Committee (Day 1) (Continued)
6: Clause 3, page 2, line 8, at end insert—
“(ba) after subsection (2) insert—“(2A) The Secretary of State must specify in the mandate maximum waiting times for access to NHS services, including—(a) a maximum waiting time standard of 18 weeks from GP referral to first treatment;(b) a waiting time standard for the time it takes to diagnose rare and less common conditions following a GP referral.””Member’s explanatory statement
This amendment would require the Secretary of State to deliver the existing 18 week waiting time target and ensure a maximum waiting time standard for the diagnosis of rare and less common conditions is introduced.
My Lords, with 6 million people in England waiting for operations and routine procedures, many of whom are in pain, I make no apology for moving my amendment at the start of this grouping, which seeks to ensure that the 18-week waiting time target is maintained as a key part of the NHS mandate. This group also covers key amendments on the commissioning role of integrated care boards in relation to specialised healthcare services, and on the duty of ICBs to share best practice on innovation and the quality of services.
On waiting lists, the pandemic has resulted in a huge backlog of care and treatment, compounding pre-existing challenges. The 18-week waiting time standard has not been met by the NHS since 2016. Instead, we have a situation where the NHS’s latest planning guidance sets out plans to eliminate only waits of 104 weeks, to reduce waits of 78 weeks and to support an overall reduction in 52-week waits. Even as a temporary measure this should be unacceptable, and at best we should have a commitment and a plan to restore performance.
Last week’s report from the Health and Social Care Select Committee described the unquantifiable challenge faced by the NHS in addressing the backlog, with 300,000 people now waiting for more than a year for treatment for surgery, such as hip or knee replacements. We know the devastating suffering that the long delays in diagnosing cancer and other diseases such as heart conditions or stroke are causing. The Secretary of State himself said that the waiting list might grow to 13 million, and that was before the current omicron wave, which has only exacerbated this challenge. His promise in November to publish the Government’s plans to meet the workforce requirements needed to address staff shortages and the record waiting lists has yet to materialise.
Of course, this is not just about elective care. In emergency departments, waiting lines in October 2021 were the worst since records began, with one in four patients waiting longer than four hours to be admitted, transferred or discharged, and with trolley waits at a record high. October last year saw the highest number of 999 calls on record. There is a serious risk that the ongoing crisis in emergency care could derail the elective recovery programme.
Although the problems are manifold, prioritisation of the elective backlog is understandable. However, a focus on those areas most amenable to numerical task risk effectively deprioritises other equally important areas such as primary care, community services and mental health services, which all play a crucial role in keeping people healthy and out of hospital. It would be helpful if the plans around recovery in other aspects of care, with some sort of target or at least objective spelled out, were also made known—access to GPs being a primary example.
We know that workforce shortages are the key limiting factor on success in tackling the backlog. Without better short and long-term workforce planning, the 9 million additional checks, tests and treatments will not be deliverable. NHS England’s chief executive, Amanda Pritchard, told the Select Committee that the NHS currently has 93,000 vacancies for NHS positions and shortages in nearly every speciality. The social care workforce has, at present, 105,000 vacancies and a turnover rate of 28.5%, rising to 38.2% for nurses working in social care. Changing the way the cap is calculated will not help this, and of course discussions on both the cap and the need for a credible and systematic workforce plan in the light of the current chronic staff shortages will follow later in the Bill.
The waiting times focus of my amendment, which seeks to insert a new paragraph into Clause 3(2), is tangible and measurable, as are the constitutional targets. In the context of the huge challenges the NHS faces, the 18-week waiting time target remains vital. The discipline it imposes helps focus the entire system on the needs of patients. It drives behaviour and focuses funding, and it facilitates the organisation of seamless care for the patient, from the GP practice through diagnostic tests, out-patient care and, ultimately, if needed, to in-patient treatment. It gives leaders at local level in particular the leverage they need to unblock barriers to speedy care, such as delayed discharges from the hospital—another key issue on which we will focus later in the Bill.
The second part of my amendment reinforces the importance of the target for care for people with rare conditions and mental health conditions, which can all too often be Cinderella areas—overlooked in favour of more common conditions. I have a personal interest, which I declare, as vice-chair of the Specialised Healthcare Alliance, a coalition of more than 100 patient-related charities, groups and corporate supporters campaigning for improvements to care for patients with rare and specialised conditions, and for greater awareness of their needs, treatment and support.
The amendment also underlines the need for speedy diagnosis for this key group of patients. The SHCA chair, the noble Lord, Lord Sharkey, has added his name to my amendment and will speak on the importance of this in his contribution. He will also speak to Amendment 19 in this group, to which I have also added my name, which would ensure that ICBs
“commission specialised services in line with national standards”,
that their performance in this regard is published and monitored, and that there are safeguards that will operate if this commissioning role is removed from an ICB.
