years before any appropriate legislative vehicle could be found to make the necessary changes.

I also hope that the noble Earl will resist the seductive invitation from the noble Lord, Lord Lester, to leave this to the Commission on the Bill of Rights. Distinguished as it is, and diligent as its endeavours have been, if we believe the Daily Telegraph, it is already split three ways on many of the issues that it has to address. I hope that the Minister will consider that he would not be wise to leave this important decision to a commission whose outcome is, at best, not yet certain.

Believe me, I try extremely hard not to do so, but I noticed that the noble Lord did not deny the account given in the Daily Telegraph. I hope that it is wrong.

For the record, I deny the account given in the Mail, in the Telegraph, by Dr Pinto-Duschinsky on the BBC, and anywhere else.

I am extremely glad to hear that. I hope that the journalists concerned have noted that important denial, which I am grateful to hear from the noble Lord.

If this issue is delayed, we could be looking at years and years when vulnerable elderly people will be denied that fundamental protection. When I was Human Rights Minister, I was certain that we needed to go further than the Health and Social Care Act 2008 in tackling this problem. We ran out of time. The Government now have the time and the vehicle to do what I wish that the previous Government had been able to do. I hope that the Government will seize this opportunity and accept the amendment.

Having listened to the debate, I differ a bit from the noble Lord, Lord Wills. I have heard enough from the two distinguished lawyers who spoke beforehand to come to the view that my noble friend would be very unwise to rush down this path without more time than whatever there is—less than a week—before the intended Third Reading of the Bill to sort out the issue.

As always, my head has been left spinning by the lawyerly contributions from my noble and learned friend here and my noble friend down there. I just want to raise a couple of innocent layman’s questions that may even be a bit naive but which relate to the point that the noble Lord, Lord Lester, raised: what is the definition of all this?

I observe that the heading of the new clause does not talk about provision at the request of a public body, just provision of certain services, implicitly by anybody, whether or not commissioned by a public body. The first sentence reads:

“A person who is commissioned to provide”,

these services, undefined. Private people commission private services from private bodies in many areas—private hospitals, private residential care homes, private chiropodists, private this, that and the other. As far as I can see, the amendment extends the definition of public body to bodies that are not public by any reasonable definition and are not commissioned by public bodies to provide a service. That seems to me to be the natural construction. This is at least as much a question for the noble Baroness, Lady Greengross, as for the Minister, but that is how I read it. If that is its purport, it is not sensible and we should not rush into it.

My Lords, these Benches strongly support the amendment tabled by the noble Baroness, Lady Greengross, and the noble Lords, Lord Low and Lord Rix, to which I have added my name. It is frustrating that we appear to have moved no further forward from Committee, when the noble Baroness, a plethora of respected organisations representing older people, mental health, disability and human rights organisations, as well as the Equality and Human Rights Commission, were saying that there was a real problem which needed to be addressed by primary legislation. There are powerful arguments for amending the Bill in line with the amendment. They have again been ably made by noble Lords and I do not need to go over them again.

I believe that my noble friend Lord Wills addressed key points raised by the noble and learned Lord, Lord Mackay, and other noble Lords—as far as I was able to follow as a non-lawyer—and indeed acknowledged that this was unfinished business on the part of the previous Government. We amended the Health and Social Care Act 2008 to address this issue in respect of residential care. What has changed dramatically since then is that well over two-thirds of home care services are now provided by the private and voluntary sectors and this Bill is likely to increase the proportion of contracted-out provision still further.

The Government’s view, expressed in Committee, that any further legislation would cause uncertainty in other areas outside health and social care is a strange one. In this light, the obvious counter-argument is that the 2008 Act has already opened the door and, in my view, that factor only strengthens the case for the loophole to be closed off. Analysis by key human rights lawyers, counsel for the Equality and Human Rights Commission, key charities and civil liberties organisations have all endorsed this approach and stressed that case law does not support the Government’s view. As we have heard only recently, the Joint Committee on Human Rights’ report on independent living again called for the current Bill to be amended to extend the public function definition to the provision of care at home. For me, that is the key point. All these organisations still argue strongly that there is a loophole that needs to be addressed.

Moreover, the Government’s argument, again in Committee, that the YL v Birmingham City Council judgment has not been challenged to demonstrate that home care services are not covered by the Act or existing legislation is also weak, in my view, and does not inspire confidence in what might happen in the future. My understanding is that the subject of the YL judgment was residential care and the scope of the 2008 Act is therefore limited to that.

I hope that the noble Earl will have good news for us that the Government have rethought this issue and recognise the very real problem and concern that exist for the future. I hope that he will accept this amendment. We all agree about the importance of taking a human rights approach to care provision, with dignity and respect for older people embedded. The current loophole in the provision of personal care in the home by third or voluntary sector providers is of deep concern to thousands of recipients of home care. We need to ensure that this key opportunity to achieve clarity in this matter in the current Bill is not missed.

My Lords, we have heard many excellent speeches in this debate, not least from the noble Baroness, Lady Greengross. I know that the noble Baroness and all those supporting her are motivated by a determination to ensure that everyone who uses publicly funded health and social care services is protected from abuses of their human rights. I want to make it clear that I absolutely share that determination.

It is crucial that we ensure that vulnerable people are protected, no matter what age they are, no matter whether they have a disability, and no matter where they happen to live or where they happen to be at any given time. The requirement for people to have their human rights protected and respected is not negotiable. This is absolutely fundamental in a civilised and democratic society. The question we have before us today is how best to achieve that, and whether the proposed amendment would help or hinder us in doing so.

Amendment 292A is intended to provide certainty about the coverage of the Human Rights Act with respect to healthcare and home care providers. I understand the noble Baroness’s arguments for her amendment, and I completely agree about the importance of the Human Rights Act and the public sector equality duty. It may provide reassurance if I state clearly and unequivocally that the Government’s view is that all providers of publicly funded health and care services should indeed consider themselves bound by the Act and the duty. This is the position that we expect private and third sector providers to follow and the position that we would argue for if a case were to be brought; and we think there are good arguments with which a court would agree.

Of course, legislative provision is far from the only mechanism we have for ensuring protection for those using healthcare and domiciliary care services and for improving the quality of that care. In fact, we would argue that in order to ensure that users of those services are protected from the kinds of tragic abuses that the noble Baroness and others have spoken about so eloquently, we need to focus efforts on changing the culture and practice of services which provide poor care. We are working hard on several fronts to drive improvements in the way that people, including older people, experience health and social care services. We know that this is essential, and much of it predates the excellent EHRC report that resulted from the inquiry led by the noble Baroness, Lady Greengross.

To offer just a couple of examples of the work that we are doing to this end, we have made the Care Quality Commission responsible for assuring quality of care from April. The CQC will undertake a programme of inspections of 200 home care providers that will specifically look at supporting home care workers, the care and welfare of those receiving home care, and the involvement of people in planning and managing their own care. The new disclosure on barring service will replace the vetting and barring scheme in November this year and will make it easier for home care employers to check the suitability of their staff by providing a seamless service and introducing portable criminal record checks.

