Parliamentary Debates House of Commons Official Report General Committees

PARLIAMENTARY DEBATES HOUSE OF COMMONS OFFICIAL REPORT GENERAL COMMITTEES

Public Bill Committee

HEALTHCARE (INTERNATIONAL ARRANGEMENTS) BILL

First Sitting

Tuesday 27 November 2018

CONTENTS Programme motion agreed to. Written evidence (Reporting to the House) motion agreed to. Motion to sit in private agreed to. Examination of witnesses. Adjourned till Thursday 29 November at half-past Eleven o’clock. Written evidence reported to the House.

PBC (Bill 279) 2017 - 2019 No proofs can be supplied. Corrections that Members suggest for the final version of the report should be clearly marked in a copy of the report—not telephoned—and must be received in the Editor’s Room, House of Commons,

not later than

Saturday 1 December 2018

© Parliamentary Copyright House of Commons 2018 This publication may be reproduced under the terms of the Open Parliament licence, which is published at www.parliament.uk/site-information/copyright/. Public Bill Committee 27 NOVEMBER 2018 Healthcare (International Arrangements) Bill

The Committee consisted of the following Members:

Chairs: MR GARY STREETER,†GRAHAM STRINGER

Witnesses

Mr Alastair Henderson, Chief Executive, Academy of Medical Royal Colleges

Raj Jethwa, Director of Policy, British Medical Association

Alisa Dolgova, Manager, Brexit, Association of British Insurers

Fiona Loud, Policy Director, Kidney Care UK 1 Public Bill Committee HOUSE OF COMMONS Healthcare (International 2 Arrangements) Bill Public Bill Committee 9.27 am The Committee deliberated in private. Tuesday 27 November 2018 Examination of Witnesses [GRAHAM STRINGER in the Chair] Mr Alastair Henderson and Raj Jethwa gave evidence. Healthcare (International 9.29 am Arrangements) Bill Q1 The Chair: We will now hear evidence from the Academy of Medical Royal Colleges and the British 9.25 am Medical Association. The Chair: Before we begin, I have a few housekeeping I remind hon. Members that questions should be notes. I ask hon. Members to switch their phones and limited to matters within the scope of the Bill, and that other electronic devices to silent mode, and remind we must stick to the timings in the programme motion them that tea and coffee are not allowed during sittings. that the Committee agreed for this session. We have Today, we will first consider the programme motion on until 10.25 am. I hope, because the Minister has to be the amendment paper, then a motion to allow the on his feet on the Floor of the House immediately after reporting of written evidence for publication, and then this, to cut a couple of minutes off the session to enable a motion to allow us to deliberate in private about our him to carry out his duties. questions before the oral evidence sessions. In view of Are there any relevant interests to declare? No. Will the time available, I hope that we can deal with those the witnesses introduce themselves? matters formally, without debate. The programme motion Mr Henderson: Thank you. I am Alastair Henderson, was discussed yesterday by the Programming Sub- the chief executive of the Academy of Medical Royal Committee for the Bill. Colleges, which is the umbrella body for all the different Ordered, medical royal colleges and faculties in the UK and That— Ireland. We represent the range of specialties, particularly (1) the Committee shall (in addition to its first meeting at on training, education and standards matters. 9.25 am on Tuesday 27 November) meet— Raj Jethwa: I am Raj Jethwa, director of policy at the (a) at 11.30 am and 2.00 pm on Thursday 29 November; British Medical Association, which is the trade union (b) at 9.25 am and 2.00 pm on Tuesday 4 December. and professional association for doctors in the UK. (2) the Committee shall hear oral evidence in accordance with the following Table: Q2 The Minister for Health (Stephen Hammond): Table Good morning, gentlemen. Thank you for coming to give evidence to us this morning. Mr Henderson, in Date Time Witness your evidence to the House of Lords European Union Tuesday Until no later than Academy of Committee, you noted that you want to see the current 27 November 10.25am Medical Royal arrangements preserved. Could you just say how you Colleges; British think the current regulations for reciprocal healthcare Medical work and why they are so satisfactory? Association Mr Henderson: Yes, certainly. I think that the feeling Tuesday Until no later than Association of 27 November 10.55 am British Insurers of clinicians and health organisations, and also of patients, is that the current regulations work well because they Tuesday Until no later than Kidney Care UK 27 November 11.25 am are simple, well understood, easy to operate and pretty well universal in their coverage. We have a good system (3) the proceedings shall (so far as not previously concluded) at the moment that is effective and easy to operate, and be brought to a conclusion at 5.00 pm on Tuesday 4 December. going forward we are looking for something that repeats —(Stephen Hammond.) or replicates that as closely as possible.

