Committee (5th Day) (Continued)
Debate on Amendment 83 resumed.
My Lords, I shall speak on this group of amendments, and I declare my health and higher education interests, as in the register—and, specifically, my honorary fellowship of the Royal College of Speech and Language Therapists. We have had some excellent speeches, and some forensic analysis, of these amendments, which are so important to ensuring that the workforce is at the centre of the reform programme under the Bill. I cannot match those contributions, so I do not intend to.
However, I would still like to support Amendments 172 and 214, in the name of the noble Baroness, Lady Finlay of Llandaff, to which I have added my name. The noble Baroness spoke eloquently to those amendments, recognising, among other things, the crucial role that allied health professionals play in the delivery of healthcare. It is worth emphasising that allied health professionals are the third largest section of the health workforce, supporting people of all ages with a range of diagnostic and therapeutic interventions both within and beyond health and social care settings. Their contribution can often be overlooked in a narrative that frequently focuses only on the role of doctors and nurses—however important those clearly are.
As we have heard, Amendments 172 and 214 are designed to address those issues. I shall comment particularly on the role of the speech and language therapy workforce; I am grateful to the Royal College of Speech and Language Therapists for its briefing on this matter. There are around 19,500 speech and language therapists in the UK, many of whom have a portfolio career and work part-time. It is estimated that about two-thirds spend at least some of their working time in the National Health Service. Those not working in, or employed by, the NHS may work for local authorities, in schools, in the justice sector—in which I have a particular interest—with speech and language therapists becoming a key part of criminal justice liaison and diversion teams, in the third sector and in independent practice.
However, as already noted, these settings are not represented in current workforce planning. This risks not enough speech and language therapists being trained to meet current and future demand. In turn, this risks people of all ages with communication and swallowing needs not being able to access the speech and language therapy they and their families desperately require. Crucially, there is already a significant backlog identified, comprising unmet need and increased demand—that increased demand exacerbated by the pandemic.
From initial discussions with speech and language therapy services, it is estimated that a minimum increase of 15% is required in this skilled workforce, whereas in recent years the profession has grown by only 1.7% net per year. Amendment 172 would mean that the duty to report by the Secretary of State would include the whole health and care workforce, not only those directly employed by the NHS in England, and Amendment 214 would ensure that workforce planning takes into account the experience and expertise of the whole social care workforce by establishing a workforce board in every ICB area.
For speech and language therapists, establishing an advisory workforce mechanism would help to address current weaknesses of workforce planning in the country. In turn, this would support better service planning and delivery, ensuring that there are sufficient speech and language therapists to meet current and future patient need. I strongly support these amendments, which recognise the value of allied health professionals across many services, who will play a crucial role in the integration of care, which is the purpose of this Bill.
Since the debate has picked up Amendment 285 on the proposal to establish an office of health and care sustainability, I add my voice in support. I was a member of the ad hoc Select Committee on the Long-term Sustainability of the NHS, so ably chaired by the noble Lord, Lord Patel. It was one of that report’s recommendations, and our key recommendation, and we will pick up that debate on another group. In the light of the comments already made on that issue, I recommend our recommendation to this Committee as we develop our thoughts on this Bill.
I hope that the Minister will give a very positive response to ensuring that the role of our allied health professionals is embedded in the plans that will come forward, crucially, on the workforce in our health and care system.
I add my support for Amendments 172 and 214, speaking as a vice-chair of the All-Party Parliamentary Group on Speech and Language Difficulties and a patron of the British Stammering Association. These amendments, which again have the support of the Royal College of Speech and Language Therapists, would do much to safeguard the position of that now rare commodity— speech and language therapists. As has been said by both noble Lords who tabled the amendment, they do not all work in the NHS.
The view of the Department of Health and Social Care is that speech and language therapists should be added to the shortage occupation list, because the profession is facing a range of pressures, including increasing demand in mental health in particular. The NHS long-term plan identified speech and language therapy as a profession in short supply. The need for those therapists must be taken account of in workforce planning.
Similarly, Amendment 214 provides an incentive to ensure that there are enough speech and language therapists to meet current and future demand, which is just not the case at present. I remind noble Lords that meeting communication needs, as well as ensuring the ability to swallow safely—both at risk from a wide range of conditions—are an essential component of well-being, and often safety itself. I hope that the Government will look favourably on these amendments.
My Lords, most of what needs to be said about this group of amendments, which I support, has been said, and said brilliantly well—it has been a wonderful debate. However, I would like to make one more key point. I chair University College London Hospitals Foundation NHS Trust and Whittington Health NHS Trust. In the last two years, during Covid, much of my time has been spent not in your Lordships’ House but walking around both of those institutions, saying thank you and listening to my exhausted staff.
One of the key reasons for putting the issue of reporting to Parliament on workforce planning into the Bill is that our staff—not just their organisations but the individuals themselves—want it to be there. They know what the issues are; they live with the shortages and they know that it has not been thought through. My noble friend Lord Stevens made that very clear: it has not been thought through. If they are not taking early retirement, as some are, they are living with the consequences. We could and should do so much better for them, and for the long term—and our staff know that. For their sake, if for no other, we must put this on the face of the Bill.
My Lords, this has been an extremely rich and vital debate on crucial amendments, albeit conducted in two parts. I will briefly offer the Green group’s support for all of these amendments. I aim not to repeat anything that has been said but to offer some uniquely Green perspectives on this set of amendments.
I will take them in two groups, starting with Amendments 170 and 173 in the names of the noble Baronesses, Lady Cumberlege and Lady Merron. These are particularly important because they very clearly and explicitly lay out the responsibility of the Secretary of State. When I tabled some amendments last week on the Secretary of State’s duty to provide, they met with something of a frosty reception in some quarters—but it is clear from all sides of your Lordships’ House that it has to be the responsibility of the Secretary of State to ensure that there is a plan for the workforce. I stress that that is coming from all sides of your Lordships’ House.
It is worth referring to the King’s Fund briefing, which I do not think anyone has mentioned yet. I will quote one sentence:
“The measures in the Bill to address chronic staff shortages remain weak.”
That is what a respected outside observer says. Your Lordships’ House is seeking to plug that gap. The noble Lord, Lord Lea, suggested that this was all terribly difficult, and that is undoubtedly true, but a lot of people have been thinking about this for a very long time. I was at a briefing for the Royal College of Physicians before the pandemic, in person, with no masks in sight. It was more than two years ago and they were talking about the need for workforce planning, saying, “We know how this should be”. Indeed, on the Royal College of Physicians’ website, more than four score organisations are listed as backing these amendments for workforce planning. So the support is very much there.
That focuses particularly on the medical side of things, but I will refer also to the Age UK briefing. We have had some very valuable contributions about care workers from the noble Baronesses, Lady Verma and Lady Hollins, but Age UK considers that we need to look at this much more broadly. It is calling for a robust accreditation scheme for care workers working in CQC-accredited facilities. We need a different system.
I think it was the noble Baroness, Lady Hollins, who talked about how this is a low-pay sector, but we also need to talk about this differently and recognise that it is also a high-skill sector. I think of some of the care workers whom I have met: care workers who cared for doubly incontinent, aggressive, advanced Alzheimer’s patients, and who had done so for decades. Anyone who claims that these are not people with amazing levels of skill really is denying an obvious fact. We need to acknowledge the skills of care workers and to make sure that they are appropriately remunerated.
I want to pick up another, perhaps specifically Green Party, point that no one else has picked up on. I noted that the chief executive of NHS England was recently forced into a new deal with private hospitals, which she said did not provide good value for money. The deal provides more care in private hospitals to help recovery from the Covid pandemic; it sees the Government going against NHS England and deliberately pushing up the role of the market in healthcare. For those who deny that this is happening, I am afraid this is very clear evidence of it.