We know that legislation has a role, which is why we intend to put adult protection on a firm statutory basis for the first time ever by requiring local authorities to convene and manage local safeguarding adult boards, by legislating for their key roles and responsibilities, and by requiring them to be in touch with and accountable to local communities. We expect to see much better sharing of information and action that will help to drive up the safety and quality of services. The forthcoming White Paper on social care, which we intend to publish later this spring, will set out the broader strategic context not only on safeguarding adults but on improving quality in care services overall. The Government also intend to respond to the Law Commission report on adult social care law by creating a single statute for social care supported by statutory principles which place the well-being of individuals at the centre of the decisions made about people.

To return to the amendment itself, I am afraid that, despite the persuasive case put by the noble Baroness and others, I am not able to support it, and I hope that noble Lords will allow me to set out why. The problem is that while, on the face of it, this amendment simply provides helpful certainty about the coverage of the Human Rights Act with respect to health and homecare providers, in reality it has very serious and unhelpful implications for the wider interpretation of the Act. This may sound like a rather dry, legal argument, but it is an extremely important one with very practical consequences. By stating expressly that providers of healthcare and homecare services were covered by the Act, we would cast doubt on whether all the areas beyond health and social care were covered by it. However we framed it—whether we made it an avoidance of doubt provision or a deeming provision—we would weaken the applicability of the general test, suggesting that a narrow interpretation of the Act was appropriate and raising doubt about the Act’s applicability to all those bodies that had not been specified explicitly in the legislation.

We would also encounter the significant problem, referred to by my noble and learned friend Lord Mackay, of how to ensure that a specific provision of this type did not have the unintended consequence of making the situation less clear with respect to healthcare and homecare services. When noble Lords think of the wide range of services that fall under the banner of homecare services, I am sure they will appreciate the difficulty of drafting legislation that covers all relevant services and avoids any potential loopholes. My noble friend Lord Lester made a similar point. We can see how the proposed amendment, as drafted, makes the situation unclear. It is not clear how it applies to a person receiving care in the home of a family member—a point made by my noble and learned friend—or whether it applies to services provided under direct payment arrangements rather than being commissioned by a local authority or NHS body.

It is for those reasons that the Human Rights Act is quite deliberately designed to make broad provision that applies to all public bodies across the whole range of services. As my noble friend Lord Lester said, the Act is very carefully put together. Any amendment of the Act must be done by looking at it in the round, otherwise we risk destabilising its careful construction. That brings me to another point mentioned by my noble friend Lord Lester.

Can the Minister clarify one point? Is his objection to the amendment a drafting one—in other words, in an ideal world, were there more time, could a draft be found that would meet the various objections that he has just outlined—or is it one of principle, and is he saying that no such amendment to cover this loophole could conceivably ever be drafted?

Perhaps I may take just a little more advantage of the Minister’s time. He mentioned earlier that, in the Government’s judgment, were a case along the lines described ever to come along, the court would find in favour of the Government’s judgment. If that were not to be the case, can the Minister say whether in those circumstances the Government would be prepared to consider an amendment along the lines of that put forward by the noble Baroness, Lady Greengross?

Before my noble friend replies, perhaps I may have a go as well. The problem is that the more specific the amendment, the more the Latin maxim applies that says that, by expressing something, you are deemed to exclude something else. Therefore there is a great danger in ambiguous specificity.

My noble friend expresses the position exactly. In answer to the noble Lord, Lord Wills, if a court in the future were to arrive at a judgment that all of us here would consider adverse, of course the Government would intervene. However, in our view, it is now highly unwise at this point to try to frame an amendment to put these matters beyond doubt in the way that the noble Baroness seeks to do because any attempt to do so is almost certain to lead to ambiguity and doubt about the applicability of the Act in other areas. That is the point. Of course I can pick holes in the drafting of this amendment, but that is not the central issue. The issue is the wider one to which I alluded earlier.

Would not any court regard this amendment as specifically designed to deal with the YL problem? It would not regard it as casting doubt on anything else.

No loophole is created by YL. That was closed in Section 145 of the Health and Social Care Act 2008. While I listened with care to the noble Lord, Lord Low, who set out the background to the YL case very ably, I disagreed with him completely. This is not unfinished business from YL. That matter was decisively closed by the previous Government in the 2008 Act.

I move to another point raised by my noble friend Lord Lester. The Government have established an independent commission, due to report at the end of this year, which is looking across the board at how human rights are protected in the UK to see whether things can be done better. The topic of Section 6 of the Human Rights Act featured in various responses to the commission’s consultation last year and has already featured in the commission’s discussions. The Government’s view is that the receipt of the commission’s final report will provide the right moment for us to consider rights protection in the round, including any issues surrounding the scope and operation of Section 6.

I recognise the noble Baroness’s point about the amendment made in 2008 to specify that providers of residential care are bound by the Human Rights Act. However, that does not change my argument. As the noble Lord, Lord Low, reminded us, the 2008 amendment was necessary in order to overturn the contrary court judgment in the case of YL, but the Government at the time deliberately resisted any wider change for the very reason that I am resisting wider change today. I realise that my response is not the one that many noble Lords wish to hear.

I am grateful to the Minister for giving way. It was not the case that the previous Government resisted the amendment. I was deeply and intimately involved in this. It is true that we did not get our act together in time; we ran out of time. I refreshed my memory from my own papers on this point. I agree with the Minister that it is a difficult issue. It is absolutely true that there were different views within government, and no settled decision was reached. There was agreement at the highest level and agreement with the noble Lord, Lord Lester, that public function—the wider issue that lies at the heart of this issue—did need to be addressed. That is what this amendment is trying to do. However, we did not resist it in the way that the noble Earl is suggesting. I appreciate that he is not perhaps as painfully familiar with the details of the previous Government as I am afraid I am.

I am grateful to the noble Lord. My main point is that, whether by accident or design, the previous Government did the right thing in our view, and that is clearly the advice of the Ministry of Justice, which is in the lead on human rights matters.

I hope I have explained why I cannot support this amendment, despite the Government’s wholehearted support for the principles involved, and that I have demonstrated how seriously we take the issues that the noble Baroness raised. To that end, I can today make four very clear statements. I can confirm that the Government maintain an expansive view of the interpretation of Section 6 and, where we have the opportunity and it is appropriate to do so, we would intervene in legal cases in support of that interpretation. I can confirm that human rights will of course be part of the underpinning framework in adult social care law. Any reforms to the law on care and support will need to ensure consistency with the obligations placed on local authorities by the Human Rights Act. I can commit to hosting a round table, along with my honourable friend the Minister of State for Care Services, to bring together all key partners, including, if she wishes, the noble Baroness, to establish how our strategy on adult social care ensures protection of human rights. Finally, I confirm that if the independent commission on human rights makes any recommendations in its final report about the reform of Section 6 of the Human Rights Act, the Government will give them serious consideration.