On treatment standards, can the Minister reaffirm that despite the current situation, every patient legally retains the right to treatment within 18 weeks? If so, what steps can patients take if the NHS does not deliver in line with this requirement? Can he assure the House that the Government have no plans to weaken this legal right and are fully committed to returning the NHS to an 18-week standard?
I am also speaking to Amendment 60 from my noble friend Lady Thornton, which would insert a new subsection, within the proposed new sections in Clause 20 on ICBs, to ensure that innovation and best practice on the quality of services
“is shared … openly and prevents individual trusts and foundation trusts from refusing to share beneficial developments or improvements through any issues around competition between organisations.”
This is crucial in helping to overcome any obstacles linked to the autonomy or independence of the organisations evolved.
We also support Amendment 215 from my noble friend Lady Merron, which would insert an important new clause after Clause 80, requiring the Secretary of State to publish an annual report to Parliament
“on waiting times for treatment in England, including disparities”
across the country. It is vital that this report also details the steps taken to ensure that patients, in line with their rights under the NHS constitution, are able to access services within minimum waiting times.
We also note Amendment 21 from my noble friend Lord Davies. He will be fully aware of Labour’s support in commissioning from the NHS as the preferred provider. His amendment is borne out of the right motivations but, I am afraid, misses the point that there are many social enterprises, charities and community organisations whose delivery of healthcare is vital to the functioning of the NHS and social care—for example, in end-of-life care—and we fully support the key role that they play.
The situation facing the NHS as it struggles to address waiting times and lists is dire, yet the recent NAO report on waiting times recovery pointed to some reasonable projections indicating that, far from improving on the current trajectory, the position will be even worse in March 2025 and beyond. That takes into account all the Government’s promised funding. The situation has echoes of the 1990s; Labour was able to address the challenges then, under different circumstances, but the current challenges are even harder. By 2010, the situation had improved to such an extent that demand for private healthcare had dropped. Now we see the opposite, with people having to pay to jump the queues.
Targets were an important part of how improvement was achieved through Labour’s three terms, backed by greater investment and a genuine commitment to public service solutions. The NHS responded to the confidence placed in it but today, there is no plan and no commitment, and totally inadequate funding to address the waiting times issue—the issue that patients are usually most concerned about. The NHS Mandate and the NHS constitution contain crucial rights and standards of care for patients and stakeholders, ensuring that the NHS has basic stability, knows what is expected of it and can be judged on its performance. We must keep the 18-week target and make sure that it is not fudged away. I beg to move.
My Lords, I declare an interest as chair of the Specialised Healthcare Alliance. I will speak to Amendment 6 and 19. I added my name to Amendment 6 and I wholeheartedly support the points made by the noble Baroness, Lady Wheeler, in her eloquent opening remarks. I will make a few brief supplementary points on rare and less common diseases.
Proposed new subsection (2A)(b) in Amendment 6 refers to waiting times for a rare disease diagnosis and is intended to probe the Government’s ambitions in this area. The Government’s rare disease framework noted that it can take years to receive a final and definitive diagnosis of a rare disease and that some people living with a rare condition may never receive one at all.
In 2019, the Government’s national conversation on rare diseases found, perhaps not entirely surprisingly, that getting the diagnosis right was the number one challenge in rare disease care. But the process of getting this diagnosis has been called, entirely understandably, an odyssey—many journeys, many ports of call, and many difficulties. This odyssey frequently involves multiple referrals, inconclusive tests and even incorrect diagnoses before a final definitive diagnosis is arrived at.
The rare disease framework makes a very welcome commitment to making improvements in this journey. I would be grateful if the Minister could say what concrete steps are being taken to bring about the desired improvements to arrive at Ithaca much earlier and in better shape. For example, the rare disease framework talks of a need to improve diagnosis rates. How is this to be measured and what is the baseline to be? Is there a target that the Government are working towards? If there is, when is it expected to be reached? The framework also commits to making use of advanced diagnostics to improve the speed of diagnosis. Can the Minister say what new technologies are being deployed and which are under active consideration? Finally, the spending review announced funds for a new newborn genetic screening programme. What might we expect in terms of a timeline for the piloting of this programme and its wider implementation if the benefits are proven?
I turn to Amendment 19, in my name and that of the noble Baroness, Lady Wheeler, for whose support I am grateful. We have around 3.5 million people with rare or less common diseases or complex conditions. This number grows as our population ages. Many of these people require specialised treatment of one kind or another. Currently, these treatments are provided by the specialised commissioning team of NHS England. In total, there are 149 specialised services directly commissioned by NHS England, and in 2018-19 £18 billion or so was spent on these services.
There are some problematical aspects to the large-scale direct national commissioning of this very large range of specialised services. The NHS points to these in its paper of last January, Integrating Care: Next Steps to Building Strong and Effective Integrated Care Systems across England. It said that
“these national commissioning arrangements can sometimes mean fragmented care pathways, misaligned incentives and missed opportunities for upstream investment and preventative intervention.”