I turn to a report of the Centre for Health and the Public Interest, which notes that the great majority of private hospitals rely entirely on NHS staff contributing outside their NHS hours on a self-employed basis. We are talking here about doctors and associated health professionals such as anaesthetists and other clinicians. The NHS paid for their training, pays for their pensions and covers their insurance, yet we talk about private hospitals “helping the NHS”. Listening to this debate, I think that perhaps as part of the amendments on Report, we need to think in the context of workforce planning about the financial contribution to be made by the private sector to the cost of training to adequately recompense the NHS for what the private sector gets out of it to make profits.
I come now to a second group of amendments—Amendments 86 and 214—which look at local responsibilities. I want to make the point that in many cases the needs are local, and that if you train up local people who are already embedded in the community, they are very likely to stay in the community. That is why it is crucial that we have local plans and training pathways, so that a care worker who might want to take those care skills and then become a nurse and maybe a doctor over a lifetime of learning and education can bring all those different skills together, stay in one community and bring all those skills to that community.
I think it was in an earlier debate that the noble Baroness, Lady Brinton, referred to the problem of the shortage of dentists. We have just had the Great British Oral Health Report, and one stat from that which really struck me was that 22% of people in the north-west have not been able to register for a routine dental appointment. This is just the kind of supply problem we are seeing all the time. In the Morecambe Bay area, there are only 49 dentists for 100,000 people, which is obviously grossly inadequate.
I will make one final point, which picks up points made in particular by the noble Lord, Lord Kakkar, and the noble Baroness, Lady Whitaker, about the global aspect of this. There was a recent report from the International Centre on Nurse Migration, working with the International Council of Nurses, which stated that there is now a global shortfall of almost 6 million nurses. On top of that, it is estimated that 13 million more nurses will be needed over the next decade. Currently, the whole workforce is 28 million. This picks up a point that the noble Lord, Lord Patel, raised about pay erosion for all medical professionals, but it is particularly evident with nurses. The noble Lord, Lord Lea, again said that it was difficult to plan. We have to acknowledge that any medical professional in the UK can potentially take those skills and find a ready place to use them all around the globe. We know that many British doctors have gone to Canada, Australia and all around the world—and nurses the same.
We are a wealthy country. Traditionally, we have imported these skills, all too often from places that have a gross shortage—even far greater shortages than we have. We have to stop doing that. We have to train significantly more people than we need, because quite a number of them will, for whatever personal reasons, decide to go elsewhere, even if we are providing them with the best possible working environment we can. So we have to train vastly more people. That is our global responsibility.
My Lords, I start by acknowledging—as I am sure we all do in your Lordships’ House—the value, commitment and contribution of the workforce who are the backbone of our health and social care services. We owe them our gratitude. The noble Baroness, Lady Finlay, and my noble friends Lady Whitaker and Lord Bradley are all absolutely right to acknowledge the breadth and depth of the workforce: that it is a team, and that each part of that team is absolutely connected with the other.
I very much agree with the noble Lord, Lord Kakkar, who said that this debate is absolutely central to all that we are here to discuss and to all that patients need from our health and social care services. I am extremely grateful to noble Lords who have tabled and supported amendments and spoken in this debate. All of them have made a compelling case for a workforce plan that will, if these amendments are taken on board by the Minister, feature a laser-like focus on valuing the entire staff team, along with providing planning, financial resources, responsibility, reviewing and reporting—all essential features of any effective strategy. This begs the question: if we see these pillars in a strategy in every other part of our economy and of the way that our whole society functions, why can we not have this for the NHS and social care?
I am glad to have tabled an amendment that calls for a duty on the Secretary of State to ensure that there are safe staffing levels—this was very clearly emphasised by the noble Baroness, Lady Walmsley, in her opening to this debate. This is extremely important because it places a duty where it ought to be and allows examination and transparency.
Of course, we all know that the situation we are discussing today is not new: the noble Lord, Lord Stevens, spoke to your Lordships’ House about a litany of unfulfilled promises and missed opportunities in workforce planning. The noble Baroness, Lady Harding, spoke of her efforts to resolve this and explained the need, which we see in these amendments, to introduce improvements to the Bill to resolve the matter of workforce supply against the demand that is there. All of that requires a lead-in time, and it has to be underpinned by the requisite funds—there is no shortcut to this. In England, we now have a whole website that is full of guidance, and NHS boards are required to take this into account, and yet there is no national workforce plan or credible plan for funding. Until there is, the ICBs will not be able to plan either. The noble Lord, Lord Warner, rightly pointed out that this is not an either/or situation: we need a national workforce plan, and it has to have the funds to deliver it.
I will draw the Minister’s attention to particular aspects of the amendments: explicit recognition of the need to consult with the workforce through trade unions; that planning must cover health and social care; that timescales for reporting should be testing but not too onerous; and that the financial projections in any workforce plan should be subjected to some level of independent expert verification, through the Office for Budget Responsibility, for example.
Behind all of these discussions, we started in a place highlighted by the noble Baronesses, Lady Masham, Lady Walmsley, Lady Watkins and Lady Bennett, and other noble Lords, who spoke of the crisis of the levels of vacancies that we now see and the impossibility of dealing with this without preparation and resource. Any national plan for the workforce needs to be built from the bottom up and not imposed from the top. I hope that the Minister will consider this when he looks at ways to improve the Bill.
I will raise a couple of related points. The scale of the workforce challenge is well established, but it goes far deeper than just numbers and structures. It goes to issues around workforce terms and conditions and career development, particularly in social care, which the noble Baroness, Lady Hollins, brought our attention to. It also has to deal with cultural issues; there is a clear indication that all is not entirely well in the NHS when it comes to diversity, whistleblowing and aspects of how staff are or are not nurtured and supported.
I have one final specific issue to raise, which we have heard about in the debate today and that I would like to extend: international recruitment. I ask that the Government do more to prevent international recruitment, particularly of nurses and midwives, from countries where it is unethical to recruit, and that this be a part of any future strategy. The existing code of practice on international recruitment is not legally enforceable, so when Unison or others report breaches of the code by recruitment agencies, there is no provision for sanctions to be brought against rogue operators. I ask the Minister to confirm that the code of conduct will be promoted and will be enforced.
The situation in which we find ourselves is fixable. I hope the Minister, in his response tonight, will show your Lordships’ House that he understands the situation, that he understands what needs to be done and that he will do it.
Well, this has been another fascinating debate, and I welcome the contributions from all noble Lords speaking from many years of experience, including former chief executives of the National Health Service and former Health Ministers, medical experts and practitioners. I am grateful to the many noble Lords who have laid amendments in this group; there clearly is a strength of feeling, not only in this Chamber but in the other place. To cut a long story short, this will clearly require more discussion.
However, I am duty bound to give the Government’s perspective on this. We have committed to publishing a plan for elective recovery and to introduce further reforms to improve recruitment and support our social care workforce, as set out in the White Paper, People at the Heart of Care: Adult Social Care Reform. I take the point of the noble Lord, Lord Stevens, that he is aware of many expectations that have passed, and I hope that this time we surprise him. We are also developing a comprehensive national plan for supporting and enabling integration between health, social care and other services that support people’s health and well-being.
The monthly workforce statistics for October 2021 show there are record numbers of staff working in the NHS, with over 1.2 million full-time equivalent staff, which is about 1.3 million in headcount. But I am also aware of the point of noble Lord, Lord Warner, that it should not just be about the number of people working—it is about much more than numbers and quantity; it is about quality and opportunities. We are also committed to delivering 50,000 more nurses and putting the NHS on a trajectory towards a sustainable long-term future. We want to meet our manifesto commitment to improve retention in nursing and support return to practice, and to invest in and diversify our training pipeline, but also, as many Lords have said, to ethically recruit internationally.