The Chair: The deadline for amendments to be considered Q3 Stephen Hammond: In your evidence to the Lords at the first line-by-line sitting of the Committee was Select Committee, you stated that pretty clearly as well. Monday 26 November and therefore has passed. The The Bill obviously aims to replicate and continue the deadline for amendments to be considered on the second current arrangements. I assume that, given your support day of line-by-line consideration of the Bill is the rise of for the regulatory system, you think that this is a the House on Thursday. sensible way for the Government to proceed. Resolved, Mr Henderson: Yes, I do; we are pleased to see that. I That, subject to the discretion of the Chair, any written evidence suppose our position is that, overall, the best and easiest received by the Committee shall be reported to the House for thing would probably be for reciprocal healthcare publication.—(Stephen Hammond.) agreements to be covered in an overall agreement. That The Chair: Copies of written evidence that the Committee seems to me to be the best thing. If we are not in the receives will be made available in the Committee Room. position of having an overall agreement, the Bill, which Resolved, puts in these complementary arrangements, seems to be That, at this and any subsequent meeting at which oral evidence exactly the right thing. We are very supportive of it and is to be heard, the Committee shall sit in private until the are pleased to see that there. witnesses are admitted.—(Stephen Hammond.) Q4 Stephen Hammond: This is my final question to The Chair: We will now go into private session to you, Mr Henderson. In your evidence to the Lords discuss the lines of questioning. Select Committee, you also made the point about costs 3 Public Bill Committee 27 NOVEMBER 2018 Healthcare (International 4 Arrangements) Bill and administrative burdens. As I understand it, if a new Q8 Justin Madders (Ellesmere Port and Neston) (Lab): system were needed or if a no-deal scenario unfortunately Mr Henderson, you said you consider that the system arose—that is not the Government’s intention—the costs works well at the moment. I think it is pretty universally or administrative burden would be a change in coding, accepted that the cost recovery element does not work rather than any other major administrative burden. Is so well. Do you feel that more ought to be done in that your understanding as well, in terms of cost recovery? respect of that, and if so what would you like to see Mr Henderson: In terms of the overall cost, that may done? well be the position. It is not known what the arrangements Mr Henderson: I do not pretend to be an expert on for cost recovery would be. Both clinicians and health the cost recovery system. I think our members would be organisations are concerned that we could end up with very clear that they believe the primary effectiveness of a system that is both administration-intensive and time- the current arrangements is about providing effective intensive. If all people in this country from the European healthcare for citizens across the EU. As clinicians, that Union or European economic area have to be charged, is their primary responsibility. what would be the implications for NHS organisations On the recovery of costs, not just in this area but for and clinicians? other areas where recoverable costs were brought in It is important to say that doctors have had a consistent more recently, there are always questions about the anxiety about becoming involved in being responsible amount of effort and return in the whole system. I am for either immigration rules or charging rules, which not at all opposed to the idea of recovery of costs, but I would potentially have a quite adverse effect on the am not sure we have yet found a hugely simple and easy doctor-patient relationship. I think it is really important way of recovering any costs really. I would happily that whatever arrangements come in are as seamless support that, but it seems to us that this works as a and as simple as possible, so that they do not take system on its most important requirement, which is people away from clinical duties or get in the way of providing quick, clear and safe healthcare for people. delivering care.