The paper goes on to propose a new model whereby the provision of some specialised services can be delegated to be more responsive to place-based needs and local collaborations.
The NHS proposes that there will be four principles underlying this new approach to the delivery of specialised services. The first is that all specialised services will continue to be subject to consistent national service specifications and evidence-based policies determining treatment eligibility. The second is that strategic commissioning, decision-making and accountability for specialised services will be led and integrated at the appropriate population level. The third is that clinical networks and provider collaborations will drive improvement, service change and transformation across specialised and non-specialised services. The fourth is that funding of specialised services will shift from provider-based allocations to population-based budgets, supporting the connection of services back to base.
Amendment 19 is a probing amendment to allow us to ask a few detailed questions about how these principles will operate in practice. The first is to do with the ability of ICBs to commission specialised services in line with ongoing national standards. How will this ability be assessed, and by whom? Can the Minister confirm that being judged to have the appropriate ability will be a transparent decision and an absolute condition of delegation? Following this, can the Minister also confirm that there will be at least an annual published review of ICBs’ performance in the commissioning of these specialised services? Can the Minister tell us what the circumstances are in which such a delegation of specialised commissioning may be withdrawn? What is the legal mechanism for doing that? Finally, there is the question of money. How can we be sure that the appropriate funds are spent by ICBs on specialised commissioning? Is a ring-fencing of funds being considered, for example?
I close by noting the many successes of the NHS specialised commissioning group and its frequent and very welcome engagement with patient groups and the Specialised Healthcare Alliance.
My Lords, I shall speak to my Amendment 21, and I support the other amendments in this group. Before I reach the meat of my remarks, it seems a long time ago, but two hours ago we were discussing mental health. I did not intervene in that debate, although the issue is very close to my heart. I totally support everything that was said in that debate, but I was gearing myself up for this contribution, not knowing that I would have a two-hour interlude.
This Bill in general is not the answer to the immediate and long-term crisis in the NHS and social care sector, but the particular concern I raise through my amendment is the widespread fear that the new arrangements being proposed will lead to the growth of the private provision of healthcare, with multi-million-pound private sector service contracts leading to the loss of the public service ethos of the NHS. I have no doubt that the Minister is well aware of these concerns. It is no secret; they have been widely discussed in the columns of the national press and professional journals. For example, Jan Shortt, the general secretary of the National Pensioners Convention, has said:
“This Bill truly represents a creeping backdoor privatisation of health care services, which despite government claims, will badly impact on the patient care across the UK.”
So I do not think that there is any question that these concerns exist.
The Government have promised that there are no plans to privatise the National Health Service, but that is quite different and distinct from the privatisation of healthcare services, shown specifically, or most starkly, by the increasing number of US-owned private companies which already provide them for the NHS and obviously seek an expanded share of the market. It is worth noting the not sufficiently reported or commented on fact that the Chancellor of the Exchequer, Rishi Sunak, was unable to attend a meeting with our hard-pressed services sector because he was busy in discussion—according to a report in the Financial Times—with US healthcare providers when he was in California recently. The Government should not insult us by suggesting that there is not an issue here of the growth in the provision of healthcare by commercial interests.
Even with the amendments to limit private companies being represented on integrated care boards, there is absolutely nothing here to stop private companies playing a part in other ways—for instance, clearly at the sub-system level via place-based partnerships and provider collaboratives. There is this whole word salad of different ways of describing these organisations operating at that level below, for or with the integrated care boards in providing services. This is the Trojan horse that will bring private provision within the walls of our publicly provided NHS.
NHS England states clearly in guidance:
“Independent sector providers can be members of a provider collaborative, but the extent of their participation may depend on the specific form and governance arrangements and the nature of a particular decision being taken by the collaborative.”
Dig through these words and they mean that we just do not know what arrangements will actually be established in this new world of provision. Guidance from NHS England also states:
“The Health and Care Bill, if enacted, will enable ICBs to delegate functions to providers including, for example, devolving budgets to provider collaboratives.”
It is this uncertain nature of the exact administrative arrangements that will apply under the new scheme that leads to the level of concern. As place-based partnerships and provider collaboratives are allowed to include private companies, the Government’s rhetoric about protecting the independence of ICBs is hollow. For all the talk from the Minister in the House of Commons of recognising that
“the involvement of the private sector, in all its forms, in ICBs is a matter of significant concern to Members in the House”—[Official Report, Commons, Health and Care Bill Committee, 14/9/21; col. 258.]
the Government have not taken the action needed to stop private companies exerting excessive influence in decision-making in the health service.
The defence against such developments will be in the hands of the ICBs, hence the concerns expressed today about their membership. This is the Minister’s opportunity to assure me, your Lordships and the many bodies outside this House which have expressed concerns that our concerns are misplaced. Simply dismissing them will not work. I note the remarks of my noble friend and maybe my amendment is not the best way of achieving my objective of getting the Government to put boundaries on commercial development within the health service, but I hope that the point of principle will be addressed and will not hide behind the limitations of my amendment.