On that, I want to make two points. The first is this. When I had a similar conversation with the Kenyan Health Minister and expressed the concern we had about taking nurses who could work in that country, the Minister was quite clear that they actually train more nurses than they have capacity for in their country—they see this as a way to earn revenue. There have been many studies on how remittances are a much more powerful way of helping countries, rather than government-to-government aid. With that in mind, we recruit ethically, and we have conversations.
The second point is also from my own experience. I was on a delegation to Uganda a few years ago and I remember speaking to a local about the issue of the brain drain and our concerns. We were talking about immigration, and he said, “You do realise, though, it is all very well for you to patronise me and say that I should stay in this country, but sometimes the opportunities are not here for me in this country. You talk about a brain drain; I see my brain in a drain”. Sometimes we have to look at the issues of individuals who are concerned that they do not have opportunities in their countries, even if the numbers dictate otherwise. Having said all that, we are committed to the WHO ethical guidelines, but I also think that we should be aware. Look at the way that, post war, the people of the Commonwealth came and helped to save our public services. I hope we are not going to use this as an excuse to keep people out, though I understand the concern that we have to make sure that we recruit ethically internationally.
On Amendments 170, 171 and 173, the department has commissioned HEE to work with partners to develop a robust long-term strategic framework for the health and social care workforce for the next 15 years, which for the first time includes regulated professionals working in adult social care such as nurses and occupational therapists. The report provided for in Clause 35 will also increase the transparency and accountability of the workforce planning process. However, this amendment would require an independently verified report to be published every two years with the assistance of HEE and NHS England. Given what we have heard tonight about some of the long lead times for training of health professionals, there is a concern that publication in a two-year cycle could be seen as too rapid given the long lead times for many health professionals.
However, one of the things to be welcomed is the different pathways into nursing. There are nursing apprenticeships, and there are also different pathways into becoming a doctor. If you have been a nurse and you have worked a certain number of hours, you can train to become a doctor. That shows that we are being innovative with regard to the different pathways into different jobs in the health and care sector.
Last year, we announced our intention to formally merge NHS England with HEE. The transfer of HEE’s functions to NHS England is subject to parliamentary approval. If approved, this will help ensure that service, workforce and finance planning are integrated in one place at a national and local level.
The Government share the wish to see safe patient care. Safe staffing remains the responsibility of local clinical and other leaders, supported by guidance and regulated by the CQC. Good quality care is influenced by a far greater range of issues than how many of each particular staff group are on any particular shift, but it is clearly important, which is why the Government are committed to continuing to grow the workforce.
On applying the lessons learned from formal reviews and commissions concerning safety incidents, in the last decade the Government have introduced significant measures to support the NHS to learn from things that go wrong, to reduce patient harm and to improve the response to harmed patients. These include a regulated duty of candour, protections for whistleblowers, the Healthcare Safety Investigation Branch, the first-ever NHS patient safety strategy, medical examiners implemented across the NHS and legislation to establish a patient safety commissioner.
On Amendments 83 and 86 from the noble Baroness, Lady Walmsley, responsibility for safe staffing rests with individual employers, and it would be inappropriate to confer such a duty on ICBs instead. Reaching the right staffing mix for the right circumstances and the right clinical outcomes requires the use of evidence-based tools, the exercise of professional judgment and a multi-professional approach, as well as considering local issues specific to individual employers. There need to be safeguards to ensure that they deliver this responsibility effectively and that robust arrangements are already in place.
Appropriate staffing levels are already a core element of the CQC registration regime for health and social care providers, and providers are required by the CQC to deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff. Staff must also receive support, training, professional development, supervision and appraisals as necessary. In this work, employers are supported by guidelines from the National Quality Board and NICE which are based on the best available clinical evidence and are designed to ensure patient safety.
Amendment 83 seeks to amend new Section 14Z41—“Duty to promote education and training”—in order to consider safe staffing. I highlight to the noble Baroness that Health Education England already has a statutory duty to exercise its functions with a view to ensuring that a sufficient number of persons with the skills and training to work as healthcare workers for the purposes of the health service is available to do so throughout England, as in Section 98 of the Care Act 2014. To place additional obligations on ICBs in relation to the workforce is at this stage seen as unnecessary.
Turning to Amendment 172, the Clause 35 report is not intended to produce assessments of supply and demand of staff itself, but rather to describe the system in place for assessing and meeting those needs. However, in relation to the coverage of non-regulated staff in the Clause 35 explanatory report, currently, Clause 35 does not seek to make a distinction between the regulated and non-regulated elements of the workforce. Clause 35 requires that the Secretary of State’s report cover the
“workforce needs of the health service.”
Our intention, therefore, is to include a description of the systems in place that cover the non-regulated elements of the health workforce, where appropriate.
The noble Baroness also raises the issue of integrated workforce planning across NHS and non-NHS employers. I hope to reassure her that we share her view of the importance of this issue and that work is under way on it. Section 1F(1) of the NHS Act 2006 places a duty on the Secretary of State for Health
“to secure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England.”
This duty is delegated to Health Education England under Section 97 of the Care Act 2014.
In discharging this function, HEE takes account of requirements of employers of health and care staff beyond the NHS in England, including independent practice, social enterprises and the voluntary sector, because to ensure that the needs of the NHS are met, the needs of other sectors with which it works must be taken into account. We heard the noble Lord, Lord Mawson, speak so eloquently about the work of social enterprises and the voluntary sector.
The amendment also calls for the assessment of workforce demand to include demand across Scotland, Wales and Northern Ireland. Although we recognise that workforces across the health services in the UK are interlinked, this amendment to formally report and assess demand is unnecessary and represents an additional burden for the devolved Governments, who have their own systems in place. Where appropriate, the department and HEE already work collaboratively with the devolved Governments and their arms-length bodies in relation to workforce planning and supply, without the need for formal legislative requirements. We must continually stress to the devolved Administrations that we recognise the constitutional settlements.
For example, the UK Foundation Programme office, which facilitates the operation and continuing development of the foundation programme for doctors, is jointly funded and governed by HEE and the devolved Governments. In addition, there is a regular dialogue, which I have alluded to previously. Also, many of the healthcare professional regulators, including the GMC, NMC and HCPC, operate on a UK-wide basis to enable doctors, nurses, midwives and other health professionals—so eloquently referred to by the noble Lord, Lord Bradley, and others—to work across the UK. As part of their regulatory activities, they publish data on how many registrants are on their register and therefore available for work in the UK. This data is available for use for workforce planning across the UK.
Turning to Amendment 174, we recognise the importance of ensuring that staff across the NHS and social care are properly paid—an issue that noble Lords have rightly raised a number of times. However, we are not sure that an annual report by the Secretary of State is the right approach. There is a well-established process in the NHS for those on national contracts. Individual NHS organisations determine what roles are required and where these fit on the agreed pay structures within national contracts. These national contracts set out progression arrangements where applicable. For those on entry level pay points, we do not expect NHS organisations to report to us on the profile of their workforce.
In addition, the vast majority of adult social care workers are employed by private sector providers, who ultimately set their pay, independent of central government. An issue with using these private sector providers is that often, they cross-subsidise taxpayer-funded patients from their private patients. But local authorities do work with care providers to determine a fair rate of pay based on local market conditions. Part of the increase in funding that we announced was to address that issue, to ensure that care homes taking taxpayer-funded patients are paid a fair rate. The Government would not expect any private sector organisations to undertake additional reporting to government on pay rates, the rates of progression available and the profile of the workforce at different pay points. We see that as an unfair additional burden on social care providers.
Amendment 146 places a requirement on ICBs to report on workforce requirements. We agree that ICBs will have a critical role to play in growing, developing, retaining and supporting the entire health and care workforce locally. To support them in fulfilling this role, in 2021, NHS England published—I use this word advisedly—draft guidance on the ICS people function.
