First, let me echo the words of the Minister and pay my own tribute to my colleague, Michael Meacher, who sadly died today. I was born and bred in his constituency, so he was my MP for a long number of years. He was greatly respected in the constituency and will be very, very sadly missed.
I wish to start by echoing the words of my hon. Friend the Member for Nottingham North (Mr Allen) who said that we need to get this Bill right. The proposals for health devolution raise a great number of questions, which I hope we will deal with in a constructive manner, as we need positive outcomes. Labour Members are concerned about overlapping areas, coterminosity, and cross-border responsibilities, and they have been highlighted by my hon. Friends the Members for Bassetlaw (John Mann), for Denton and Reddish (Andrew Gwynne), for Hemsworth (Jon Trickett) and for Bristol South (Karin Smyth). We need some clarity about how the devolved responsibilities will work in practice.
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The implications of the Bill for the English NHS and the social care system are enormous. It includes important new powers to remove functions from NHS hospitals, from commissioners and from other bodies and to transfer them to the local or regional authorities. Depending on the implementation, the interpretation and the limits
on these powers, such transfers of powers might fundamentally reshape our health service in years to come. We must ensure that we keep the “national” in our national health service. We do not want a postcode lottery of healthcare that is dependent on where one happens to live.
Accountability and scrutiny remain crucial for a well-run NHS, delivering the best care it can for everyone no matter where they live. The Bill could provide for the transfer of healthcare functions in England away from hospitals and NHS commissioners to local authorities. That would be a major historic shift and would create questions about how the system of NHS accountability and leadership could work with a complicated mixture of regional and national powers. Can national standards and duties for health and social care really be enforced centrally, as they are now, under a devolved regime? Or will central and regional government squabble over the responsibility for meeting population needs and making difficult decisions, such as closing hospitals or propping up overspending healthcare providers? What will happen to neighbouring areas?
It is not clear whether the deals that are possible mean that NHS funding could melt into wider regional authority budgets, making ring-fencing or protection impossible. Given the importance of healthcare spending to everyone, that needs clarity and scrutiny. Whether clause 19 is modified or removed will have an important impact on the extent to which NHS goals and standards can be allowed to vary under different authorities. However, that already occurs to some extent and could continue following devolution under the Bill.
There are good arguments on both sides about whether local or regional variation should be encouraged or opposed, but it is very important that we are clear about the limits of variation, who decides those limits and the justification for them. Devolution to combined authorities will have a centralising effect for many health and social care functions, as mentioned by the hon. Member for Central Suffolk and North Ipswich (Dr Poulter), and I thank him for his comments. However, devolution could take power away from councils representing smaller communities and clinical commissioning groups representing clinicians. Although that might be desirable in some cases, it is also important to consider how the positive elements those bodies bring to health and social care can be preserved.
Clause 19 creates an important limit on transfers of NHS functions. The Secretary of State responsible for the NHS must remain able to meet his duties under NHS legislation and must not transfer national regulatory or supervisory functions. That suggests that inspections and targets will still be national, but it does prompt questions. Will combined authorities be required to engage and consult on changes and closures of services, as NHS bodies do now under various legislation? Will NHS pricing rules and procedures apply to the new combined authorities? Or will areas such as London, currently reported to be applying for powers to set prices, be allowed to go their own way? If so, will that allow providers to compete to provide lower prices, which has been associated with the risk of lowering quality?
I shall say a little about scrutiny and control in the transfer process. Clause 18 states that the Secretary of State’s power to transfer the functions of public bodies to local authorities only applies as long as the local
authority consents. Should there be a similar provision requiring the consent of NHS bodies where their functions are to be transferred? There is also a case for looking at a formal requirement for local authorities to specify in advance how they intend to use transferred powers, supporting more thorough scrutiny at the point of transfer. It seems likely that it would be advantageous for local relationships and co-operative leadership to ensure that both the NHS and local authorities give informed consent to the new arrangements prior to devolution.
The Bill was designed to encourage the devolution of powers held by Ministers to elected mayors as a single point of accountability. Clause 9 and schedule 3 set up overview and scrutiny and audit committees for combined authorities, providing some non-political oversight, but no such requirements appear to be attached to commissioning plans to ensure that the combined authorities have taken and acted on appropriate public health expertise, such as aligning commissioning to population needs, taking account of inequalities in commissioning decisions, using the best evidence to inform interventions and service delivery, and identifying health service and treatment priorities.
Section 26 of the Health and Social Care Act 2012 requires that CCGs have due regard for addressing inequalities in their decisions. Will the same apply to the new combined authorities, and how will they be held to account? As my hon. Friend the Member for North Durham (Mr Jones) said, where does the buck stop? What happens if things go wrong? So far the mechanisms by which standards and finances will be overseen are unclear. How will the Secretary of State ensure compliance with clause 19 when he does not have control over local authorities? How will NHS regulators enforce breaches? Will NHS debts and liabilities, including private finance initiatives and clinical negligence claims, be guaranteed by the Secretary of State for the Department for Communities and Local Government?
As the Bill stands, the capacity to transfer functions appears to go only in one direction. Whatever happens, there is no way that a power can be returned to the NHS without primary legislation, and it is not clear that this asymmetry is justified or wise.
Many of the transfers of functions from the NHS to local authorities enabled under the Bill appear to require a transfer of the related funding to the local authority budget. This raises a series of important questions. Would this allow local authorities to move spending originally allocated to the NHS to functions not related to health and care? That could lead to greatly increased variation in funding across local areas, influenced by the pressure on other local services and the scope for local taxation. It would also mean that there was no defined NHS budget which could be protected or increased by central Government decisions. The implications for the Government’s ability to commit to NHS spending pledges and for the concept of a national health service are potentially very wide.
The underlying question of whether the NHS should have one single national standard or a local variation presents us with a moral and political quandary. It seems right that local communities should have the right to decide democratically which services they put first. Communities, rural or urban, old or young, with different ethnic mixes, may have genuinely different needs, calling for different choices.
On service closures and downgrades, decisions to move or close NHS services are often some of the most controversial in any local area. An important question will be whether combined authorities with strong local visibility and accountability will be able to give people more faith that these decisions are made fairly, and assure them that overall provision within the city or county will be maintained or improved.
My hon. Friend the Member for Bristol South also referred to specialised health services. Devolution of responsibility for specialised health services needs to be considered, as no region is entirely self-sufficient, and smaller patient populations—those with a spinal injury or a genetic disorder, for example—can easily be left behind at local level. The Bill must therefore be extremely clear that NHS England’s national standards for specialised services are maintained and that devolution takes place only to the extent that is appropriate for the region concerned.
Those are complex decisions for the NHS, and specialised commissioning was moved from local to national level in 2013 for a good reason. In that regard, NHS England has developed its own principles and decision-making criteria for devolution. Can the Minister provide an assurance that those will determine the extent to which devolution occurs in any given region? Can he also provide an assurance that there will continue to be clearly defined accountability for specialised services at whatever level they are commissioned?