Q5 Stephen Hammond: Thank you. Q9 Justin Madders: You say that you have basically Mr Jethwa, good morning. I noticed in your written the same system for 32 or 33 different countries. If we brief that the BMA stated that the Government should end up in a situation in which we have to make undertake every effort to retain the current model of arrangements with each individual country—potentially reciprocal healthcare. My first question is the same as significantly different arrangements depending on what that to Mr Henderson: can you state why you think the is negotiated—what effect do you think that will have current system works so well? on your members, in terms of what they can deliver? Raj Jethwa: For exactly the same reasons my colleague Mr Henderson: It is not a hugely attractive prospect, sets out: the arrangements are wide-ranging, secure and is it, 32 different settings, for those presumably trying to simple. They give security and clarity and are well agree the arrangements? In practical terms, the idea established. Our view is that the best possible arrangement that if you are a GP or a hospital doctor trying to work is for those arrangements to continue. If they cannot, out whether there are different arrangements for 32 different the arrangements that come in their place should mirror lots of patients sounds pretty much like a nightmare them as far as possible. set-up. What clinicians on the ground want is a clear and simple system—ideally a single system—that will Q6 Stephen Hammond: Given that, and given that cover all the people they are seeing. that is the intention of the Bill, do you think that the Government are taking the right approach to ensuring Q10 Justin Madders: May I ask Mr Jethwa some that they put those arrangements in place and that the questions? Have you looked at all at the situation as it legislation has the flexibility to cover both what we might affect the island of Ireland? hope for, which is an achievable deal, and a no-deal situation? Raj Jethwa: We have done some work on that. Raj Jethwa: We largely welcome the Bill for exactly the intention behind it, but because the detail in it is Justin Madders: Would you like to say what you are limited we have some concerns about exactly the clarity doing? going forward that the Bill allows for. We support the Raj Jethwa: Our concern about the situation there is broad intentions behind the Bill, but we would like to primarily based on the fact that there are some very see more detail about exactly how the arrangements will effective cross-border agreements which have facilitated operate in practice, particularly the scrutiny arrangements healthcare over the last two or three decades, particularly to ensure there is clarity and transparency in what the through co-operation and working together as a arrangements negotiated and facilitated through the programme. That is only one aspect of it. Given the Bill would look like. population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, Q7 Stephen Hammond: In terms of the security there have been some fantastic examples of where clinicians arrangements, do you mean security of data? have either co-located services in a particular trust or Raj Jethwa: No, I beg your pardon. We do have facility where there is not the demand from the local concerns about security, but I meant clarity, from the population to warrant it, or travelled across the border perspective of patients understanding and being secure to work on different sites. Those two facets together in themselves about what the arrangements would mean. have meant that there have been some great examples of cross-border co-operation. One of our concerns is that Stephen Hammond: Thank you. those arrangements remain in place in the future. 5 Public Bill Committee HOUSE OF COMMONS Healthcare (International 6 Arrangements) Bill Q11 Justin Madders: Do you have any idea what the Raj Jethwa: We would like to see much more emphasis contingency plans might be if an appropriate deal is not on scrutiny of all the discussions in the arrangements put in place? going forward. There are some negative procedures—I Raj Jethwa: That is something that we can write to think that is the term. Given the weight of the issue and the Committee about afterwards. We have been talking the number of people that could be affected by it—I to our members about this situation. Our anticipation—our have mentioned the 190,000 UK pensioners who live hope—is that an arrangement will remain in place abroad at the moment, but there are close to 3 million whereby that work can continue. people from the European Union who access healthcare in this country, and there are many more than that who travel across the European Union at the moment—there Q12 Justin Madders: Have you looked at what the probably needs to be greater scrutiny of any arrangements possible impact might be of a no-deal scenario on going forward. increased demand on services if, for example, pensioners currently living abroad came back? Q16 Matt Western (Warwick and Leamington) (Lab): Raj Jethwa: We are familiar with the research that Mr Henderson, I think you described the existing the Nuffield Trust has done on this, as most people are. arrangements as pretty well universal. Could you explain Our members are very cognisant of this. I know the a little more what the gaps are? Committee will be familiar with the figure of approximately 190,000 UK pensioners who may require access to Mr Henderson: I am not actually sure I have all the healthcare facilities in the future if the S1 arrangements detail. My understanding is that the European health do not remain in place. We have concerns about that. In insurance card and such arrangements work for all particular, if the arrangements do not remain in place emergency situations, certainly, and most normal in the future, those people may need to access healthcare circumstances. I think, and Raj may know better than I, facilities back in the United Kingdom. That would be a that there are some areas that are not covered particularly, concern in terms of doctor and clinician numbers and but as I understand it, it is fairly universal. I am not an beds, and the tight financial resources that the NHS has absolute expert in that, I am afraid. to work under at the moment. Raj Jethwa: We can write to the Committee. My opinion is that it is pretty universal. There are probably Q13 Julie Cooper (Burnley) (Lab): Good morning. niche areas that may not be covered. We can look into Mr Henderson, you mentioned the protections around that and get back to the Committee if that would be personal data in the Bill. Do you feel that the Bill gives helpful. enough protection? Are there enough controls in the Bill? Q17 Justin Madders: I have one more question to Mr Henderson: As Raj says, this is an enabling Bill, so both of you—I am not sure if either of you will know it is slightly hard to say whether there is sufficient the answer. Some of the reciprocal arrangements we protection there or not. Clearly, it is a hugely important have at the moment are based on the actual cost expended issue that needs to be fully addressed. Equally, we and some are based on an average—Estonia, Denmark, would say very strongly that, while individual patients’ Finland, Hungary, Malta and Norway. I am not clear data must be protected, the free flow of data and why that is the case. Is there some sort of historical exchange of information are absolutely crucial. We issue? If either of you can shed any light on that, that should never forget that side of the equation: properly would be extremely helpful. One of you is shaking your and safely sharing anonymised data for research purposes, head. clinical trials and so on is crucial. While it is absolutely Raj Jethwa: I do not know that, but again we are essential that we ensure that personal data is protected, happy to look into that and to come back to you if we I would put more emphasis on that other side, which is find out that somebody back home does know the ensuring that we continue to share and benefit from the answer. I am not sure that I know. exchange of anonymised data for purposes that benefit Mr Henderson: It is probably lost in the mists of the health service and research. various previous agreements.