My Lords, I would like to intervene on this group, in particular to support Amendment 19. I am grateful to the noble Lord, Lord Sharkey, and the noble Baroness, Lady Wheeler, for tabling it. As the noble Lord said, it gives us an opportunity to probe the arrangements for the commissioning of specialised services in the future. I hope my noble friend will be able to clarify that tonight and perhaps add further clarity as we go on.
I want to talk about this because I remember that a decade or more ago, even though the NHS was a single organisation with a single responsibility for specialised commissioning, most of this was in fact delegated to strategic health authorities. My experience was that, with the separate budgetary responsibilities of strategic health authorities and their ability to commission those services themselves, we ended up with considerable disparities and inconsistencies in the commissioning of specialised services. We know this must be the case because, after NHS England took over the responsibility in 2013, one of its most challenging tasks, not least in financial terms, was to secure a common specification and common service standards. The objective was of course not to level down, but level up, in the finest traditions of the present Government, and that levelling up was expensive. As we will all discover as time goes on, levelling up is expensive by nature. It was challenging to NHS England at a point when resources were highly constrained.
That having been achieved, we are all very clear that we do not want to go back to the bad old days but—I thought the noble Lord, Lord Sharkey, was very fair about this—there is a counterargument. Many patients, even if they have a less common condition, actually receive much of their healthcare locally, from local providers through local commissioning arrangements. They need to be integrated, and things such as access to chemotherapy for common cancers or diagnostics through the community diagnostic centres, as they are created, may be more appropriately commissioned for those patients by a local integrated care board rather than NHS England directly.
However, as the noble Lord, Lord Sharkey, referred to, there is the principle of setting commissioning at appropriate population levels. As I know from experience, the NHS can consume endless time and energy trying to work out the geography of these things and what population is right for what purpose. If nothing else, even if they multiply the tiers from place-based to ICSs to regional teams to NHS England, the present arrangements at least give specialised services a chance to be commissioned and led at an appropriate population level. For many specialised services, that is not at the level of an integrated care board, as the population may be too small for them.
We know that highly specialised services will be retained by NHS England. If some services that need to be integrated locally, for the benefit of patients, are with the ICSs, there is none the less a question, about which we need to hear more, on the extent to which NHS England will manage the commissioning by using regional teams to try to maintain national specifications and service standards through their own responsibilities.
An opportunity that has not been referred to and is not in the Bill, but may be useful in practice, is to learn from the experience and, I hope, capability of the specialised commissioning team at NHS England and have a specialised commissioning support unit. It could stand behind the regional teams or even the ICSs, if appropriate, to help them have the capability to commission effectively. Amendment 19 asks the right question: this responsibility should not be delegated to individual integrated care boards unless NHS England is clear that the capability subsists at that level. We have to accept at the start that it probably does not.
I referred earlier to outcomes which, for providers in the NHS, are often at their highest in specialist hospitals. We have a dozen or more specialist hospitals, of which the majority of services—up to 80% in one or more cases—are commissioned as specialised services. We want them to have a more coherent structure of commission; we do not want them to have dozens of contracts with integrated care boards, all over the country. I hope that NHS England, in the regime that puts commissioners and providers close to one another, at least looks out for specialist hospitals and says, “We should have a lead commissioner of these services”. It may well be that the lead commissioner is in NHS England and sets up the contract there.
My final point is on the very reasonable question asked by the noble Lord, Lord Sharkey, about budgets. Why were strategic health authorities differentiating in the way they did? Their budgets forced them into different decisions in different places and, over time, that increased the degree of divergence and inconsistency. The same will happen with ICSs, unless some very clear countermeasures are taken. They could be ring-fenced budgets or some other such mechanism, but the budgets might have to be held not locally but centrally, even if some of the functions are delegated more locally. We have to be aware that, when you start to shift and delegate budgets, it is very hard then to maintain national service standards. That should be done only when it is very clear that the safeguards are in place. I hope we can use the debates on the Bill as a mechanism to give those who rely on specialist services and the providers of them greater clarity and assurance about how they will go about that in the future.
My Lords, I support Amendment 60 in the name of my noble friend Lady Thornton on the need for ICBs to share innovations and good practice widely, in the spirit of collaboration. The NHS has for many years been rather poor at sharing and adopting innovations compared with, for example, local government, where several effective networks exist for the sharing of good practice and there is a real culture of such sharing.
The Science and Technology Committee, under the chairmanship of the noble Lord, Lord Patel, reporting on its inquiry into the life sciences, found that the NHS ought to be a unique opportunity for the spread of innovation across the system—that is what the “N” in NHS is all about—but that it was a long way from realising that aspiration. The evidence from NHS England’s director of innovation was lacklustre in the extreme, and progress from NHS Improvement was slow. The Select Committee report said that the current structure of the NHS “stifles innovation”.
