By Martha Burgess and Mike Birtwistle.
There has been a great deal of focus on the House of Lords Second Reading of the Health and Social Care Bill. On Monday Andy Burnham declared that there were “72 hours to save the NHS” which, judging by yesterday’s result, presumably means that Britain’s most cherished institution no longer exists. The truth – as ever – is somewhat more complex. Second Reading was never going to make the Bill, even if there was a (slim) chance it could break it. The real action will occur in the Committee and Report stages.
Peers are always reticent to throw out whole pieces of legislation, seeing it as not being their job to challenge the will of the democratically-elected chamber. Instead, their focus is on improving the detail, even if this can have the effect of delivering substantive change. There have been nearly a hundred amendments already tabled to the Bill (about one for every peer who spoke). What we can learn from Second Reading is more about the different schools of thought which exist in the Lords. As ever, it is somewhat more complex than the party lines in the Commons. There are six key groups who will determine the future shape of the Health and Social Care Bill.
The Coalition won all the votes yesterday and the major reason it did so was the number of loyal Conservative peers it could call on. These range from people with experience of running the NHS (such as Virginia Bottomley) through to hereditary peers (of course including Lord Howe). The test for the loyalists will come if and when Labour seeks to force all night sittings on the detail. This group can be expected to support the Government, but most of them do not see their position in the Lords as a full time role, let alone a 24/7 role.
Labour can call on plenty of tribal peers, many of whom have spent a lifetime in politics, to maintain fierce opposition to the Bill, on a line-by-line basis if necessary. Lord Rooker – always a political streetfighter – has already tabled a series of amendments to the Bill. Baroness Royall spoke movingly about her husband’s experience of NHS services and can be expected to play an active role in rallying opposition, supporting Baroness Thornton, who will lead for the Opposition.
That there was little enthusiasm for the Bill on the Liberal Democrat benches was plain to see. Nick Clegg may have famously claimed ‘victory’ on the pause, brandishing a scorecard to make his point, but his peers seemed somewhat less than impressed. However, Liberal Democrat peers are a disciplined bunch and most fell into line behind the Government’s position. Whether this discipline holds at Committee Stage remains to be seen; many other peers may be tempted to join Baroness Tonge and Lady Nicholson in opposing the Government’s position as the Bill progresses.
Advocates of the House of Lords point to the expertise that resides in the chamber and this was certainly on display at Second Reading. A string of former health ministers spoke on both sides of the debate, including lords Warner, Fowler, Hutton, Hunt, Darzi and Baroness Bottomley. On top of this, there was of course a series of medical experts, including Lords Winston, Lady Finlay, Lord Walton and well-known health campaigners such as Lord Adebowale, Baroness Morgan and Lord Rix.
Many peers, particularly crossbenchers, take their cue from experts in the field, so the views of peers with experience of healthcare will be critical as debate on the Bill continues. Reflecting the public debate, the views of the experts will by no means be uniform. Expect the experts to divide on critical issues such as the responsibilities of the Secretary of State, competition and regulation.
Underpinning a number of the interventions made by the groups above is a strong sense that the NHS has been messed about by the listening exercise, and more than anything else needs clarity – and quick. It is notable that even amongst those peers who supported Lord Owen’s efforts to secure a new select committee on the Bill, many made the point that the worst option was further delay. As Lord Darzi said in the debate:
“I am a surgeon, so perhaps I may be allowed a surgical analogy. It is the area I know best. The patient-the NHS-is on the table. It has been put to sleep and we have spent the past 18 months worrying more about new commissioning structures than about raising quality and productivity. The incision has been made, the old structures have been swept away and the new structures are beginning to form. The team could not agree on what operation to do. We have already had time out, and future forums have made some good suggestions after the Government failed to listen to the concerns of patients and staff from the start. The question is: what next? Is more waiting around what the NHS needs? The answer is no. We need to know where we are going and how and when we will get there.”
This argument will be used by the Government as it attempts to resist further changes which may water down the intention of the reforms, or delay their application. Those wishing to see more detail put on the bones of the Bill will no doubt also call on this argument as they seek to secure greater clarity through legislation.
The religious vote:
Those on the Labour benches have often decried the influence of Lords Spiritual, particularly in relation to social legislation. So it may have come as something of a surprise to see the bishops line up to a man in opposition to the Bill. Whether this opposition to the principles underpinning the Bill is translated in to active opposition on the detail could be one of the critical determinants of the future of this legislation.
The importance of the Second Reading debate was overstated by all sides and many stakeholders. Yet the debate – unprecedented in its length and number of participants – has provided an important insight in to the different groups that will determine the legislative future of NHS reform.