ICBs will have specific responsibilities for delivering against the themes and actions set out in the NHS people plan, as well as the functions outlined in guidance. These functions include growing the workforce for the future and enabling adequate workforce supply, through strategic planning and collaboration on recruitment and retention across the system. NHS England will have a role in supporting this. It has also set out an expectation that ICBs will develop collaborative workforce plans based on population health needs and take an integrated approach to planning across workforce, finance and activity. We expect this approach to tie into their strategic planning cycle. The guidance also asks ICBs to work with regional and national workforce teams to support aggregated workforce planning and to inform on priorities.
On Amendment 214, most, if not all, ICSs already currently have an ICS people board or equivalent for overseeing delivery of these plans. The draft ICS people function guidance sets the expectation that these will continue to be in place, including as part of preparatory arrangements for formal establishment.
As previously discussed, the Bill intentionally sets a floor, not a ceiling, for ICB membership. This is one of the issues we will have to continue to discuss, given all the amendments noble Lords have submitted on mandatory places on integrated care boards; this is clearly going to mean discussions in the round. The ICS design framework, published in June 2021, sets out the proposed requirement for ICBs to have executive board roles that include, as a minimum, a chief finance officer, a medical director and an executive chief nurse. NHS England and NHS Improvement’s guidance on effective clinical and care professional leadership, published in September 2021, aims to support future ICBs in ensuring appropriate involvement of multi-professional clinical and care leadership in decision-making within the ICB area.
Having said all this, I see that the number of amendments that have been tabled reflects the strength of feeling in this House and the other place on workforce issues and workforce planning. I hope I have been able to assure the Committee of the department’s extensive, ongoing work to support the entire health and social care workforce.
I am sorry to interrupt the Minister. I have been listening extremely carefully to his response to these amendments and have to say, as gently as I can, that I did not hear many concessions to the points made by noble Lords across the Committee. Unless something really exciting is going to come in the last couple of pages of his brief—I have been watching him turn them over—I suggest that he needs to go back to those above his pay grade and bring home to them the level of distrust about whether the Government are serious about putting proper amendments on workforce issues and planning into this Bill.
I thank the Minister for his comprehensive response to this debate, which the noble Baroness, Lady Harding, suggested was probably the most important that we have had and will have in Committee on the Bill. Staff are absolutely central to the delivery of health services.
Unfortunately, in this debate we have heard about a great deal of failure. We have failed the staff because we have not provided them with enough colleagues for them to be able to do their work without feeling stressed, being worried about risk to patients, feeling burnout or wanting to reduce their hours or retire early. We have failed to provide enough GPs; we were promised 5,000 or 6,000 extra, but, as the noble Lord, Lord Patel, said, we have fewer than we had in 2015. We rely on 30% of doctors from abroad—an enormous number. Although I absolutely accept what the noble Lord says about the appropriateness of temporary training placements, opportunities and remittances going back to the countries from doctors and nurses coming here, it sounds a little excessive to me. Perhaps we need to do better in planning our own workforce.
It is not just doctors and nurses: the noble Baroness, Lady Finlay, highlighted the allied health professionals, whom I mentioned only briefly in my introduction. They are very important too, and there is a lot of shortfall there. She also mentioned CPD, which is vital, particularly as health technologies, practices and opportunities for treatments change.
There is a great deal more to do. The Minister is quite right that those of us who have been talking about these issues will undoubtedly get together over the next few weeks and, I hope, have discussions with him. The noble Baroness, Lady Cumberlege, has put forward a comprehensive measure that could be put in place—I was so pleased that she agreed with me on this—not just for normal service but for the unexpected needs of the health service. I can assure your Lordships that there will be some.
The noble Lord, Lord Stevens, gave us a woeful litany of failures. My husband always says that the family motto is, “Who can we blame?”. The noble Lord, Lord Stevens, fairly and squarely blamed the Treasury, so I hope it is listening. Doing what needs to be done will cost more money, but if we do not do it there could be a total disaster in our health and care services. In fact, in social care there already is.
I was surprised, and I think the noble Baroness, Lady Verma, was probably surprised, to hear the Minister say that care homes are paid a fair rate for publicly funded patients in social care. I do not think we would have private payers charged more if that was really the case. Perhaps her managers might agree with that.
One noble Lord—I cannot remember who—said that we need a system-wide understanding of what is needed and the right way to go about providing it. The noble Lord, Lord Warner, and others mentioned that we have a very competitive global market in all the health professions, and therefore we need to be very clever about recruiting enough for this country while at the same time fulfilling our obligations to the rest of the world and lower and middle-income countries.
I turn briefly to my two amendments. I accept what the Minister says about the fact that duties exist to train enough staff to provide safe staffing levels. However, this whole debate has proved that those duties are not being carried out. Employers are not able to carry them out, because there is not enough of a pool of the right staff in the right places at the right training level to enable them to carry out that duty. That is why it is perhaps a good idea to restate it.
This has been an excellent debate, and I know that the Minister has heard what we have to say and that there will be more discussions. In that light, I beg leave to withdraw my amendment.
Amendment 83 withdrawn.
Amendments 84 to 92 not moved.
93: Clause 20, page 18, line 26, at end insert—
“(d) the impact on the diversity of provision of health and care services, including social enterprises, independent providers and charities in that area.”Member’s explanatory statement
The amendment would place a duty on NHS England and Integrated Care Boards to ensure that there is a diversity of provision within local areas including social enterprises so that there is a range of choice and expertise available to local communities.
My Lords, it has been rather a long wait, though I doubt that we shall spend as much time on this group as we did on the last. I do not pretend that the issue of procurement is as important as that of the workforce; none the less, when we come to Clause 70 there are some very important considerations.
I should say that, although my own two amendments are narrowly focused, in opening this debate I must register with the Minister concerns about the open-ended nature of the power to be given to Ministers under this clause. In essence, through secondary legislation, the whole procurement regime can be changed at the whim of an executive order. Services could be privatised or outsourced or whatever Ministers choose to do with them subject to regulations. It seems rather extraordinary that we are taking out the marketisation sections from current legislation only to replace them with an open-ended power and a procurement regime when we simply do not know what it will be.
I remind the Minister that the Delegated Powers Committee has been very clear that Clause 70 needs very careful attention. As it says,
“initial consultation has been carried out by NHS England on the content of the”
procurement regime, but
“full analysis has not been completed and there has not been time to produce a more developed proposal.”
The Delegated Powers Committee concluded:
“We do not accept that the inclusion of regulation-making powers should be a cover for inadequately developed policy.”
I hope that the Minister, when he winds up the debate, will say something more about this and how the Government intend to respond. I think it very unlikely that we will let this Bill leave this House with this clause unaltered. Indeed, I note that the noble Lord, Lord Lansley, intends to oppose that Clause 70 stand part of the Bill.
My two amendments are probably the easiest that the Minister will have to deal with in this group and I hope that, for once, he will just get up and say that he accepts them both because they are very sensible and helpful to the way in which one wishes to see the NHS develop commissioning arrangements at the local level. The first, Amendment 93, requires NHS England and integrated care boards to consider the impact of their decisions on the diversity of provision for health and social care services, particularly social enterprises and charities.
I just want to talk about social enterprises: they are set up with a social mission and deliver that mission with all the income that they receive. Over the past 20 years, they have become an ever more important part of delivery of healthcare services. My understanding, from Social Enterprise UK, is that there are 15,000 social enterprises delivering health and care services in this country and that there is very strong evidence to suggest that these organisations are very good at what they do—often better than the alternatives. Indeed, according to a review of public service mutuals, a form of social enterprise, commissioned by DCMS in 2019, these organisations are developing high levels of productivity and better outcomes than their peers and the private sector. Their productivity has increased 10 times faster than that of the rest of the public sector over the past decade. Why? They have done it through innovation: by listening to communities and focusing on their social mission, social enterprises have been able to prepare to make changes to service delivery that other providers have been unwilling to do. As a consequence, a report in 2020 by the King’s Fund described social enterprises as
“‘engines of innovation’ within health and care”.