Q14 Julie Cooper: Thank you. Mr Jethwa, would you Q18 Stephen Hammond: Can I come back on the like to comment on the same issue? data point that you both commented on? Clause 4 deals Raj Jethwa: It is important that an agreement can directly with that and provides the usual protections in allow a seamless operation, but there are some well- terms of data. I heard Mr Henderson’s point, and it is established ethical principles and safeguards in relation important that there needs to be a flow of data, although to this. First, it has to be relevant data and it has to be that needs to be secure. Are you happy that the protections accessed on a need-to-know basis, and only when it is in in the Bill at the moment are the normal and adequate line with patients’ expectations. Data sharing has to be protections? transparent. We would be absolutely concerned that Raj Jethwa: One of the concerns we have is the any safeguards meet those criteria and principles. I do reference to the authorised person and who could fit not think the details in the Bill make that clear at the into that category. Without seeing more detail about moment. We would like to see more clarity and detail what the arrangements will look like in the future, we about that in future. do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly Q15 Maggie Throup (Erewash) (Con): Mr Jethwa, what process will be used to, for example, recoup the when you look at the current regulations, do you think money or make payments, it is hard to know exactly the powers in the proposed legislation are proportionate? what those arrangements would look like and on what 7 Public Bill Committee 27 NOVEMBER 2018 Healthcare (International 8 Arrangements) Bill basis information would be shared. We do have concerns Alisa Dolgova: That is difficult. Insurers do not know about the authorised person aspect of the Bill, and we what the impact is going to be, because currently they need to ensure that we have greater understanding do not have the data on where the policyholders travel about exactly who would be an authorised person, to. By far the most common type of travel policy that is beyond that list of specific bodies and individuals who bought in the market is a multi-year insurance policy, are named in the Bill at the moment. which covers an individual who can travel anywhere in the EU—or the rest of the world, for that matter. The Chair: Does the Committee have anymore questions? Currently, because part of that is covered by EHIC, No. I thank the witnesses for helping the Committee insurers do not have the breakdown, and it is therefore with its deliberations, and call the next witness. difficult to give a number for what might happen.