When I was chief executive of Diabetes UK, I discovered how even getting innovations and improvements that would save the NHS substantial money was like pulling teeth. In frustration, I wrote to the then Chancellor—slightly tongue in cheek—to tell him how to save a billion quid by implementing the best practice patient pathways for diabetes patients. I am still waiting for a response.
In an effort to see how other countries’ health systems handled improvement and innovation in diabetes care, I went to Canada and the USA, and came to the conclusion that collaborative health systems such as Canada’s were better at sharing and then adopting improvement and innovation than competitive ones like the United States. My noble friend Lady Thornton’s amendment is highly necessary and sets the tone for a collaborative rather than a competitive approach, which should be at the heart of the NHS for the future.
My Lords, I will say a few words about specialised services on the basis of a committee that I chaired about five or six years ago at those services’ request. It followed the demise of strategic health authorities under the 2012 Act. The one thing that this committee demonstrated very clearly was that population was significant and that, if you ignored population, you were not likely to get good outcomes. There was no magic figure on population but it was of a size common in the territories of most of the SHAs. That is not to say that the SHAs did a crackingly good job, but they were the organisations with the size of population necessary for good commissioning of many of these specialised services.
The trouble was—and it is the same trouble mentioned by the noble Lords, Lord Lansley and Lord Sharkey—that if you have a regional system, by definition you give it some degree of control over its priorities. It follows almost as night follows day that different regions will take different views about the significance of specialised services in their particular region. We have struggled with this issue for many decades and not found it easy to come up with a solution.
You can go the whole hog and put it on NHS England, but that poses the problems that the noble Lord, Lord Sharkey, honestly owned up to: many of the people with these conditions are getting a range of services outside that specialised commissioning service. I came to the conclusion that you have to have something that is of the size of, or of a similar size to, the former SHAs, but you do need a role at the centre trying to ensure a level of consistency of approach in those larger areas. I think we are still fumbling our way towards the right mix of that and I cannot see that we will be able to put in this legislation a definitive answer to that particular set of conundrums.
While I am on my feet, I shall speak to Amendment 215, to which I have added my name. To some extent, I reinforce the seriousness of the situation that Ministers and the public face with the enormous backlog of patients awaiting treatment that the noble Baroness, Lady Wheeler, drew attention to. I refer the Committee’s attention to the excellent report by the National Audit Office published about six weeks ago. This report made it absolutely clear that in September 2021 there were nearly 6 million people on the waiting list for elective care and that one-third of these people had been waiting longer than the waiting standard of 18 weeks. Some 300,000 rather unlucky people had been waiting in pain and discomfort for more than a year. The NAO made it clear that even before Covid-19, many parts of the NHS were not meeting the waiting time standard and that about one in five cancer patients was not meeting the waiting standard for urgent referrals by GPs—that is a pre-Covid situation that has simply got worse as time has progressed.
I recognise that the Government have promised to provide an additional £8 billion between 2022-23 and 2024-25, some of which they expect the NHS to use to increase elective capacity by 2024-25 by 10% more than its pre-pandemic plans. I have to say, as a former Minister responsible for reducing waiting times and implementing the original 18-week maximum wait, that Ministers need to realise that announcing the extra money is the easy bit; putting in place a system for ensuring that the NHS leviathan actually uses the money for its intended purpose and can demonstrate delivery of the promised outcome is an entirely different matter. It took the Blair-Brown Governments from late 2004 to early 2008 to deliver the 18-week maximum wait and the cancer targets, using a lot of different tools in the ministerial toolbox.
There is not one simple solution to delivering these changes. The regimes that were implemented by those two Governments used a lot of extra money; a relentless, transparent measurement; and a great deal of clinical and political management pressure. They used expanded patient choice, so that patients could drive change, and I have to say to the noble Lord, Lord Davies of Brixton, that they also used the private healthcare system to increase diagnostic and surgical capacity by about 10% to 12%, but they did so at NHS prices. So, there is not a single solution; there are a lot of solutions that have to be applied and measured.
A critical factor in this is keeping everybody honest through transparent information about how progress is being made. If that is lacking, you are probably doomed to fail. The strength of Amendment 215 is that it puts in place a system for regular reporting of progress being made—or not being made, in some cases. It is important, as my own experience has shown, to know which parts of the country are doing well and which are not doing so well, so you can actually ensure that some action is taken on the slowest ships, as they say, in the convoy.
It should come as no surprise from what I have said that I strongly support Amendments 6 and 19 and do not support Amendment 21. I recognise, as we were discussing earlier this afternoon—time flies; I mean this evening—the whole issue of health outcomes and outcomes frameworks. Those are very important. However, at the end of the day, you cannot secure good outcomes without speedy access to clinical services. You do not get them. Waiting times of the length we currently have can lead only to poor outcomes. We must put in place systems that measure the progress being made in driving these waiting lists down. Given the seriousness of the situation, we need something about this in primary legislation to ensure that people across the country and the NHS are moving in the same direction in driving waiting times down.