The Bill as it stands does not provide any duty, responsibilities or guidance for integrated care systems or NHS England to consider social enterprises within their activity. My understanding is that, because we already have these shadow ICBs, it is being interpreted at local level that there is not a future for social enterprises within local systems. There is a risk that decisions are now being made by these shadow organisations, which have no statutory being at all, that there will be a reduced role for these social enterprises in the future. That would be a tragedy, and I must ask the Minister to look at my amendment. It is very innocuous: all it asks ICSs and the NHS to do is to consider the impact of their decisions on a wider provider lattice. He could go further. It would be very simple for a message to be sent down the service from this debate to say that they got it wrong about social enterprises and they should indeed be thinking of commissioning more services in the future from there.
My Amendment 211 is linked to it. It deals with social value and how they should be embedded into procurement processes by integrated care boards. The definition of social value is the process by which public bodies seek to maximise the additional social, environmental and economic outcomes of the money that they spend. The coalition Government in 2012 supported the passage of the Public Services (Social Value) Act 2012. The adoption of the Act in the NHS has been very patchy indeed. I shall not delay the Committee by going into the details, but it is very disappointing. All my amendment would do is put a simple duty on NHS England to create guidance and ensure that social value is clearly understood across the system. It would be only guidance: it surely could not be a problem for the Government to endorse their own policy on social value in the NHS. I hope that the Minister will be sympathetic. I beg to move.
The noble Lord, Lord Howarth, is taking part remotely and I now invite him to speak.
My Lords, I support my noble friend in his aim, expressed in Amendments 93 and 211, to require that procurement practices by the NHS are such as to ensure diversity of provision and maintain social value. The case was made convincingly, I hope, in previous debates that the non-clinical and voluntary community and social enterprise sectors have important contributions to make to preventing ill health, both physical and mental, aiding recovery and reducing health inequalities. That being so, it is only common sense that the NHS, and ICBs in particular, should use their power and influence to ensure that there is a flourishing ecology of the community organisations that share their agenda. The NHS should engage with them, listen to them, enlist them and cherish them.
Although the value of community organisations to healthcare has long been obvious, that has been all too little recognised in the actual practice of the NHS. Responsibility here, however, does not rest only with the NHS. The non-clinical sector must help the NHS to relate effectively to it. The King’s Fund has been doing important work on contractual models for commissioning integrated care. This was the basis, for example, for the way arts and cultural organisations came together in Gloucestershire to enable the CCG to fund the work without having to deal with lots of small organisations and individual artists. In Suffolk, the CCG has provided administrative support and leadership in providing training for arts and cultural workers to connect to link workers. We cannot expect ICB commissioners to deal with a mass of organisations in the VCSE sector, but they can support that sector to develop suitable models of co-ordination. I think “market-placed development” is the bureaucratic term here. Organisations such as the National Centre for Creative Health and the Culture, Health and Wellbeing Alliance stand ready to support non-clinical providers to get their act together to enable ICBs to negotiate with them productively.
On procurement regulations—the subject of Clause 70 —I want to see among the general objectives the relevant authorities specifically enjoined to support the non-clinical sector to play its full part in contributing to the better health of the nation. On the provision referred to in new subsection (3)(a), on
“fairness in relation to procurement”,
I want to see a requirement of financial equity between clinical and non-clinical bodies from which the services are procured. Rates of pay in the non-clinical sector should bear a decent relationship to those in clinical organisations. Public health should no longer be the poor relation.
Non-clinical organisations should have the core costs of providing services to the NHS realistically funded, and provider organisations should be enabled to budget over sensible periods of time. That way, they will be able to provide a more reliable and higher-quality service. On financial grounds alone, it is in the interests of the NHS to invest constructively in the non-clinical sector in order to ensure that high-quality services are available when and where they are needed. If enabled to do this, the sector would provide remarkable value for money for the NHS.
My Lords, I am pleased to follow the noble Lord and I endorse the points he makes about the diversity of provision, which is certainly something that we should aim for; I am not sure how we will make sure it is in the Bill, but we will get to that later on. I will not dwell on the other amendments; I will simply explain why I oppose Clause 70 standing part. I was pleased to see that the noble Baroness, Lady Thornton, shares that view, although she may do so for different reasons.
This gives me an opportunity to explain something that I have been saying to Ministers—not necessarily these Ministers but their predecessors—for the last two or three years: if the NHS took the view that the structure of the procurement regime that was applied to it was a constraint, cumbersome and the various other words that it used, Ministers could do something about it very quickly because, in the legislation, they have the power to change the regulations. So why do they not do so? I also want to explain that the existing regulations do not impose some of the constraints that it is argued they do. That begs the question behind my opposition to the clause standing part: why are we legislating in this way in this clause, when the effect is to remove a power to make regulations relating to the procurement regime in order to then put into the Bill a power to do just that? It really does nothing much more than that.
Of course, in truth, we do not know what these new regulations will look like because they have not been published, as the noble Lord, Lord Hunt of Kings Heath, rightly said. The issue lies in the regulations because, as I will demonstrate, what mattered to the service, as it turned out, was not what was in Section 75 of the 2012 Act but what was in the subsequent 2013 procurement, choice and competition regulations. I am sorry, but this is going to take a few minutes.
Clause 70 does nothing much more than refer to the fact that there should be transparent and fair processes, that “managing conflicts of interest” should take place and that compliance should be verified—I do not know quite what that means but it is probably a good thing. It also makes reference to general procurement objectives. You might ask what those are, since they are not specified in Clause 70 itself.
If one goes back to the previous legislation, one gets to the point in the NHS (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013, which are also revoked later in Clause 70. In the regulations, there is a paragraph that says what the procurement objectives are:
“for the purposes of the NHS … a relevant body must act with a view to … securing the needs of the people who use the services … improving the quality of the services, and … improving efficiency in the provision of the services”.
I rather hope that we are not yet encountering anything to which people would object. It then goes on to say:
“including through the services being provided in an integrated way (including with other health care services, health-related services, or social care services).”
Frankly, we have had years now of people explaining that the legislation did not allow them to do things in an integrated way. But when one looks back to 2013 and the regulations brought in, they say that the objective is to do things in an integrated way. I slightly wonder why the NHS did not do that, rather than complain that it could not.
Let me go on. When looking at the general requirements of procurement subsequently in that regulation, it includes the provision to
“act in a transparent and proportionate way, and … treat providers equally and in a non-discriminatory way”,
and wants projects delivered with “best value”. So far, again, there is nothing to which people object.
In Regulation 3(4) we hit something that people might object to. In defining what quality and efficiency look like, the regulations go on to say that the services should be
“provided in a more integrated way”—
which we have already heard about, and it repeats exactly that point—
“enabling providers to compete to provide the services”.
This may be where the objection came from, in which case my argument to Ministers is this: if that is what you do not like in the regulations, omit it from them. Ministers could have done it literally in a matter of weeks.
What is the other objection to the existing structure of the legislation? Section 75 of the Health and Social Care Act 2012, about the power and what it should be used to do, talked about good practice in procurement and the right to patient choice. I mentioned in a previous group the importance of, in my view, putting the right to patient choice into the provider selection regime, but we will come on to that again at a later stage.
Here is a third point, and something to which I think some people objected to, and have objected to subsequently; that providers
“do not engage in anti-competitive behaviour which is against the interests of people who use such services.”