On this basis, I hope that the noble Baroness will recognise the extent to which we have tried to address her concerns and will feel able to withdraw her amendment. If not, I beg noble Lords to think twice before voting for it.

My Lords, I thank the Minister for what he has just said, which was extremely encouraging. I have never doubted his commitment to getting this right. I am not a lawyer, but listening to the discussion, I think there was some misunderstanding about the wording of the amendment and the context in which it stands. For example, the word “certain” is defined in the next paragraph as,

“personal care to an individual living in their own home”.

I agree that there could be ambiguity if somebody goes to stay with their daughter and I agree that there could be ambiguity in the drafting, although the amendment was not drafted by me but by the EHRC with the help of very learned lawyers who have worked on this extremely hard. It is limited not to services provided by anybody but to services commissioned or arranged by a public body. Therefore, those particular points that were raised by noble Lords do not apply, although if I thought they did I would agree that it would be a bit silly to try to insist on this amendment.

I feel that in spite of the Minister’s very welcome commitment—we have had time together when he has expressed this so I know that he feels this way—I would like to see the work that the noble Lord, Lord Wills, referred to carried forward, as so many other good policies have been, as there is no party-political disagreement about the aims of particular bits of legislation or the desire to get things right. I would like this to be the case. I am really sorry that the Government feel that we have to wait for those very worthwhile undertakings and pieces of work to be taken on board before we can protect these very vulnerable people who are just not being protected because they happen to be doing what all older people seem to want, which is getting services in their own home rather than going to a residential home. That is what the Government seem to want them to do, and that is what most older and vulnerable people want, as well as many younger disabled people who want to live independently, and many people with learning disabilities. This is not just about one group, although it primarily concerns older people. I just feel sad. I ask the noble Earl to continue with his good intentions but to build on them by incorporating a redrafted amendment in those intentions. On that basis, I feel bound to say that I should like to test the opinion of the House.

Clause 284 : Monitor: duty to co-operate with Care Quality Commission

Amendment 293 not moved.

Clause 287 : Breaches of duties to co-operate

Amendments 294 and 295 not moved.

Clause 290 : Failure to discharge functions

Amendment 296

Moved by

296: Clause 290, page 263, line 6, at end insert—

“( ) For the purposes of this section a failure to perform a function properly includes a failure to perform it consistently with what the Secretary of State considers to be the interests of the health service in England or (as the case may be) with what otherwise appears to the Secretary of State to be the purpose for which it is conferred; and “the health service” has the same meaning as in the National Health Service Act 2006.”

Amendment 296 agreed.

Amendment 297

Moved by

297: After Clause 294, insert the following new Clause—

“Contravention of section 64 of the Medicines Act 1968: due diligence defence

In section 67 of the Medicines Act 1968 (offences under Part 3), after subsection (2) insert—“(2A) But it is a defence for a person charged with an offence under subsection (2) in respect of a contravention of section 64 to show that the person exercised all due diligence to avoid committing the offence.””

My Lords, in moving Amendment 297, I shall speak also to Amendment 301. First, I declare an interest as chairman of the council of the School of Pharmacy, University of London. For the avoidance of doubt from the outset, I will not press these amendments.

In Committee, I moved an amendment to provide a due diligence defence to the currently strict liability criminal offence committed under Section 64 of the Medicines Act 1968. This has the potential to operate very harshly on those making single errors dispensing medicines, whether in retail or hospital pharmacies. The intent of the original amendment was to remove the injustice that pharmacists and some others among healthcare professionals face criminalisation through single dispensing errors.

It was also very importantly designed to increase patient safety by removing barriers to a learning culture within the pharmacy profession and to ensure that pharmacists who wish to declare a dispensing error in the interests of patient safety are not penalised. The formulation of a defence, which gains universal acceptance among the pharmacy profession, has however proved more difficult than originally anticipated. Although the regulator, the General Pharmaceutical Council, has been supportive of the proposed amendment, there is as yet no consensus with the pharmacy professional bodies as to the best way legally of formulating a defence that meets these objectives.

There is, however, a unanimous view among professional pharmacy bodies that it would be better not to amend the Act at this juncture in this way but to wait for the full review of offences under the Medicines Act due to be carried out by the Medicines and Healthcare products Regulatory Agency, the MHRA. There have of course been helpful discussions to this effect with the chief pharmacist and his colleagues at the department, and agreement, as I understand it, that we should go forward on this basis.

In this context, it would extremely helpful for all concerned if the Minister could confirm the timetable for the scoping of the sanctions and penalties in medicines legislation review to be carried out by the MHRA and any other details of the review that he can give at the present time, such as the procedure, the timetable, and the involvement of the regulator—the GPhC—and professional bodies.

Although this is not directly within the gift of the Minister, it would be extremely helpful if he could also indicate that the department will engage with the DPP and the Crown Prosecution Service to encourage them in the mean time to engage with the profession and the regulator in reviewing the prosecution guidelines for offences under the Medicines Act. That would be extremely welcome to all those concerned in the profession. I beg to move.

I must say that I am surprised that the noble Lord moved this amendment. He told me yesterday that he was not going to and did not have the courtesy to tell me that today he is. The amendment raises a very interesting question. No doubt we will be very interested to hear the response of the noble Earl, Lord Howe. He might perhaps add the membership of the review team to the details of the review.

My Lords, I am very grateful to my noble friend, to whom I should like to pay a particular tribute for his work to bring interested parties together on this important issue to see whether a common view could be found on a practical way forward.

Both I and my ministerial colleagues are determined to ensure that we address the concerns of pharmacists and registered pharmacy technicians about the risk of prosecution for inadvertent as opposed to wilful or reckless dispensing errors. We and the profession want to see a learning culture that encourages the reporting of dispensing errors so that any helpful lessons can be learnt. Equally, we must make sure that any changes we introduce continue to give patients protection under the law and do not in any way compromise patient safety. It was therefore disappointing to me that, after a great deal of dialogue in recent months, there has not been a sufficient measure of agreement to proceed on a specific legislative change at this time. I have to accept the reality of that, despite everyone’s best efforts.

I turn to the next steps in resolving this issue. The Medicines and Healthcare products Regulatory Agency intends to carry out a review of sanctions and penalties in medicines legislation. This will extend well beyond issues that have arisen in dispensing errors, but the review will look at the respective roles of medicines legislation and professional regulation in this area. It will also enable other important stakeholders, such as patients and the public, to contribute. Indeed, I have no doubt that the MHRA will encourage all interested parties to have their say. The possible role of a due diligence defence will remain on the table for consideration in the wider context of this review. It is worth stressing this point as due diligence defences have a well established usage in association with strict liability offences in many areas of legislation, including medicines legislation.

This will be a significant and wide-ranging review, and it is important to ensure that it covers the right ground. The MHRA would aim to scope the coverage, conduct and timetable of the review by September 2012. I will just say to the noble Lord, Lord Hunt, that membership of the review team will be established as part of the scoping work. As part of that scoping, we will look at the feasibility of including an independent element to the conduct of the review as it relates to the challenging task of achieving a suitable balance between the roles of medicines legislation and professional regulation.