Examination of Witness Q23 Stephen Hammond: Do you have some indication Alisa Dolgova gave evidence. of what the typical current premiums are for people with complex and acute conditions who travel to Europe, 9.49 am and what the premium increase would be if reciprocal arrangements were not in place? Q19 The Chair: The next evidence is from the Association Alisa Dolgova: Generally speaking, premiums will be of British Insurers. Good morning. Would you please higher for two reasons: first, if the chance of the person introduce yourself? claiming is higher, and secondly, if the volume of payout Alisa Dolgova: Hi. I am Alisa Dolgova. I am the is likely to be higher—so, if someone has a condition manager looking after Brexit at the Association of that is particularly expensive to treat. That is why health British Insurers. We are a membership organisation is one of the risk factors that may increase premiums. representing more than 250 insurance and long-term Again, it is quite difficult to say what the difference in savings firms in the UK, ranging across general, life and the potential increase would be between those who have reinsurance companies. existing conditions and those who are in good health, because it basically depends on where that group of Q20 Stephen Hammond: Good morning, and thank people is likely to travel to, in terms of how expensive you for coming to give evidence this morning. Could healthcare is in that country. For example, if someone you set out the advantages of the EHIC scheme as the travels to the US, that is a lot more expensive than if ABI sees them? they were to travel to some other destinations. I would Alisa Dolgova: I agree with those who gave evidence just say that if you look at countries where you do not before me, in that the advantage of the EHIC is that it is have EHIC or reciprocal arrangements, insurance policies a simple, easy-to-understand system. From an insurance are available but it may require a bit more effort to perspective, the EHIC covers the medical treatment of locate the right product for the right individual. We are UK nationals travelling through one of the covered working with the Financial Conduct Authority,Macmillan countries, in the same way as local nationals would be and other organisations on that. covered in terms of state provision of healthcare. The insurance then covers anything that is not covered by Q24 Stephen Hammond: I want to ask you broadly EHIC, meaning things that are not covered by the state the same set of questions, but specifically with regard to healthcare system—some countries have a greater tradition health insurance and what the implications would be if of state healthcare than others—but also things such as reciprocal arrangements were not in place for UK citizens repatriation. The advantage of the current system travelling to the EU. continuing for customers is mainly that it is a system Alisa Dolgova: Most private medical insurance policies that is well understood, and there is a minimum that is in the UK are generally designed to cover treatment covered for everybody, irrespective of whether they within the UK. It is relatively rare for the policies to have travel insurance. also cover healthcare while you are travelling. Q21 Stephen Hammond: Specifically on travel insurance, if reciprocal arrangements were not in place, what Q25 Stephen Hammond: If reciprocal arrangements would be the implications in terms of cost, and are were not in place, you would have to have extra healthcare there any other potential implications that we should insurance to cover eventualities abroad and in the EU. understand? Alisa Dolgova: Yes. It may vary depending on the Alisa Dolgova: If EHIC were not in place, those costs type of policy, but generally speaking that is the most would be covered by the person’s travel insurance, if common situation. they have insurance in place. That means that costs that are currently covered by EHIC would be borne by the Q26 Stephen Hammond: Have you given any thought insurer. I think £156 million is currently covered by as to what the cost implications would be if you had to EHIC, so part of that would be covered by the insurer, put those arrangements in place? and that would have an impact on the claims costs for Alisa Dolgova: For health insurance? insurance companies—costs that currently are not there. That might have an impact on the premiums that insurers charge their customers. Stephen Hammond: Yes, for health specifically. Alisa Dolgova: The implications for health insurance Q22 Stephen Hammond: Have you made any estimate are a lot less than for travel insurance. Apart from that, of what the increase in premiums would be if reciprocal health insurance would primarily be affected in the arrangements were not in place? same way as any other insurance in terms of transferring 9 Public Bill Committee HOUSE OF COMMONS Healthcare (International 10 Arrangements) Bill data across borders. I am not sure there is likely to be a market but they may be difficult to locate at the moment, significant impact on health insurance if the reciprocal which is why we are doing additional work at the healthcare arrangements are not in place. moment. So there are products available that will cover people. Q27 Stephen Hammond: Given what we have just said and some of the implications for not having reciprocal Q32 Justin Madders: I appreciate that. There will arrangements in place, can I assume that in principle almost always be a product; it is the size of the premium the ABI thinks that the Government are acting in the that can dictate whether that product is really available. correct way to put in place reciprocal arrangements, or Have you looked at the potential size of premiums in arrangements to make reciprocal arrangements? those situations? Are there particular pre-existing conditions Alisa Dolgova: We are supportive of the Bill and that people might have that will have a negative impact giving the Government the powers they need to implement on the size of the premium? reciprocal healthcare arrangements. From the insurers’ Alisa Dolgova: I do not have information with me perspective, the most important thing for us is to know about which types of conditions are more expensive as early as possible, whatever the outcome, so that than others, but it will be the types of conditions that insurers can plan for any changes and so that we can let are more likely to require treatment while you are our customers know what the impact is likely to be. travelling, and insurers do take factors into account such as, “What has been your recovery time?” Stephen Hammond: So, the sooner the Bill gets Royal Assent, the happier you will be. Q33 Justin Madders: My final question is about the overlap between EHIC costs and insurance costs. I had Q28 Justin Madders: On the cost point, I think some a recent example in my constituency of a constituent evidence was given to the House of Lords Committee who came back from Spain with a medical bill for that in a no deal you expected premiums to increase by £15,000. It was not for repatriation costs; it was purely between 5% and 10%. Does that sound like a familiar for medical treatment. Obviously, the question is, why is figure? that not covered by the normal arrangements? How Alisa Dolgova: My colleague Hugh Savill gave evidence often does that situation arise, and can you give me to the House of Lords, where he stated that there is some insight as to why that might be happening? likely to be an increase of between 10% and 20%. To be Alisa Dolgova: Yes, sure. EHIC covers you for public honest, we do not really know, because it very much healthcare in the same way as a person from that depends on the particular insurer, who it insures and country would be covered, and healthcare provision where that specific group of people travels to. differs a lot, depending on which EU country you are in. Some countries, such as Italy, have healthcare systems Q29 Justin Madders: In that context, what advice are that are much closer to the NHS than others, and if you you giving to people about insurance requirements post travel there, EHIC will give you greater coverage. Some 29 March 2019? countries, such as Spain, have a mixed public/private Alisa Dolgova: The main message that insurers are system and some countries, such as Germany, have a giving to the customers is that it has always been greater tradition of private healthcare. Actually, that important to have travel insurance because it covers means the degree you are covered by EHIC varies things that EHIC does not, but it will be even more depending on where you travel and that is why you need important to have it in case there is not a transitional insurance. period, because travellers would no longer have the benefit of EHIC. The message is that you need to have Q34 Justin Madders: Okay. I think my constituent’s travel insurance in place, and that travel insurance will situation was an emergency and I do not think that any cover you, irrespective