I might say that if the anti-competitive behaviour is in the interests of the people who use those services, it is not necessarily objectionable. However, when one looks further, Regulation 10 of the subsequent regulations describes the circumstances in which anti-competitive behaviour might be justified:
“unless to do so is in the interests of people who use health care services … which may include … the services being provided in an integrated way”.
We keep coming back to this.
The other point I would make—she is not here, but the noble Baroness, Lady Blackwood, said it at Second Reading—is that the NHS objected to the fact that it was required to engage in compulsory competitive tendering. Section 75 of the 2012 legislation says that the regulations may
“impose requirements relating to … competitive tendering”,
as well as to the management of conflicts of interest, but it does not require the regulations to be made at all, and it certainly does not require the regulations to include compulsory competitive tendering, and nor do the subsequent regulations published in 2013 require that.
All of that leads me to the conclusion that Section 75 of the 2012 Act simply creates a power; it does not need to be changed for new regulations to have been made. Section 75 says that subsequent 2013 regulations may be objectionable to people in so far as they refer to qualified providers and to competitive tendering. If that was the problem, you should revise the regulations, publish them, take out the bits you object to and give the NHS a provider selection regime that fits their anticipated needs. The objectives are all there: quality, efficiency, best value, fairness, proportionality and an integrated service—and an integration, if that is what this Bill is all about, was already there in the 2012 legislation.
My question to my noble friend for before Report, and the question asked by the stand part debate, is: why are we doing what we are doing in Clause 70? Cannot we do it perhaps more simply and effectively by amending the existing legislation, rather than by trying to do wholesale repeals, introducing something that we will not know what it looks like until after this Bill has passed through this House?
My Lords, Amendment 213 is in my name and that of the noble Baroness, Lady Thornton, and I am very grateful for her support. I can be briefer than I was expecting to be, given what the noble Lords, Lord Lansley and Lord Hunt, have said in the last few minutes.
My amendment addresses another instance of an attempt by the Government to bypass parliamentary scrutiny, and it proposes in response an enhanced form of parliamentary scrutiny. As the noble Lord, Lord Hunt, remarked, the DPRRC report on the Bill notes that the delegated powers memorandum says that, although initial consultation has been carried out by NHS England on the content of the procurement regime, full analysis has not been completed and there has not been time to produce a more developed proposal. Clause 70 gives the Minister the power to impose a new procurement regime, without giving any details of what it might be. This is the clearest possible example of the Government taking powers to make policy without specifying at all what that policy may be.
The DPRRC rejects the inclusion of regulation-making powers as a cover for inadequately developed, or undeveloped, policy. What is worse, the delegated powers memorandum says that a Cabinet Office procurement Bill will most likely follow this Bill, and it may require some amendments to the regulation-making powers that we are discussing in this Bill. The regulatory powers in question are to be subject to the negative procedure. I think we all, except for the Government Front Bench, would recognise that the negative procedure is emphatically not effective parliamentary scrutiny.
What we have here is a skeleton clause, with regulation-making powers of very broad scope. There is nothing in this clause, or in the Bill more generally, which would in practice constrain how broadly these powers could be used in constructing a procurement regime. It would probably be better, from the point of view of parliamentary scrutiny, to leave out Clause 70 entirely, as the noble Lord, Lord Lansley, my noble friend Lady Walmsley and the noble Baroness, Lady Thornton, propose, and wait for the full policy to be set out in the Bill, as promised to follow soon from the Cabinet Office.
If the Minister can advance compelling reasons why this Bill should be the vehicle for setting up the procurement regime by regulations, there is one route we could take, as set out in my amendment. This amendment imposes the super-affirmative procedure on the delegated powers proposal. The super-affirmative procedure is designed and used to deliver a measure of real scrutiny in circumstances that require it. In proceedings on the recent Medicines and Medical Devices Bill, the Minister very helpfully summarised the super-affirmative procedure as follows, saying that the
“procedure would require an initial draft of the regulations to be laid before Parliament alongside an explanatory statement and that a committee must be convened to report on those draft regulations within 30 days of publication. Only after a minimum of 30 days following the publication of the initial draft regulations may the Secretary of State lay regulations, accompanied by a further published statement on any changes to the regulations. They must then be debated as normal in both Houses and approved by resolution.”—[Official Report, 19/10/20; col. GC 376.]
According to the Library, the last recorded insertion in a Bill of a super-affirmative procedure was by the Government themselves, in October 2017, in what became the Financial Guidance and Claims Act.
I repeat that, if the Minister really can convince us that he has a compelling reason to have this new procurement regime set up by regulations in the Bill, my amendment would provide the opportunity for detailed parliamentary scrutiny. If he cannot accept that, then we would be wise to take out Clause 70 in its entirety.
My Lords, I will briefly speak in support of the amendment in the name of the noble Lord, Lord Hunt, and echo many of the points made by the noble Lord, Lord Lansley, although I draw slightly different conclusions to him.
We have been around this track on social enterprise over the last 15 or 16 years and, in what I might call the good old days, there was a social enterprise unit in the Department of Health. That arose—it is worth remembering this—because many NHS staff preferred to work in a social enterprise unit rather than be direct employees of the NHS. The early days of social enterprises saw a number of groups of staff, particularly nurses, producing, in effect, co-operatives to work as social enterprises. While the noble Lord is entitled to feel a little anxious if there is nothing in the Bill even as modest as Amendment 93 in the name of the noble Lord, Lord Hunt, that arrangement gives some degree of protection to social enterprises which have served the NHS pretty well over the last 15 or 16 years. So, the least the Government could do is accept Amendment 93.
To some extent, the points made by the noble Lord, Lord Lansley, relate to the points I made earlier about Amendment 72. The bottom line on all this is that the way the Government have gone about trying to say, in Clause 70, that there needs to be a new provider selection regime, while not declaring their hands, has actually created the worst suspicions. If indeed, as the noble Lord, Lord Lansley, says, there is adequate provision already, why create the suspicion that some dastardly deed is going to be produced at a later stage by putting in Clause 70 and then not producing the draft regulations before the House clears the Bill?
The Government have got themselves into a fair tangle over this issue, and the Minister would perhaps do well to take this back to the department and try to reassure people as to what the Government are up to. Are they trying to change the Section 75 arrangements, and, if so, in what way? We want a lot more clarity about what the future provider regime will actually look like.
My Lords, I will speak very briefly, having attached my name to a couple of amendments in this group. The issues around Clause 70 have been very clearly addressed, and I will just add one reflection, looking back to a discussion on an earlier group last week, when I said that if the Secretary of State gets great power, with that comes great responsibility. From the debate in your Lordships’ House, the noble Lord, Lord Hunt, is right to say that the Bill will not leave the House in this condition, but, if it were to, or if, after future amendments and ping-pong it were to end up back in this condition, the Secretary of State would really be in quite a dangerous place.
I pick up on social enterprises and the amendment of the noble Lord, Lord Hunt. We will be coming to some amendments, perhaps on Wednesday, when I will be talking about the impact of privatisation on social care. There will at some point—we have already seen this several times—be a huge crisis of the financialised social care sector, particularly care homes. When large chains fall apart and we have to find a way forward, social enterprises will be one way. I am aware that Clause 70 mentions healthcare and associated services, but to think about this in a whole and integrated way, we should ensure that there is recognition for social enterprise.
I attached my name to Amendment 208 because I thought it was important to demonstrate maximum cross-party support. Dare I say that events in the House earlier today demonstrated the need for transparency and openness in official contracts? There is great public concern about the misallocation of resources and the need for a guarantee of openness in government and official spending, so that amendment is crucial.