In the mean time, we are encouraged by the guidance to government prosecutors in England and Wales issued by the Crown Prosecution Service in June 2010 and by more recent dialogue. It is clear from this that the CPS takes very seriously the issue of judging the question of whether there is a public interest in mounting a prosecution. I am sure, too, that the Director of Public Prosecutions will read tonight’s debate and consider very carefully the comments that have been made. We will certainly look to encourage any opportunity for further constructive dialogue on the issue.

It is important to emphasise that all parties have their part to play in developing a solution and a culture that protects the public while encouraging and supporting pharmacists and pharmacy technicians to report, and learn from, mistakes—which in turn improves patient safety. In this regard, we see the role of the professional leadership bodies for pharmacists and pharmacy technicians as critical; and we would encourage pharmacists and pharmacy technicians to ensure that they are well placed to respond to the professional regulator in a manner that makes the public’s interest central to any future discussion.

In conclusion, I reiterate my thanks to my noble friend for enabling this afternoon’s debate on the issue. I hope he will be reassured by the undertakings I have given that, despite the current lack of consensus, we will continue to work with interested parties on a way forward.

My Lords, I thank the Minister for that reply. First, let me say to the noble Lord, Lord Hunt, that no discourtesy at all was intended. We may have misunderstood each other. I never intended to press the amendment, but of course wished to raise the issue in order to get a response from the Minister about the way forward in the absence of this amendment being incorporated in the Bill. I apologise if I inadvertently misled the noble Lord.

We all have the same purpose, which is, as the Minister said, to encourage a learning culture within the profession so that it no longer has hanging over it a lack of a defence to the absolute liability in Section 64 of the Medicines Act; and, it may well be, other aspects of the Act as well, which no doubt will be uncovered as the MHRA carries on its work. I, too, share the Minister’s disappointment that we were not able to agree a suitable solution between the department, the regulator and the pharmacy profession.

I thank the Minister for showing us the way forward with the MHRA review of the scoping that will be done by September 2012. I very much hope that, as he said, the DPP will consider this debate very carefully, and that he will respond favourably and engage in a review of the guidelines. I also reiterate the Minister’s wish and hope that the profession will engage very closely with the MHRA in this review and in any review of the guidelines by the Crown Prosecution Service. In the mean time, I beg leave to withdraw the amendment.

Amendment 297 withdrawn.

Schedule 23 : Property transfer schemes

Amendments 297A and 297B

Moved by

297A: Schedule 23, page 444, line 5, at end insert—

“The Special Health Authority known as the NHS Business Services Authority

The Health and Social Care Information Centre”

297B: Schedule 23, page 444, line 21, second column, at end insert—

“The Health and Social Care Information Centre”

Amendments 297A and 297B agreed.

Schedule 24 : Staff transfer schemes

Amendments 297C and 297D

Moved by

297C: Schedule 24, page 445, line 38, at end insert—

“The Special Health Authority known as the NHS Business Services Authority

The Health and Social Care Information Centre”

297D: Schedule 24, page 446, line 18, second column, at end insert—

“The Health and Social Care Information Centre”

Amendments 297C and 297D agreed.

Clause 300 : Regulations, orders and directions

Amendment 298 not moved.

Amendments 299 to 300ZB

Moved by

299: Clause 300, page 269, line 24, at end insert—

“( ) the first regulations under section 84 (licensing requirement: exemption regulations);”

300: Clause 300, page 269, line 24, at end insert—

“( ) the first order under section 87 (approval by Secretary of State of licensing criteria);”

300ZA: Clause 300, page 269, line 33, leave out paragraph (e)

300ZB: Clause 300, page 270, line 45, leave out subsection (11)

Amendments 299 to 300ZB agreed.

Clause 302 : Commencement

Amendment 300A

Moved by

300A: Clause 302, page 271, line 35, at end insert—

“(A1) Part 3 of this Act shall come into force, by order, on a date to be determined by Parliament, which shall not be before April 2016.

(A2) Before bringing forward any order to bring Part 3 of this Act into force the Secretary of State shall consult the NHS Commissioning Board, the Independent Regulator of Foundation Trusts, the Care Quality Commission, patients or their representatives, and staff delivering NHS services or their representatives, and shall report to Parliament on the outcomes of the consultation.

(A3) Any such order must be laid in draft and approved by a resolution of each House of Parliament.”

My Lords, as we near the end of our deliberations on Report, I hope to set out the case for changing not the policy but the pace of implementation. We have discussed extensively the policy background and the legal and other implications of this Bill. We have agreed on some things and disagreed on others. The case for Amendments 300A and 300B is simply that we have learnt a great deal in the past 13 months since my noble friend Lady Wheeler and I asked 18 other noble Lords to join us in organising seminars about this Bill because we felt that the House needed to understand it better. I have to say that 13 months later I am not sure whether we do understand it any better. However, what is quite clear from those seminars and our discussions since the autumn is that there are risks involved in this Bill. There are credible claims that detrimental consequences brought about by the scale of change are already being felt. There are some extreme assertions, such as from regional risk registers, that patient care could be seriously impacted.

In these remarks I am really only going to assert what we know. We know what is in those risk registers, we know the risks that we have discussed and we know that this is the largest reorganisation that the NHS has ever undergone, including the one that set it up. The evidence that we collected in our seminars raised the scale of those risks. During our debates risks have been mentioned time and again—risks to children, to older people and to people with long-term conditions. The Health Select Committee and the Public Accounts Committee have both added weight to those expressing concerns about the scale and pace of change, and that is the point of these amendments.

We still do not know what the key risks are in the risk register, which is a grave disappointment, but that may actually add to our concerns. Our concerns should also be heightened by the poor track record of the Department of Health to oversee and manage change on this scale. The wisdom of ex-Ministers in this House is such that they know very well how hard change is to manage within our NHS. Added to this particular programme is one of the worst impact assessments that I have ever seen and, one suspects, a deficient risk management process. The level of organisational change was acknowledged when the coalition agreement specifically ruled out any such major programme.

In adding to the risk inherent with the implementation of this Bill, we have put forward an amendment that is intended to ensure that part of the Bill is deferred and the major part of the Bill is proceeded with. That is what this amendment is about, and I think it has advantages. First, we have to allow time and bring about some stability for the Nicholson challenge, as it has been called, to deliver the savings. We know that economic regulation is not a key factor in delivering those savings, as evidence to the Health Select Committee demonstrated. Reforms in both commissioning and provision can continue as now in advance of economic regulation in the full market. That is the first reason. The Nicholson challenge and the savings need time to embed themselves and to work their way through the system.