of whether you have EHIC. consideration was given to the type of hospital. I think that what you are saying is that reciprocal arrangements Q30 Justin Madders: Has there been an increase in do not necessarily give you the same or equivalent premiums because of that added uncertainty, do you coverage in other countries, because it depends on the know? system that operates there. Alisa Dolgova: We have not currently seen an increase Alisa Dolgova: Yes. It will give you more coverage in premiums. Firms are currently pricing in the assumption across all countries, but what that coverage is depends that there will be a withdrawal agreement in place with on what the situation is in that country. a transitional period that will allow more time for the Government to enter into a reciprocal healthcare Q35 Alberto Costa (South Leicestershire) (Con): You arrangement. said that private insurance policies cover the areas above the benefits of the EHIC. But is it not the case that Q31 Justin Madders: In the event that there are not those of us who take out private travel insurance policies arrangements in place, have your members done any precisely for the healthcare benefits may not make use work on the number of people who might not be able to of EHIC? And is it the case that, because of that, the travel, because they effectively become uninsurable or premium costs for private travel insurance are less, the premiums are so high that they are prohibitive? given that those of us who take out private insurance Alisa Dolgova: I have briefly alluded to the work that might not use EHIC and might rely on the private we have been doing with the Financial Conduct Authority. healthcare side instead? The FCA published a feedback statement in June this Alisa Dolgova: It depends on the specific terms of the year,looking at travel for people with pre-existing conditions. travel insurance policy that you have. For example, The finding was that there are products available on the some policies have a specific provision that you need to 11 Public Bill Committee 27 NOVEMBER 2018 Healthcare (International 12 Arrangements) Bill use EHIC first and then have resort to your insurance emotional, financial and practical help to patients and policy, and insurers may also provide incentives to use their families who are affected by kidney disease, but EHIC as well. For example, they might provide a waiver particularly kidney failure. for access costs of EHIC; that has been used. Q39 Stephen Hammond: Good morning and thank Q36 Alberto Costa: What I am trying to ask is you for coming. I am particularly keen to hear evidence whether it might be the case that, without this Bill and from you about how the current reciprocal arrangements without reciprocal arrangements, the cost of travel health work for patients with high needs and complex insurance is likely to go up? Those of us who take out arrangements. It would be very helpful to hear how you these policies are not necessarily reliant on EHIC, because think the current arrangements work. we would refer to the private claim, whereas others who Fiona Loud: At the moment, 29,000 people in the UK perhaps do not have healthcare benefits under a travel are dependent on dialysis. That is three times a week, insurance policy would be entirely reliant on EHIC. about five hours at a time, and those people cannot miss What I am trying to tease out is whether, without this a session, because those sessions maintain their life. If a Bill, the healthcare side of travel insurance—the person is on dialysis and wishes to travel—anywhere in premiums—would potentially go up? the world, but let us talk about the EU here—whether Alisa Dolgova: The claims cost will definitely increase, to meet family, to have a holiday, or to work, they need which may lead to an increase in travel insurance costs to be able to pre-book a slot or slots at a dialysis unit as well. that is convenient to the place they are travelling to. At the moment, the EHIC card either covers it completely Q37 Matt Western: Out of interest, can I ask you a or, in countries where there is a co-payment because really simple question? What happens currently, but local residents make a co-payment, it covers the bulk of also perhaps in future, when someone is abroad and has your care. Many patients tend to go to places such as an injury, an accident or whatever for which some form Spain and France, and some go to Italy, because they of implant is required, and that implant subsequently are holiday-type destinations. It works for them because fails when the person returns to the UK and it is not they get the EHIC, are able to get their life-maintaining supported by the NHS? Where does the cost burden fall treatment and have the opportunity, for themselves and and how does that impact on insurance, and how may their families, for a much-needed break. That is an example that work in future if we do not have regulatory alignment? of one of the main reasons people might use that. Alisa Dolgova: Sorry, your question is who would So it works well at the moment. It is not completely pick up the cost if treatment were provided overseas, perfect because sometimes units that were public become but it fails? private and it may occasionally happen that someone has booked a holiday a long way in advance. But, in Matt Western: Yes. If that implant failed, whatever it general terms, it means that people are able to go away might be, and the cost to revise that implant were then with the confidence that they will be able to be supported borne by the NHS, who picks up the cost, and how does and receive the treatment they need. that work? How does it work currently, and how might it work in the future based on this? Q40 Stephen Hammond: You will have heard the Alisa Dolgova: I am not sure I have a detailed enough evidence we have just taken from ABI. I was particularly answer to give at the moment. I would be happy to keen to understand the variations in insurance and come back to the Committee on that, but again, I think exclusions that might currently exist where there are it would ultimately depend on exactly what travel insurance high needs and complex conditions. Could you set out policy is in place. I would assume that the travel insurance for the Committee the experience of Kidney Care UK? policy is likely to cover a person for the treatment they Fiona Loud: For people with a pre-existing condition, receive overseas, and if they then need additional medical such as kidney failure, we always advise that they take treatment back in the UK, they would be treated within out insurance in addition to having a current EHIC the UK healthcare system in the same way as they are card, because there will be situations in which they may currently. need to cancel their travel at very short notice due to illness. What we regularly hear from patients—this is The Chair: Are there any more questions from members probably one of the most common questions asked on of the Committee? If not, I thank you very much for our closed social media forums, especially at holiday helping the Committee with its deliberations on this time—is, “Where do I book? Where do I get insurance Bill, and I call the next witness. from? Where do I get the best deal?” My understanding is that some people go to specialist insurers to get their Examination of Witness cover—they will be those that we tend to recommend to people because they are much more likely to understand Fiona Loud gave evidence. and to be able to support these complex conditions. Whether everyone gets insurance, I honestly do not know. 10.8 am Some people will say that it is so expensive that they Q38 The Chair: We will now hear oral evidence from cannot afford it, and that could put them off travelling. Kidney Care UK. Could you introduce yourself, please? Other people will say that they have incredibly cheap Fiona Loud: My name is Fiona Loud, and I am the deals, and I do wonder whether those would actually policy director for Kidney Care UK. We have been cover the situation of someone really needing care. around for over 40 years and were formerly known as Let me give you a recent example of someone who the British Kidney Patient Association. We are the booked a holiday a year in advance, not in the EU but national kidney patient support charity, so we give further away. They took out specialist travel insurance 13 Public Bill Committee HOUSE OF COMMONS Healthcare (International 14 Arrangements) Bill and during that time their transplant failed, which than one or two days in between dialysis sessions. NHS meant that they became dependent on dialysis, were staff will help and do their very best, but it is easier to particular ill and had to cancel the holiday for them and go away for two weeks in Europe and take a break in all their family. They were able to get all their money that way than it is to get two weeks in a UK unit, back because they had given a clear declaration and unfortunately. that had been accepted. That is how it should work, and it was some comfort to them in what was not a very Q44 Justin Madders: It is alarming to hear about good situation. some of your members seeing the expiry date on their We have people who are taking the option to travel EHIC card and assuming that carries— now because they have no idea what will happen after Fiona Loud: I have heard it as a comment. 