I do not know how I missed Amendment 209 in the name of the noble Baroness, Lady Thornton, but I certainly would have attached my name to it had I not done so. It is often commented that I cover a very broad range of subjects in your Lordships’ House, so I often talk about trade deals in other contexts, but there are very grave concerns about trade deals undercutting principles and priorities that have been identified in British politics, so that amendment is also important.
Finally, on Amendment 211, we have seen that giving government contracts to the lowest cash bidder has had disastrous consequences across a whole range of sectors. It has benefited a handful of giant companies, some of which have collapsed, some of which have engaged in rampant fraud and all of which have delivered a disastrous quality of services, exploiting poorly paid staff. Social enterprise is a different approach, a different way of commissioning and a way out of that. It is a way of relocalisation: stopping those few large companies that keep winning contracts because the whole thing is structured so that only a handful of companies can bid for them anyway. These are all really important amendments.
I have my name to Amendment 93 and Clause 70 stand part. As the noble Lord, Lord Warner, just told us, Clause 70 is a bit of a mess, and having listened to the explanation of the noble Lord, Lord Lansley, of why it is a bit of a mess, I do not find much need to say much more. However, on the issue of compulsory competitive tendering, I understood that the Bill will reduce its importance. I wonder how those things link together and whether the Minister can explain it to me.
On the amendment of the noble Lord, Lord Hunt, about diversity of provision, it is usual that those with the biggest voices shout the loudest and, in the health sector, it is often also those with the biggest budgets, such as the acute hospitals. We have this very valuable not-for-profit sector that has a small voice and a small budget—at least individually, although it adds up to quite a lot—and a great deal of it comes from the NHS.
As has been said, many of them are spin-offs, comprising former NHS staff who prefer to work in that context. There are an awful lot of them—about 15,000—and they feel particularly threatened by the Bill because, despite the fact that they are specifically mentioned in the ICS design framework as a vital cornerstone of a progressive health and care system, they are not referred to in the Bill and there appears to be little, if any, recognition of the potential impact of the new structures of provider collaboratives and place-based partnerships on their funding and, crucially, their involvement in decision-making. As others have said, that missing piece has caused a lot of suspicion and concern in the sector, and we must not lose these important organisations, because they really understand their client base: they are local, they are flexible, they are fleet of foot, they innovate and they are vital in providing services, in particular for those with complex needs. We must make sure that their voice is heard.
My Lords, this group is in two parts. The first part consists of the amendments tabled by my noble friend Lord Hunt. I need to declare an interest as a patron and the founding chair of Social Enterprise UK, and also as an associate of E3M, for public sector social enterprise leaders, particularly in the healthcare sector, so I have been living with this. Indeed, I must declare an interest as the Minister who helped take through the right to request in the NHS for our staff. I am very committed to these amendments, and to the need for social enterprises to continue to innovate and deliver in our health and social care system, which they do at the moment. There is a report due out very soon from the group chaired by the noble Earl, Lord Devon, on Covid and social enterprise; the way that social enterprises have delivered during Covid is stunning.
I turn to the amendments in the second part of this group, many of which have my name on them. I think that the noble Lord, Lord Lansley, and I find ourselves in broadly the same place: it is a mess. Our first thought was, “Why is this clause here?”, because it does both the things that my former noble friend Lord Warner—I still regard him as a friend—said. This clause does not tell us what is going to happen but it makes us extremely suspicious about what might happen. My amendments—and also, I think, the amendments of the noble Lord, Lord Sharkey—are about that suspicion. It is quite right that the regulatory committee also said that we needed to pay attention to this, because it gives the Secretary of State very wide powers and it does not tell us what the Secretary of State will do with them.
I have quite a long speaking note, but I do not intend to go into the detail now. I simply say to the Minister that if, by the next stage of the Bill, we have not resolved the issues behind this clause, the Government may find themselves struggling to get it, as it stands, through your Lordships’ House.
My Lords, again, I have heard the excellent contributions that have been made, really holding the Government to account on a number of these amendments.
I begin with Amendment 93, tabled by the noble Lord, Lord Hunt. I assure him that social value is a very important matter for the Government. I know that this importance is echoed across the NHS, as the country’s largest employer and public service, and that we see the value of the excellent services and innovation that social enterprises, independent providers and charities bring to health and care—indeed, not just to health and care but to the wider economy. However, we do not think that this is an appropriate duty to put on NHS commissioners, or an appropriate addition to the triple aim.
We have been discussing the triple aim and other issues around how that ends up. We fundamentally believe that the focus of NHS commissioning decisions should be on offering the best possible treatments and services based on quality, rather than any decision being based on the type of provider, but, again, while recognising the diversity of non-clinical providers, especially social enterprises, voluntary organisations and charities. The duty of the triple aim is intended to be shared across the NHS. The aims represent a core shared vision of what the NHS should offer, and are intended to align NHS bodies around a common set of objectives and support a shift towards integrated systems. In this context we would not want to split the duty by adding a section relevant to commissioners, NHS England and ICBs, but not to trusts and foundation trusts.
On Amendment 211, in its long-term plan the NHS committed to reducing health inequalities and supporting wider social goals. Again, this refers back to previous debates on how we make sure that we really capture the essence of tackling inequalities in the Bill. We recognise that NHS organisations can contribute to social and economic development, and aim to reduce the impact of social determinants of health and reduce heath inequalities. It is with this in mind that social value, alongside sustainability, has been proposed as one of the key criteria which will be used for decision-making under the provider selection regime.
We believe that this amendment, at this stage, is not necessary, as alongside the role of social value as a key decision-making criterion, NHS England and NHS Improvement will produce guidance on applying net zero and social value in healthcare procurement, which includes taking account of social value in the award of central contracts.
The Cabinet Office social value model has been applied to procurement decisions taken by NHS England and NHS Improvement since 1 April 2021 and will be extended to the whole NHS system from 1 April 2022. Adopting the Cabinet Office social value model across the NHS complements strategic initiatives and policy within the NHS.
Amendment 206 is on the wider provider selection regime reforms. The NHS procures many services, but has specifically asked us to introduce a new tailored provider selection regime with key criteria that would enable decision-makers to arrange healthcare services in a more flexible way and deliver value for patients. With regard to the noble Baroness’s desire to cover non-clinical services—catering, porters, et cetera—while these are valued roles within the NHS, it is right that the procurement of these services should still fall under the Public Contracts Regulations 2015 and, in future, the new Cabinet Office procurement regime so that these services are arranged in a way that continues to add the best value to the healthcare system.
There may also be cases where it is essential that a service is procured as part of a healthcare service contract. It is for this reason that we have included the ability for regulations made under this power to include provision in relation to mixed procurements, where other goods and services are procured together with healthcare services. The regulation of these mixed procurements needs to work both for the effective management of health services and for the arrangement of wider public services. We are working closely with the Cabinet Office and stakeholders across the health service to ensure that this is the case.
If a contract were not awarded to a trust or foundation trust, Amendment 207 would require a commissioning body to conduct a consultation on the process and to specify terms and conditions. As we have set out, we intend that the new provider selection regime will allow the NHS and local government the flexibility to best arrange healthcare services for patients.
I assume it will be but, as I am about to say on a number of other issues, there is clearly a lot to take back to the department, not only tonight but on the whole Bill. I pledge to take that back to the department.
Where there is only one possible provider or where the incumbent is delivering well, it is intended that the regime will enable commissioners to continue contracts in an efficient way. However, if a trust or foundation trust currently holds a contract or did hold a contract, it should not be assumed that it is or was always with the most suitable provider. It is the view of the Government and the NHS that patients should be able to access services based on quality and value, delivering the best possible outcome, rather than basing the decision on what type of provider they are.