Secondly, many in this House and outside have expressed concerns that the role of Monitor as the independent regulator of foundation trusts should not be weakened. To some extent that has already been acknowledged in the changes made to the Bill, but the addition of new rules and duties to Monitor is, we believe, in itself a risk. Under our amendment, Monitor would complete its role in authorising foundation trusts and be well on its way to moving to a light-touch regulation, so that the inevitable conflicts of interest, which many noble Lords have raised during the course of this Bill and outside the Chamber, would be lessened. The pipeline of expectant foundation trusts is still long and will not decrease any time soon. It seems that there is a job of work for Monitor to do in managing things such as mergers, takeovers, and franchising for laggards. That process, of itself, is enough, and we want to reduce the risks of failure in those processes.

It also seems that developing and building the capacity and capabilities required in a wholly new regulatory regime will and should take time. There is much to do, and we think that undue haste brings with it its own risks. The emerging clinical commissioning groups will be commissioning with billions of pounds of public money, yet they are young organisations with only light governance. They will need time to grow and to build capacity, capability and experience before they have the additional complexities of market regulation, and this amendment allows for that.

The most compelling reason for sequencing—a term that I openly acknowledge I first picked up from the noble Baroness, Lady Williams—is that it will give time to work with those who have to implement the changes, as opposed to forcing those changes upon them. Even those in the Government and on the Liberal Democrat Benches cannot really pretend that the widespread opposition to this Bill and the arguments for it to be reconsidered are all part of some Labour plot, as has been suggested. Would that it were that the Labour Party had such influence and strength. I do not think that is the case, but calling distinguished academics and leaders of professional bodies Labour stooges is both offensive and counterproductive. There is widespread opposition to and fear of the risks that this Bill brings. They are not borne of ignorance and ideology but based on knowledge, evidence and experience, so the Government would be wise to take time to win people over to what they want to achieve. As the Prime Minister himself said last year, he would not wish to move forward with these reforms without the support and commitment of the National Health Service’s staff and patients.

My final point is about the consequences of sequencing. At the outset, we heard claims that the NHS was in urgent need of competition to drive through reforms to improve outcomes, but evidence has been compiled to show that while our NHS is far from perfect—and indeed may need reform—it is still arguably up there with the best in the world. Where we lag behind, we are closing the gap, which is testimony to our support and investment in the NHS. We believe that there is no urgent reason for implementing Part 3 of this Bill, either for clinical or financial reasons. On the positive side, we are not suggesting any delay in developing other aspects that have wider support, such as clinically informed commissioning, health and well-being boards, HealthWatch and much else. These changes need not be delayed if our amendment were passed—indeed, they are pretty much going ahead anyway—but could proceed with less risk. By sequencing the changes, the risks posed to patients can be lessened and the prospects of delivering the Nicholson challenge increased.

While other parts of the Bill bed in and foundation trusts can be regulated and registered as far as possible, it seems to me that May 2016 is the right time to implement Part 3 of the Bill. At some point in this Bill, the Government had set that date for getting foundation trusts set up, as far as they could be. That will be when all the other work has been done and is bedded in, and has perhaps built up some support with less fear and hostility than it does at the moment. I beg to move.

My Lords, the case has been made extremely well for accepting that one of the most vehement elements of criticism could be somewhat defused if this amendment was accepted by the Government. After all, some people have argued that the whole of Part 3 should be abolished. By accepting that the Government are going to go ahead but just asking that the relevant measures should be phased in seems to me a very rational and reasonable way of acknowledging that there is very deep-seated and justifiable criticism of this legislation.

Reference has been made to the primacy of the need to make the efficiency savings and the need to carry the people in the health service with regard to the provisions in the Bill. I do not want to weary the House by listing the royal colleges that are now opposed to this legislation but it is a staggering development. Nobody can deny the phenomenon that we are seeing; it is unprecedented. I would never have conceived it possible that there would be this degree of professional criticism of the Bill when I first started to look at it and realised that it was in my judgment a very bad Bill. Indeed, it remains so in my judgment. However, I am not here to argue all these cases. This seems to me an important amendment which is geared to accepting that the Government will certainly resist the dropping of Part 3, but may be amenable to phasing it in. Indeed, the Minister might propose a different phasing-in period. It would seem to be a very wise course to deal with the essential elements—the efficiency savings—then bed in some of the other aspects that are new in the Bill and may well be accepted within a short period of time, and leave the element which causes the most deep-seated opposition until later. I hope that the Minister will listen to the argument, reflect it in his speech and be ready to make this important concession to his critics.

My Lords, I am afraid that I cannot agree with the noble Lord, Lord Owen, as regards supporting the amendment. However, I appreciate that the noble Baroness, Lady Thornton, has adopted a much more emollient line on Amendment 300A, is not making a full frontal attack on the whole Bill and is looking simply at Part 3. There is certainly an argument to be explored in what she had to say but I cannot understand the logic of why, of all the parts of the Bill that she has talked about today, she is focusing on Part 3. I find it extraordinary that throughout the debates that have taken place on the Bill the Opposition have refused to accept that the National Health Service Act 2006 introduced price competition into the NHS. If Part 3 did nothing else but plug some of the competition problems in the 2006 Act, I would support it.

Would the noble Lord care to tell me to which part of the 2006 Act he is referring because, according to my recollection of the Act, it does not mention the word “competition” anywhere?

My Lords, that is precisely the point and that is precisely why the Labour Government were avoiding any argument because that is where the big loophole lies. Any competition lawyer will tell you that that was the point where EU competition law started to bite in the NHS. That is a fact which you cannot deny. The establishment of independent treatment centres constituted a major introduction of the private sector into the health service by the Labour Government. That process was far more unregulated than it will be in the future under this Bill. There were major flaws in the 2006 Act which have never been fully acknowledged by the Labour Party throughout these debates. The noble Baroness’s speech could have been written three or four weeks ago. The Opposition refuse to accept the value and benefit of the amendments that have been made to Part 3 just in the past two weeks. I will not adumbrate them all. I refer the Opposition to the House of Commons paper that has just been written which sets out in great detail something like 2,000 amendments that have been made to the Bill since it started its passage through the House of Commons. We have had Future Forum, we have had 1,000 amendments tabled in this House alone and we have had changes to the Competition Commission’s involvement.

What is the noble Lord’s answer to the question which I put? I was not attacking him and his party. I realise that he has to attack; that is his method of dealing with issues. That is a shame as I have from time to time tempted him not to do so. However, does he accept what the noble Lord, Lord Owen, said about the hundreds of thousands of people and professionals who are fearful of this Bill? Attacking me as much as he likes will not alter that fact.