My Lords, I want to say a brief word in support of the amendment on innovation in the name of the noble Baroness, Lady Thornton.
Having just been the Minister for Innovation, I can tell noble Lords that they could fill their entire diary travelling the country and seeing fantastic innovation in the NHS up and down the country. Noble Lords could fill their Zoom calls speaking to countries around the world that look to the NHS for some of the best innovation and partner with it on innovative programmes. However, that innovation is often extremely isolated and rarely spread evenly across the whole country. In fact, I often thought that my job title should have been not Minister for Innovation but Minister for Adoption because my role should have been to take the best that the NHS does and spread it across the country more evenly. That is the objective of the Government’s health policy at the moment: to see a much more even spread of best practice right across the country.
Although we cannot legislate for culture, we can give signals to the system about what we think is important. I therefore think that the noble Baroness, Lady Thornton, is on to something in suggesting this amendment. It should be given careful thought by the Minister.
My Lords, I rise to offer Green support for all the amendments in this group. I will split them into two groups internally. First, I will speak to Amendments 6, 19, 60 and 215; I will then deal with Amendment 21 in the name of the noble Lord, Lord Davies, separately.
All these amendments are about transparency and targets. When we look back to when targets were a particular focus—when the NHS was under the control of the party on these Benches—there were concerns that targets could sway provision and medical judgments. There was a concern that this was about the management of targets rather than the outcome for the patient. However, if we think of targets as foundations and basic standards that need to be met, it is really important that we ensure that there is enough funding for local priorities and concerns to be addressed to reach a higher level.
Amendment 215, which refers to an annual report, is particularly interesting; I know that it has full cross-party support. This is about people knowing what the NHS is achieving and, importantly, whether there is enough provision in it. Of course, your Lordships’ House is not in a position to demand that more money goes into the NHS; by constitutional norms, we cannot deal with spending. However, I think that we should frame this debate—this is my first contribution in Committee—by looking at the pre-Covid figures. The UK was spending £2,989 per person on healthcare; this was the second-lowest in the G7. France was spending £3,737; Germany, £4,432.
Of course, the great outlier in this is the US, spending £7,736 a year. It is worth noting that we seem to be chasing so much after the US healthcare model, which is so absolutely disastrous. Most of the amendments in this group are a way for your Lordships’ House to give the public the tools to say that we need to improve the resources of our NHS.
The noble Lord, Lord Warner, really got to the point of just how much under pressure the system was, even before we hit Covid-19. I briefly draw your Lordships’ attention to the Central Bylines website, and the tragic report of the death of Jacob Roche, written by his wife, June Roche. I was going to talk about this in detail, but I am aware of the time and will not. However, I urge noble Lords to look at the incredibly stretched nature of our NHS—the report is about December, so before omicron—which cannot be solely attributed to Covid, as the noble Lord said.
Amendment 21 sits rather oddly in this group, and I think many issues I raised at Second Reading will come up in later groups. I associate myself with all the comments of the noble Lord, Lord Davies of Brixton, about the concern around private sector involvement. My reading of his amendment is that it does not address a community-run hospice or a local consortium of physiotherapists. It is particularly looking at integrated care boards and the involvement of the private sector in management systems. If we analyse why the US system is so expensive for such disastrous results, we see that administrative costs are a really important part of that.
I would say that the profit motive should have no place in healthcare. Think about the cost of the profit motive. It has an influence on decisions because, after all, the private companies’ job is to make profits; there is also the fact that money going into profits is not going to healthcare.
My Lords, these are important amendments and I am grateful to all the noble Lords who tabled them. Perhaps I could start with the amendments relating to waiting times, before going on to those about ICB functions.
Beginning at the end, as it were, Amendment 215 would legislate for an additional duty for the Secretary of State to publish a report annually on waiting times for treatment in England, disparities in waiting times for treatment and the steps being taken to ensure that patients can access services within maximum waiting times, in accordance with their rights in the NHS constitution.
I entirely understand the intention behind the proposed new clause. It is important that patients can access healthcare within reasonable waiting times and it is important for all of us to have visibility of the waiting list size, as well as waiting times, in England. Your Lordships will understand that the Covid-19 pandemic has caused an unprecedented strain on the NHS, bring about significant disruption. It has shone a light on disparities and led to the largest NHS waiting list on record. It is a priority of this Government to reduce waiting times, tackle disparities and provide access to healthcare as quickly as possible to patients.
Although the situation is difficult, I think I can give reassurance on three grounds. First, the NHS already has waiting time standards. Some are enshrined in legislation and some are operational standards, but all are described in the NHS constitution and the accompanying handbook. Since March 2007 the NHS has published monthly official statistics on waiting times. This includes consultant-led referral-to-treatment waiting times, which monitor the length of time from referral through to elective treatment. It also includes the number of patients who began cancer treatment and waited longer than 62 days for cancer treatment. NHS England also publishes monthly management data on the number of people currently waiting longer than 62 days for diagnosis or treatment.