Amendment 208 would require a competitive tender for contracts with an annual value of over £5 million. While we recognise the role of competitive tender—and expect that, in many cases, this may be the appropriate route—the NHS asked the Government for greater flexibility in tendering contracts. It is for local commissioners to select the most appropriate provider for a service and to do so in a robust way. We agree with the importance of open, transparent and robust decision-making. Regulations and statutory guidance made under the provision in Clause 70 will set out rules to ensure transparency and scrutiny of decisions to award healthcare contracts. Decision-makers will also need to adhere to any relevant existing duties, act with transparency and appropriately manage conflicts of interest. This and other aspects of the regime will provide sufficient safeguards to fulfil the important need for fairness when making decisions about the arrangement of services.
On Amendment 209, the Government’s position on trade agreements is clear. We have been unequivocal that the procurement of NHS healthcare services is off the table in our future trade negotiations. This is a fundamental principle of the UK’s international trade policy. In fact, it dates back to the days when we were a member of the European Union; this issue came up a number of times. I remember working in the European Parliament with colleagues from the Labour Party and elsewhere to ensure that this was part of our agreements. Therefore, we do not consider the noble Baroness’s amendment necessary. My department has worked with the Department for International Trade to ensure robust protections for public services. For example, in the recent UK-Australia trade agreement, it was clearly stated that the procurement of health services is not included in the scope of the agreement’s services procurement coverage. We will ensure that our right to choose how we deliver public services is protected in future trade agreements.
Amendment 212 would mean that the provisions of Clause 70 expired three years after the day on which they commenced. In 2019, the NHS provided recommendations to the Government and Parliament for this NHS Bill. These recommendations told us that
“there is strong public and NHS staff support for scrapping Section 75 of the Health and Social Care Act 2012 and for removing the commissioning of NHS healthcare services from the jurisdiction of the Public Contract Regulations 2015.”
The recommendations also voiced support for the removal of the presumption of automatic tendering of these services. Our intention is that, through this clause and the new procurement regulations to be made under it, we will deliver what the NHS has asked for: new rules for arranging services that work for the NHS, and, most importantly, for patients.
I am very sorry—I know it is late—but, frankly, these are not rules that will serve the locality. At the moment it looks as if these rules will be set by the Secretary of State and will serve the Secretary of State. That is what the Bill says at the moment; those are the powers that this clause takes.
Before the Minister answers that question, could he make clear whether the primary concern of the Government is the interests of the patient or of the NHS? They could be in conflict. Much of what he has said implies that they are the same but they are not, and some of the issues on which the Minister is saying “We’re doing what the NHS wanted” concern me about where the patient’s perspective is in that kind of approach.
The noble Lord raises a concern that I have heard a number of times: that we should be careful about saying “This is what the NHS wanted”—that the focus has to be about patients. We clearly take the view that this should be patient-centred and patient-focused. Indeed, I have had a number of conversations with many noble Lords about how we make sure that it is patient-focused. We understand, however, that concerns have been raised that Clause 70 may in part be a temporary measure, to be replaced or significantly edited by the Cabinet Office procurement Bill to follow. This is not and never has been our intention, but I understand the concern and recognise that there is value to aligning processes when such alignment is in the wider system interest. We continue to engage with the Cabinet Office on its proposals.
Amendment 213 would make regulations under Clause 70 subject to the super-affirmative procedure. I appreciate the intention behind this amendment. However, we do not feel at the moment that the super-affirmative procedure is necessary. As set out in our delegated powers memorandum, the powers created by Clause 70 are inserted into the NHS Act 2006, in line with the vast majority of regulation-making powers under that Act.
We know that there is significant parliamentary interest around the rules determining how healthcare services are arranged, so it is vital that we strike the right balance between democratic scrutiny and operational flexibility. The negative procedure provides that balance and ensures transparency and scrutiny. We will continue to engage widely on the proposals for the regulations to be made under these powers, to ensure that they will deliver—
We do not believe that they are, but clearly there is a difference of opinion about it.
I would like to turn, however, to the point made by my noble friend Lord Lansley on Clause 70. The regulations that we create under Clause 70 will have a broader scope than those currently created under Section 75. The provider selection regime will include public health services commissioned by local authorities, thereby recognising their role as part of joined-up health services delivered for the public. While we always want to act in the interests of people who use our services, our regime recognises the reality that in some cases integration, rather than competition, is the best way to achieve this for the health service. Finally, removing the section and creating a new bespoke regime, is—despite the scepticism of the noble Lord, Lord Warner—what the NHS has asked for. There is strong public and NHS support for scrapping Section 75 of the 2012 Act—
I am sorry—it is getting late—but will my noble friend at least, at some point, tell us: did Ministers ever challenge the NHS on whether what it was asking for required primary legislation? Did they ever ask, “What are you trying to achieve?”—and then let us, the Government and Parliament, who actually pass the legislation, see how it should be achieved? Or has Parliament in practice now become merely the cypher for the NHS?
I take the point that my noble friend makes, and I completely understand the concerns; that is why it is important that I take many of the concerns raised today back to the department.
Clause 70 inserts a new Section 12ZB into the NHS Act 2006, allowing the Secretary of State to make regulations. I have a lengthy explanation here but, frankly, I am not sure that it will pass muster. If noble Lords will allow me to go back to the department—I may be a sucker for punishment, but I accept the concerns and I will go back—
As the noble Lord will recognise, when I was appointed to this job, I did say that I wanted to consult as many previous Health Ministers as possible, as well as people who have worked in the field. It is clear from this debate that more consultation and discussion are needed, so I would welcome noble Lords’ advice. On that note, I beg that Clause 70 stand part of this Bill and hope that the noble Lord will withdraw his amendment.
My Lords, the hour is late. We cannot have the extensive debate that we probably require. I shall be very brief. I should have declared an interest as president of the Health Care Supply Association, the NHS procurement professionals.
On social value, I am very grateful to the Minister because he said that guidance will be issued to the health service on this, which is gratifying. On social enterprise, my noble friend Lord Howarth, the noble Lord, Lord Warner, the noble Baronesses, Lady Bennett and Lady Walmsley, and my noble friend Lady Thornton of course, all referred to the value of social enterprises. The Minister is not convinced that we need to put anything in the Bill. The point I need to put to him is this: it is clear from intelligence from the health service what the people running what I call the shadow ICBs want. I do wonder what we are doing legislating when obviously, everything is up and running; it is very difficult to know why we are here tonight debating these issues. Clearly, the NHS wants it, so it has got it and it is Parliament’s job, presumably, to just legitimise what it is already doing.
Having said that, these integrated care boards believe that social enterprises are not to be invested in in the future. So, my appeal to the Minister is this: fine, do not put it in the Bill, but please get a message out to the 42 ICBs telling them not to be so silly as to think that they should carve social enterprises out of the new regime.
More generally, on procurement, it is very interesting to be debating with the noble Lord, Lord Lansley. We fought tooth and nail for days on Section 75 of the 2012 legislation. Along come the Government, now saying, “Oh, we’re going to get rid of it. We don’t know what we will replace it with, but it is all right because we can have some negative regulations which mean we can steam it through without any scrutiny apart from a desultory debate as a dinner-break business sometime in the future. Oh, and by the way, there’s procurement legislation coming along too, but we can’t tell you what will be in there.”
Somehow, between now and Report, collectively we need to find a way through. I confess to the noble Lord, Lord Lansley, that I am rather pleased to see Section 75 go. However, something has to be put in its place, or we will just leave the NHS to get on with it and await future regulations and legislation. One thing for sure is that the idea of leaving the Bill with Section 70 and not even accepting the noble Lord’s sensible suggestion of the super-affirmative procedure is quite remarkable, and clearly it will not run. Having said that, I beg leave to withdraw my amendment.
Amendment 93 withdrawn.
Amendments 94 to 101 not moved.
Amendment 101A had been withdrawn from the Marshalled List.
Amendments 101B to 105 not moved.
House adjourned at 10.17 pm