My Lords, I really enjoyed the noble Baroness’s intervention. Today’s news about the change in attitude of the Royal College of General Practitioners shows that we have reached a genuine watershed. It may not have changed its mind absolutely, although it appears that membership pressure is being applied to the leadership of the royal college, but this is a real watershed whereby the acceptance of the fact that the Bill is going through is changing hearts and minds—not just minds but hearts as well. I am far more optimistic than the noble Lord, Lord Owen, because I believe that the other royal colleges will follow suit. They are actually looking at the substance of the Bill, not at some of the alarmist propaganda being put out. They are considering how mergers between foundation trusts will be regulated, how Monitor will do its duty and the additional powers that Monitor will have following consideration by Future Forum and Members of this House. They are also considering the impact of EU competition law following the Pepper v Hart statement that was made the other day. They are looking at the substance, which is exactly the way to look at the Bill. I believe that Part 3 is one of the most valuable parts of the Bill. I did not believe that it was acceptable to start with. That is precisely why I put down amendments in Committee and on Report. I am very pleased to say that it is much improved. The Bill should not be held up because of Part 3. In fact, it should be celebrated because of Part 3.

My Lords, those who have been here will have realised by now that this is one of my “good boy” days. At the risk of seeming sycophantic, even beyond being a good boy, I support every word that my noble friend Lord Clement-Jones has just said. I will refer back in a moment to something the noble Baroness, Lady Thornton, said about former Ministers. This chunk of the Bill—Part 3—is largely about Monitor and includes a lot that the House has been pressing for in terms of increasing Monitor’s power to intervene and do sensible things in a sensible way. It also includes all the stuff about pricing and tariffs, which in my view need to be addressed now, not in four years’ time.

My main point concerns what the noble Baroness, Lady Thornton, said about former Ministers knowing about the problems caused by upheaval. We do. I became very much aware that the publication of a White Paper was the start of a process, not the end. Too often Ministers think that all they have to do is publish an edict and everybody on the ground will carry it out. These things take time, trouble and involve culture change. However—this is the point here—what is equally or even more damaging is year upon year of uncertainty, which is what this amendment seeks to bring about.

I have referred on a number of occasions to the merger/takeover proceedings in which I was involved last year with the health trust that I then chaired. That occurred partly against the background of Monitor and the competition matters that are being changed in this Bill for the better. The worst thing was the uncertainty for everybody involved—the way it was dragging on and nobody knew what the future was. Good people started to leave or think about whether they had a future with the organisation. It would be insane to go down this path and I strongly recommend that the House should not do so.

My Lords, I fully understand the fervour and passion with which my noble friend Lord Clement-Jones spoke, because he feels very strongly that he, with the help of others, brought about a real change in Part 3. I make no pretence about the fact that I began by being totally opposed to Part 3. I was on public record as saying that I thought it was a very bad thing indeed, but very sweeping changes have been made to it, and on that I agree with the noble Lord, Lord Newton of Braintree.

However, I do not want to stop at that point. My noble friend said that we were at a watershed and I believe that we are. I pay tribute to the noble Baroness, Lady Thornton, and her colleague, the noble Lord, Lord Beecham, for tabling this important amendment, and I shall explain why. In this House, we have a great deal of trust in the Minister. Repeatedly and rightly, huge tribute has been paid to him throughout these debates for his understanding, his patience, his willingness to go a very long way to meet the needs and requirements of other people and, if I may say so, his permanent consciousness and awareness of why the British public love the NHS so much. More than virtually any other politician that I can think of, he has real empathy with what people want and expect from their health service and it is important to recognise that.

The noble Earl has punched—if I may say so politely—well above his weight. His weight is not, of course, that great but his punch is terrific. He has persuaded a great many of us—not, I suspect, only on this side of the House—with the elegant and generous way in which he has put forward compromises and concessions. Many of us have accepted these or, like the noble Baroness, Lady Greengross, decided to wait a little longer to see what might come out of what he said. That is an immense personal contribution.

We would be in a world of illusion if we did not recognise that outside this House and the other place, where my honourable friend Mr Burstow is doing his very best on the social care side, there is, as the noble Baroness, Lady Thornton, rightly said, massive distrust and disbelief in what we are trying to do. We have to address that or we can forget altogether about doing what the noble Lord, Lord Newton of Braintree, rightly said we need to do—to give the National Health Service some stability, some confidence and some sense that it has a future. This is the most labour-intensive public service. Our whole capacity for addressing the Nicholson challenge and the problems of an ageing and often chronically troubled society, and for delivering what most of us want and which is enshrined in the words that we wrote into the Bill at the very beginning of its passage in this House—the responsibility and accountability of the Secretary of State for a comprehensive health service free at the point of need—will go with the wind without the support and morale of the professional services, the staff and the public.

As Members of this House will remember, we owe a great deal to the noble and learned Lord, Lord Mackay of Clashfern, for the Conservative Party, we owe a great deal to the noble Baroness, Lady Thornton, and her team for the Labour Party, and we owe a very great deal to the Cross-Benchers for the steady support they have given to maintaining the stability and future of the National Health Service, which all of us recognise as probably the greatest single social achievement of this country since the Second World War.

What I like very much about the amendment is the second section, where the noble Baroness, Lady Thornton, and the noble Lord, Lord Beecham, point to the need for consultation before there is a move towards bringing Part 3 into full effect—I would go wider and say before bringing into full effect the Bill itself. It is vital that, when the Bill has completed its passage, the Government and the Department of Health in particular seek to hold a wider consensual discussion, bringing in the main bodies but also the main people who have been involved in the Bill, regardless of whether they stood for or against it, in order to give the National Health Service the foundation it needs to address the huge scale of the problems it faces.

I agree about sequencing. I suspect that it is really difficult to demand that the NHS seeks both to meet the Nicholson challenge right away and to deal with the effects of reorganisation. In so far as there can be some delay in the second of those—I have in mind, for example, whether strategic health authorities should be got rid of as quickly as the Bill currently proposes—there is clearly room for some meeting of minds about the best way to bring about the necessary changes without affecting the central issue of how that is done in the face of financial stringency.

I do not wish to hold up the House for long but I do want to say that we need, once again, to engage the royal colleges. I take the point of the noble Baroness, Lady Thornton, that they have, to a great extent, been alienated. It is crucial that we get across the changes that have been made. I will be among the first to say—because I paid the price for this—that many of the public do not know very much at all about the changes that this House has made. We have certainly been poor at communication. That is not entirely our fault because the Government, understandably, made their concessions at the very last moment of the procedures in this House—often, literally, just before we started debating. Understandable though that is, the drawback is that there is a total failure of communication, and the press—usually somewhat thinly represented in the Press Gallery of this House—is not terribly good at conveying what is happening as distinct from the scope and passion of contention, much of it totally beside the point.

In conclusion, it is now contingent upon us all, regardless of our party, to make a real effort to make this reformed Bill work. I do not like the Bill very much but I like it a great deal better now than I did when we began this long process. It has been a long and arduous process. I hope that we can turn our minds to the deep consultation with all those involved referred to in the middle part of the amendment, which I strongly applaud. That is the essential bridge across the watershed to which my noble friend Lord Clement-Jones and the noble Lord, Lord Owen referred. I hope that we can end on a note which will say how much this matters, and I hope that the Government will consider it very sensitively and carefully, because I think they will need it as much as the rest of us do.