Secondly, the department already submits information on waiting times to Parliament as part of its annual report. Much of this data is very similar to that asked for in this amendment.
Thirdly, as I speak, extensive work is already being undertaken by the NHS so that patients can access services within maximum waiting times. The funding we have announced for elective recovery, including cancer services—with £2 billion this year through the elective recovery fund and £8 billion over the next three years through the health and social care levy—will increase activity, reduce waiting times and deliver millions more checks, scans, procedures and treatments. We also announced £5.9 billion of capital funding at the October 2021 spending review to support elective recovery, diagnostics and technology over the next three years, which will further reduce patient waiting times.
Fourthly and finally, we will set out in the elective recovery delivery plan how the NHS will deliver increased elective capacity and reduced patient waiting times for elective services, including for cancer patients. I hope that provides a degree of reassurance that we approach reducing waiting times seriously and that the data is available to hold us and the NHS to account for progress.
I now turn to Amendment 6 tabled by the noble Baroness, Lady Wheeler, and the noble Lord, Lord Sharkey, which would require the mandate to specify maximum waiting times that NHS England should ensure the NHS meets. This would include the current 18-week referral-to-treatment waiting time standard as well as waiting times for diagnosis of rare and less common diseases.
The Government should always consider whether the mandate to NHS England should set expectations on waiting times. I do not think the mandate has ever been silent on waiting time standards, and nor would I expect it to be. I firmly believe, though, in the principle that the Government of the day should be free to set a mandate based on the priorities that they have been democratically elected to deliver. These will inevitably change over time in light of improvements in services and technology, as well as evolving patient need.
However, requiring the mandate to continuously include waiting time standards is unnecessary because important waiting times set out in legislation or NHS operating standards are reflected in the NHS constitution, as I mentioned. NHS England and other organisations that commission or provide NHS services have a long-standing duty to have regard to the constitution, in addition to NHS England’s duties in respect of the mandate.
I now turn to the amendments relating to ICB functions. I again thank noble Lords for bringing these matters to the Committee today. Amendment 19, tabled by the noble Baroness, Lady Wheeler, and the noble Lord, Lord Sharkey, seeks to amend Clause 8, which ensures that NHS England is able to direct integrated care boards to take on responsibility for the commissioning of specialised services on its behalf. The noble Lord, Lord Sharkey, asked me a series of detailed questions on that theme. If he will allow, I will write to him on those that I am unable to deal with in the remarks that follow.
The first thing to say here is that NHS England does not propose to use Clause 8 initially. The intention is that any delegation is agreed with ICBs. Delegating some direct and specialised commissioning to ICBs makes sense, because it is likely to be an enabler for integrating care and improving population health. It gives the flexibility to join up key pathways of care, leading to better outcomes and experiences for patients and less bureaucracy and duplication for clinicians and other staff.
My concern about the amendment is that it would add to the bureaucratic burden rather than reduce it. It would create an unnecessary set of regulations as well as duplicative reporting mechanisms, as regulations made under Section 13YB(3) can already be used to impose conditions, which could include creating national standards. Furthermore, Section 14Z50(7) already puts a duty on NHS England to undertake yearly performance assessments of each ICB. These are focused on how each ICB has performed its function through the year, including the commissioning of specialised services that may have been delegated.
I say to the noble Lord, Lord Sharkey, that we fully recognise that Covid has significantly impacted on waiting lists, including for specialised services. The investment that we have announced to reduce waiting times should also impact on waiting times for specialised services. NHS England is keen to see progress in that area as much as in any other. We will hold it to account for that progress.
My noble friend Lord Lansley and the noble Lord, Lord Warner, expressed concerns about the risk of growing disparities and inconsistency in the quality of specialised healthcare around the country. The key point that I would emphasise is that NHS England will retain responsibility for setting national standards as well as service specifications and access policies. These will apply to all prescribed specialised services, whether they are retained for commissioning by NHS England or become the responsibility of ICBs to commission. It may be a single ICB, but it may be a group of ICBs commissioning; it will depend on the type of service and the size of the ICB.
NHS England will therefore remain the accountable commissioner for all specialised services and will ensure that the appropriate safeguards are put in place for those services that may be delegated to ICBs or groups of ICBs. Only services that are considered appropriate for more integrated commissioning would be delegated; that is, those services that are suitable and ready. There will be services that are not appropriate, and these will be retained for commissioning by NHS England. As I am sure the noble Lord, Lord Warner, well knows, we need to remember that the list of prescribed specialised services contains very highly specialised services such as hand transplants and much more routine services such as dialysis. Whereas those on the upper end of the scale will always need to be commissioned nationally —I cannot see any alternative there—it is right that those more common services can be commissioned more locally.