29 March. For them, the ability to travel with confidence—I think there is something in the Bill about people being able to travel with confidence—is something they can Q45 Justin Madders: It is perfectly understandable: do now, and they are not confident yet that they will be why would they not assume that? Are you aware of any able to do that after 29 March. publicly available guidance to warn people that that date may not be absolutely set in stone? Q41 Stephen Hammond: The intention of the Bill is Fiona Loud: I have not come across any publicly to provide that confidence, so may I ask whether you available guidance on that at all. We have given advice support that intention in principle? and organisations that we work with give advice, but it Fiona Loud: We understand the reason for it and we is informal advice. It is not formal, because it comes support its intentions. You may have seen some of our from us as a charity, not from any public health or other comments: we want more assurance, some more detail such body. and some things about contingency as well but, yes, we have been hoping for some time that something could Q46 Justin Madders: Obviously, we hope that we do be put in place to set this process in motion. not need to get into that situation. Do your members plan things quite far in advance because of the need to Q42 Stephen Hammond: I know that you and my get the right treatment? colleague, the noble Lord O’Shaughnessy, have had a Fiona Loud: That is what many people would do, for discussion. Could you tell this Committee what the the very reasons we have given. We have people who are contingency issues you refer to are? sometimes thinking about two years in advance. If you Fiona Loud: The contingency issues would be for people have kidney failure, it may well be that your income is who have holidays already booked for after 29 March. quite limited. If you are spending three days a week in There are people who have already done that and, hospital and you are not particularly well, you would be because their EHIC card has a date of after 29 March—the likely to plan a long way in advance, because it is so cards will go on for many years afterwards, as we all important. As a charity, we give grants to kidney patients know; they are issued for five or 10-year chunks—they to be able to go away and have that break, so we hear imagine that they can go away and receive their dialysis. quite a lot about it from various patients. Some can be What happens in the case of no deal, where holidays are up to two years in advance; others will be at shorter booked on that presumption? Will there be cover? notice. The second question will be about emergency cover. I have just given an example of somebody who was fine Q47 Julie Cooper: Good morning and thank you for when they booked the holiday but who now may not be coming along to help us. I want to ask about a couple of fine, because people’s health state can change. Generally things. The aim of the Bill is to provide the confidence speaking, holidays are booked in advance. It is basically that we have talked about, to mirror as far as possible about looking at what the immediate arrangements the reciprocal arrangements that we already enjoy.However, would be and to make sure that no citizens are caught in it does give the Secretary of State the authority to enter the gap of assuming they have cover and somehow not into any number of differential agreements with individual realising that things have changed. There is an awful lot EU states. Do you have concerns about that? If we were about Brexit at the moment and this is a very specific in this situation—I hope we are not—the Bill empowers detail in a much noisier environment. Those are the the Secretary of State to do that. What would be your people who might be caught out and whom we are view be on the arrangement with Spain being one thing concerned about. and that with Italy another, and so on? Fiona Loud: Although we completely understand the Q43 Stephen Hammond: Finally, without putting need to be able to have the latitude to make bilateral reciprocal arrangements in place, as this Bill intends to arrangements for everyone’s benefit, from a patient give the Government the powers to do, presumably it point of view we would like to see a simple arrangement would make it more or less impossible for your sufferers that is the same across all countries. People will not be to travel. sitting in these Committees or reading these Bills in Fiona Loud: Yes, it is our conclusion that it would be great detail. They simply want to be able to go away. very hard. It is worth mentioning that at the moment it They know how a system works at the moment: they is generally easier to obtain dialysis at a unit away from will perhaps turn to somebody in their own NHS unit, your home in Europe than it is in the UK, because we or they will turn to us or to other specialists, and ask, have a heavily pressed NHS. Trying to get capacity in “How do I go ahead and book my holiday?” and they other units is possible with a lot of planning, but if you will assume that, because they have that card, that is want to travel for a funeral or for something at short how it will be. That would be our wish and our preference, notice, it becomes very difficult to go away for more but we understand that that is not always possible. 15 Public Bill Committee 27 NOVEMBER 2018 Healthcare (International 16 Arrangements) Bill If I may make a separate comment about Northern lower income than average. If it is not possible to Ireland, there are potential issues there that are nothing continue something similar to the EHIC card, are you to do with holiday but are simply about residents who concerned that transferring extra costs to insurance are used to going across the border day to day for their premiums is going to make travel virtually impossible? care and treatments. There are pre-existing arrangements Fiona Loud: We are. A dialysis session in the EU and protocols there. For example, somebody might be would cost between ¤250 and ¤350, so that is about on dialysis in Northern Ireland but, because the rest of ¤1,000 a week. We have had correspondence with Sabine their family live in Ireland—it is only 10 or 15 miles Weyand, who is the deputy chief negotiator for exiting away—they might be planning to retire there in a year the EU. She confirmed to us that British nationals or two and assume that they can just carry on having would be treated as third-country nationals, in the case their dialysis there. of no negotiation being in place. Therefore, our conclusion The provision exists for people who live in Northern is that for third-country nationals, those costs that I Ireland to be listed on the Irish organ donor register—you have just referred to would be applied. Therefore, only can only be on one—and vice versa. They will need to people who were able to afford that, alongside a higher look at where they are registered. Does that change insurance policy—which would not cover the dialysis, immediately? There are also other arrangements for though it would cover other things—would be able to organ sharing. If an organ is donated in one of those travel, effectively making it out of reach for most patients, two jurisdictions and the weather is too bad to take it to unfortunately. the mainland, it can be taken across by road. That is not The Chair: Are there any more questions from the used very often, but those are just a couple of examples Committee? If not, I thank you very much for helping of some of the detail that might affect people. That is to us with our deliberations today. That concludes our do with healthcare but it is also separate. There may, oral evidence-gathering for the Bill. The Committee will therefore, need to be some other bilateral arrangement meet again on Thursday 29 November at 11.30 am in for Northern Ireland, which is separate from the more Room 12, when we will commence line-by-line consideration general one that we have just discussed. of the Bill. Ordered, That further consideration be now adjourned. —(Wendy Morton.) Q48 Julie Cooper: Thank you, that is very helpful. Could I just ask you one more question about costs? 10.23 am You rightly made the point that, if somebody is attending Adjourned till Thursday 29 November at half-past for dialysis three days a week, they are likely to have Eleven o’clock. 17 Public Bill Committee HOUSE OF COMMONS Healthcare (International 18 Arrangements) Bill Written evidence reported to the House HIAB01 Jill Brian HIAB02 Expat Citizen Rights in EU (ECREU) PARLIAMENTARY DEBATES HOUSE OF COMMONS OFFICIAL REPORT GENERAL COMMITTEES