My Lords, I had not intended to speak on the amendment, but I want to say a word or two in support of what the noble Baroness, Lady Williams, has just said. She and others have referred to the rift that has been created as the Bill has gone through Parliament and been discussed in the country. I am sure the Minister recognises that, but I know that he also recognises that now is the time to move towards healing that rift. Many people have, for whatever reason, been scared by what has been said and many people have also been scarred by what has been said. The noble Baroness is absolutely right to draw attention to the second part of the amendment and the opportunity that it gives to start to bring people together around the practicalities. We talk about the legislation but many people out there have to talk about the practicalities and how you make it happen—something with which many Members of your Lordships’ House, including the noble Lord, Lord Newton, are very familiar.

This has also been about failing communication. I believe there is now more that unites people than divides them. There are many things that people agree on. There are still some very significant differences and, like the noble Baroness, Lady Williams, I am not a fan of the Bill. It has been a damaging process but now is the time for healing. It would be good to see some cross-party approaches to bringing people together in a positive fashion to deal with the practicalities, rather as is laid out in the second part of the amendment.

My Lords, I think that it is important for me to begin by acknowledging fully the force of the wonderful speech by my noble friend Lady Williams, and indeed acknowledging the powerful points made by other noble Lords regarding the climate of opinion among the medical royal colleges and others in relation to the Bill. I cannot fail to be conscious of the suspicion and doubt expressed by many members of that community, although I have to say that opinions vary as to what the real views of some of the royal colleges are, bearing in mind that only a small percentage of their members were canvassed. However, I cast that aside because I am very aware of the validity of the points made by the noble Lord, Lord Owen. The Government are undoubtedly fighting a battle to convince the medical community of the merits of the Bill, a battle that we have so far not won. I can therefore very readily confirm to my noble friend that the first thing we would wish to do once the Bill reaches the statute book is to build bridges with the royal colleges, the BMA and all those who have an interest in seeing this Bill work, to make sure that its implementation is securely grounded. I completely agree with her that the Government should work with NHS staff, all our stakeholders and, indeed, patient groups during the coming months to make sure that implementation really is a collaborative process. I hope that the undoubted wounds that have been created will be healed, and healed rapidly.

I am grateful to all noble Lords who have spoken in this debate. In particular, I listened carefully to what the noble Baroness, Lady Thornton, had to say, as I always do. The question posed by her amendment is, on the face of it, “How can we improve Part 3?”. The answer that she has given us is, “To postpone it”. However, the subtext of her question is, “Why should we have Part 3 at all?”. I am happy to set out once more exactly why it is essential that we have Part 3 —and not just have it, but have it without delay. We need it for two compelling reasons: to protect patients’ interests, and to help the NHS meet the significant quality and productivity challenges it faces. They are benefits that I am afraid the amendment would stop in their tracks.

Part 3 sets out a clear, overriding purpose for regulating NHS services—to protect and promote patients’ interests. That contrasts with Monitor’s duty under the National Health Service Act 2006, which is merely,

“to exercise its functions in a manner consistent with the performance by the Secretary of State of his”

functions. That 2006 duty is not adequate as it stands. It does not mention patients’ interests and it is unclear. However, that duty is what would apply if Amendment 300A were accepted. The amendment would also discard the recommendations of the NHS Future Forum that Monitor should have additional duties: first, to involve patients and the public in carrying out its functions, as my noble friend Lady Cumberlege and the noble Lords, Lord Patel and Lord Warner, rightly emphasised; and, secondly, to enable integration.

It needs to be made clear that the provisions in the Bill interlock and are interdependent. Deferring Part 3 would not achieve the continuation of the status quo, but it would leave an NHS without strategic health authorities and primary care trusts and without a comprehensive and effective framework for sector regulation. There would be no organisation with the powers needed to support commissioners in developing more integrated services. That is something that the noble Baroness, Lady Finlay, and others have rightly demanded. There would be no organisation capable of enforcing requirements on providers regarding integration and co-operation. Neither would there be sector-specific regulation to address anticompetitive conduct that harmed patients’ interests. The powers that currently exist to enforce advice of the Co-operation and Competition Panel would no longer be available. Instead, it would be reserved to the OFT to consider complaints under the Competition Act, rather than by a sector-specific healthcare regulator with a duty to protect patients’ interests.

I mentioned protecting patients for a good reason.

Surely the Co-operation and Competition Panel still exists, will continue to exist, and can deal with any competition issues that are raised—as it already does.

My Lords, the proposal that we have made in the Bill is for the Co-operation and Competition Panel to be part of new Monitor. If the noble Baroness’s amendment runs a coach and horses through those new arrangements, they are clearly very seriously destabilised.

Part 3 provides for a comprehensive system of regulation, covering all providers of NHS services and so protecting all patients whenever they use the NHS. The amendment would mean that patients using services supplied by the independent sector, social enterprises or charities would continue to be denied those protections. The protections would not, for example, apply to the 500,000 people in Hull and the East Riding of Yorkshire who receive NHS services from the City Health Care Partnership, a community interest company established under the previous Administration. The partnership offers a range of community-based treatments as well as early interventions to help minimise the need for acute care in hospital and promote healthy lifestyles. Monitor does not currently regulate the partnership, because it is a social enterprise.

Part 3 will extend equivalent safeguards to protect patients’ interests, irrespective of who provides their treatment. That is a huge step forward. For the first time, there would be regulation to protect patients from the risk that poor management decisions may put essential NHS facilities and continuity of services at risk. By contrast, the amendment would perpetuate the situation whereby such protection exists only where patients receive essential services from foundation trusts. This would not recognise the nature of our NHS as a comprehensive service delivered by a diverse range of providers.

As well as providing for comprehensive regulation, Part 3 provides for effective regulation that will benefit patients by better enabling positive change. The noble Baroness mentioned the Nicholson challenge. Change in service delivery will play a vital role in achieving the Nicholson challenge of realising up to £20 billion of recurrent productivity improvements in the NHS, for example by providing older people and those with long-term conditions with more integrated care outside hospitals.

Part 3 will enable such change by empowering clinical commissioners to decide how best to improve services and when, where or, indeed, if to use competition as a means to that end. The amendment would leave no provision for sector-specific rules of this kind. Let me explain what that would mean. It would mean that clinical commissioners would face continuing risk of legal challenge whenever they decided to secure services without competition. It takes little imagination to see how that would stifle enthusiasm for clinical commissioning and potentially prevent the sort of innovative, integrated solutions needed to meet the demands of caring for an ageing population.

Part 3 would also enhance the NHS’s ability to deliver positive change by improving the current pricing system. Improving the pricing system is important for three reasons: to strengthen incentives for improvement, to enable integration and to remove incentives for cherry-picking. Part 3 will establish a transparent, legally enforceable pricing system that rewards providers for treating NHS patients. Money will follow the patient, and providers will be paid a fair price for treating complex cases. Again, this is central to the Nicholson challenge. Reform of the tariff in a systematic way will encourage service redesign and better integration. The current system, under Department of Health control, has, I am afraid, often failed to achieve these aims. For example, although foundation trusts should have been paid for every NHS patient treated, that has not always been happening. There have been unacceptable levels of cross-subsidy, and prices for complex cases have sometimes been woefully inadequate.