I turn next to Amendment 21, which I am grateful to the noble Lord, Lord Davies, for bringing forward. I do not in the least dismiss the issues that he has raised. I understand the spirit in which the amendment was brought and hope that I can give some reassurance on two counts: first, that it is not our intention for ICB functions to be delegated to private entities, and, secondly, that safeguards are already in place.
It is perhaps also worth drawing the Committee’s attention to the narrowness that this amendment would impose on the delegation of functions. It would prevent delegation of functions to other statutory public bodies such as local authorities. As the noble Lord will appreciate, this would run counter to our desire to support further integration and to allow the pooling of budgets and functions between the NHS and local authorities. This has been a fairly long established practice and has worked well to support joint commissioning, service improvements and more seamless services for patients.
The power to delegate functions is crucial to unlocking the innovation and integration that the Bill is aiming for. Different areas will have different circumstances, and it is important that they have the flexibility to build arrangements that work best for them, their patients and the public. However, I understand the concern that functions could be delegated to private companies; I assure the Committee that this is not the intention and we do not expect it to happen.
Private providers are not included in the specific list of bodies which an ICB can arrange for functions to be exercised by or jointly with in the Bill. Furthermore, NHS England may issue statutory guidance on delegation and joint committees, which we expect it to do. This is likely to include scenarios, case studies and model delegation agreements. ICBs will have to have regard to this guidance.
Crucially, regardless of whether or not a function is delegated, the ICB will always remain ultimately responsible for it and will continue to be assessed and overseen by NHS England on how well it is discharging its functions. The key point here is that delegation is not a means to avoid accountability. Neither we nor NHS England will allow it to become so.
On the integrated care provider contract, I assure the Committee that it continues to be our intention that it should be awarded only to statutory bodies. The published draft integrated care provider contract is suitable for entering into only with statutory bodies. This was based on the recommendation from the Health and Social Care Committee.
Finally, Amendment 60, in the name of the noble Baroness, Lady Thornton, would place a duty on ICBs to promote and share best practice and work to remove barriers to achieving this. I am very sympathetic to her concerns to ensure that our health service is effectively integrated and that innovations are shared throughout the system. I am glad to reassure her that this sort of integration is a core part of the Bill and will already be delivered by existing proposals in Clause 20.
I remind the Committee of the proposed duty for ICBs to promote innovation. This would include ensuring that new innovations and best practices are spread freely to ensure that the whole system works efficiently. Secondly, I remind the Committee of ICBs’ duty to promote integration. This requires ICBs to ensure that health services are delivered in an integrated way where they consider that this would improve the quality of services and reduce inequalities of access or outcome. In combination, these duties require ICBs to work to ensure that different elements of the health service effectively communicate with one another to implement innovations and share best practices.
The work to share best practice is already well established. NHS England currently collates and shares best practice case studies of how non-statutory ICSs are supporting innovation and research through its funding of the academic health science networks— 15 regional bodies set up to support the identification, adoption and spread of innovation. The work of AHSNs, which are commissioned by the Accelerated Access Collaborative to spread proven innovation at pace and scale, is a key lever in all this. The national network of AHSNs provides a critical interface between national and local systems in the identification, adoption, spread and scale of innovation. AHSNs drive both the generation of demonstrably useful, evidence-based innovations and their adoption and spread. This includes thousands of innovations supported in the last year, covering millions of patients.
I hope that I have given a measure of reassurance on these matters and that, in consequence, the noble Baroness, Lady Wheeler, will feel able to withdraw her Amendment 6.
I thank the Minister for his detailed and considered response; I very much appreciated it. I listened carefully to what he said about waiting lists; I did not exactly hear his commitment to the 18 weeks, but I understand the reasons that he set out for the Government’s current position on that. I just stress the importance of retaining the 18-week waiting time standard: it must remain a key part of the NHS mandate. Without this target, this discipline—particularly the importance of organising around patients’ needs—will be lost.
I am particularly grateful for the Minister’s detailed explanation on specialised services. I know he has a background in this, as do I and the noble Lord, Lord Sharkey. Commissioning specialised services is very complex and detailed. I was pleased with the way that the Minister described the different roles there would be at national and ICB level. We need to look carefully at what he said to see whether we need to come back to anything, but I hope the Minister will commit to having a full discussion and consultation with charities, patient groups and noble Lords on these complex issues. A number of noble Lords spoke very deeply and movingly about specialised services and their importance, and that is important to the House. Continued discussions, particularly on how the relationship between national standards and ICBs will work, are also important.
I thank my noble friend Lady Young for her support for Amendment 60 and her salutary comments on how difficult it can be to make sure best practice is achieved and followed. That was very helpful. On the Minister’s comments about the reporting to Parliament role, I need to look carefully at what he said about what exists and takes place. I take the point made by the noble Lord, Lord Warner, that it needs to be much more coherent, and we will look carefully at that to see if there is anything we need to come back to. Meanwhile, I am happy to withdraw my amendment.
Amendment 6 withdrawn.
Amendments 7 to 10 not moved.
House adjourned at 9.53 pm.