These and other problems have been highlighted by the royal colleges and are well documented, including in the recent report by PricewaterhouseCoopers. However these are also complex issues that will take time to solve, and as the noble Baroness, Lady Thornton, herself has said, it has taken time and is likely to take time. Therefore time is of the essence. The NHS cannot afford further delays. For all of these reasons, there is a clear, compelling and urgent case for moving forward with Part 3 of the Bill. I hope that I have been able to able reassure noble Lords exactly why it is that we need it.

Let me return for a moment to the question that the noble Baroness is not asking us—how can Part 3 be improved? I should like to pay tribute to all noble Lords who have played such a constructive role in asking this particular question over the past six months: for example, my noble friend Lord Clement-Jones, who has helped us improve provisions relating to competition; the noble Baroness, Lady Murphy, who made proposals about the list of matters that Monitor must have regard to; my noble friends Lord Marks and Lady Williams for their focus on Monitor’s accountability and the role of the Secretary of State; the noble Baroness, Lady Finlay, who has been a tireless advocate for greater provisions relating to integration; and the noble Lord, Lord Warner, with his improvements to the pre-failure regime. All of these amendments have improved the Bill, and it once again shows the range of expertise within your Lordships’ House.

Given the scrutiny that Part 3 has had and the improvements that have been made, these amendments are not only unnecessary but, I would also submit, deeply damaging. They would harm patients’ interests, denying them the benefits and protections that a comprehensive, purposeful and effective system of regulation will bring. Key providers of essential NHS services would not be subject to sufficient regulation. To sum up, pricing would not be reformed to address the flaws in the current system. The OFT and the Competition Commission would have sole jurisdiction over competition law. There would be no sector-specific legislation to give commissioners legal clarity on securing services without competition. This would mean there was no sector-specific regime for complaints and the only way to challenge decisions would be through the courts, creating a veritable lawyer’s charter, something I think we would all wish to avoid. These amendments are highly misguided and I urge the noble Baroness not to press them.

I thank the noble Earl for his, as usual, extremely expert and very technical response, and I think that he completely missed the point. He did not address the risks that I mentioned all the way through the Bill, the risks that are contingent on implementing so much change so quickly and simultaneously. We will be back here very soon, I suspect, when we will be trying somehow to manage and mend.

I want to make just one or two remarks and will not keep the House very long on this matter. I would like to read to the House a Motion that Liberal Democrat MPs have tabled in the debate that is going on in the Commons right now. Both ends of this building are, as we speak, engaged with their concerns about the Bill. In seeking to amend the Labour amendment in the other place, colleagues of the noble Baroness, Lady Williams, and the noble Lord, Lord Clement-Jones, have said that they decline,

“to support the Bill in its current form”,

and they call for,

“an urgent summit of the royal colleges, professional bodies, patients’ organisations and the government to plan health reforms based on the coalition agreement”.

Would the noble Baroness like to say how many Liberal Democrat MPs have put their name to that particular Motion?

It does not really matter. Five of his colleagues have put their names to it. The point I am making to the noble Lord is that I agree with them about the way forward. It echoes very much what the noble Baroness, Lady Williams, was saying about recognising the disquiet, hostility and fear that exists towards this Bill, particularly this part.

At the end of the day, the Royal College of General Practitioners and the other royal colleges, trade unions, nurses and doctors are the people who will save our NHS, whatever the Government have decided to do to it. They are the people who will actually deliver the healthcare. That is what the royal college of GPs is saying now. It did not say that it resiled from its position about this Bill; not at all. It is acknowledging that, along with the nurses and everybody else, it will deliver this Bill. It will put patients at the heart of the health system. I think that we should all pay tribute to that and be reassured by it.

The noble Lord, Lord Newton, said that mergers will still proceed. They will still proceed regardless of whether this amendment is agreed. However, he also said that good people leave when there is disruption in the health service. That is very true. They are leaving in their droves. We are losing hundreds if not thousands of good people from the National Health Service because of the past two years, the White Paper and the Bill.

I thank the noble Lord, Lord Crisp, for his remarks—I think he was very wise—and the noble Baroness, Lady Williams, for hers. She is quite right. I am flattered that she took my remarks seriously, because this is not about wrecking the Bill. I did not tackle any of the policy issues that the noble Earl chose to stand up as Aunt Sallies and then knock down. When I introduced the amendment, I said that this was about doing things in an orderly fashion, in a way that would help to save our NHS. That is the point. The noble Earl did not tackle any of the risks that I raised about how to deliver the Nicholson challenge simultaneously with all the other changes in the Bill. In fact, he went close to saying that we have gone too far anyway to stop that. I was not convinced by his remarks about the risks and how they might be mitigated. We need time to work on this. We need time to get support for it, if it goes through. The amendment allows us to do that. I wish to test the opinion of the House.

Amendments 300B and 301 not moved.

Amendment 302

Moved by Earl Howe

302: Clause 302, page 272, line 14, at end insert—

“( ) An order under subsection (4) which brings paragraph 16 of Schedule 1A to the National Health Service Act 2006 (inserted by Schedule 2) into force may make provision—

(a) for the duty of a clinical commissioning group under sub-paragraph (1) or (2) of that paragraph not to apply in relation to the whole or any part of the initial period (within the meaning of Schedule 6), and

(b) for the duty of the Board under paragraph 16 of Schedule A1 to that Act (inserted by Schedule 1) to have effect subject to such modifications specified in the order as the Secretary of State considers appropriate in consequence of the provision made under paragraph (a).”

Earl Howe: My Lords, I shall speak to the amendment very briefly. It is a minor and technical amendment that would clarify the Secretary of State’s power to commence the provisions of the Bill relating to clinical commissioning groups. The amendment would apply when it was clear that one or more clinical commissioning groups established before 1 April 2013 would not receive any income nor incur or commit any expenditure directly during the period between their establishment and 31 March 2013. In that event the Secretary of State could when making the order commencing the provisions of the Bill about clinical commissioning groups disapply the accounting and audit requirements for that period. This avoids such CCGs having to create blank accounts for that period, which we do not think is a sensible approach. I beg to move.

Baroness Thornton: My Lords, we would not wish the CCGs to have blank accounts. I would merely like to congratulate the noble Earl on the 336 government amendments made to the Bill. When added to the 1,200 or so amendments made at the other end, they probably make for a very different Bill. I think that I might be able to say with confidence that it is probably a bit of a mess.

Earl Howe: That was a bit of a curate’s egg of a response, but I take it in the spirit in which it was meant. I think that this House has played a very important part in making this a better Bill. I could not claim that this amendment is a particularly large part of those improvements, but I think that it will be a useful one.

Amendment 302 agreed.

House adjourned at 6.23 pm.