Public Bill Committee

HEALTHCARE (INTERNATIONAL ARRANGEMENTS) BILL

Second Sitting

Thursday 29 November 2018

(Morning)

CONTENTS

CLAUSES 1 TO 6 agreed to. New clauses under consideration when the Committee adjourned till this day at Two o’clock.

not later than

Monday 3 December 2018

© Parliamentary Copyright House of Commons 2018 This publication may be reproduced under the terms of the Open Parliament licence, which is published at www.parliament.uk/site-information/copyright/. 19 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 20 Arrangements) Bill

The Committee consisted of the following Members:

Chairs: MR GARY STREETER,†GRAHAM STRINGER

The Delegated Powers and Regulatory Reform MEANING OF “HEALTHCARE” AND “HEALTHCARE Committee in the other place went further than that, AGREEMENT” describing the scope of clause 2 as “breath-taking”. As Question proposed, That the clause stand part of the that Committee correctly pointed out, there is no limit Bill. to the amount of any payments, to who can be funded or to the types of healthcare being funded. The regulations can confer or delegate functions to anyone, anywhere, Stephen Hammond: Mr Speaker—sorry, Mr Stringer: and primary legislation can be amended for these purposes. although who knows what may happen later next year? It is also worth noting that although this legislation has been presented as a Bill to enable us, as far as The Chair: A serious promotion! possible, to retain the arrangements that we already have—who would disagree with that?—the powers Stephen Hammond: One that I am sure would be conferred by the clause, as I think has been conceded by welcomed by Members on both sides of the Committee. the Minister, can go far beyond the current EU and EEA countries that we are primarily concerned about. Clause 3 is very simple and sets out the definition of “healthcare” and “healthcare agreement” used within Weconsider the powers in the clause to be inappropriately the Bill. The definition of healthcare is modelled on the wide, if they are not going to be subject to the correct definition provided in the Health and Social Care Act levels of scrutiny. At this eleventh hour, we understand 2012, which we have adapted to include the additional why a certain level of flexibility is being sought by the element of ancillary care. That is to reflect where current Government, but with that request comes a responsibility arrangements provide for ancillary costs, such as travel, to ensure that proper parliamentary scrutiny is exercised. which do not fit strictly within the definition of healthcare. Rather than oppose the clause in its entirety, we As in France, this is for use in circumstances where believe that the appropriate remedy would be to ensure residents are reimbursed a contribution of their travel that any regulations introduced under the Bill will be costs when attending healthcare appointments. subject to the affirmative procedure. We will return to I would like to clarify that access to social care in that point when we consider amendment 2 to clause 5. England would not be provided for through any reciprocal healthcare agreement. It is up to each individual country Stephen Hammond: The hon. Gentleman is right to to determine what is available through the public healthcare say that these powers are flexible. Part of the reason for system, just as we do with the NHS. The clause would that is that there may well be a need to anticipate the enable individuals to access healthcare on those terms. sort of bilateral arrangements that we put in place in A healthcare agreement could be made either bilaterally the future—notwithstanding our hopes that we will or multilaterally, or it could be an agreement between secure a continuation of the current reciprocal healthcare states, countries or multilateral organisations. Such arrangements, which is our ambition. When we come to agreements provide access to agreed forms of healthcare debate not only the hon. Gentleman’s amendment, but when individuals from one country seek healthcare in clause 5—when the discussion on scrutiny of these the other, and vice versa. They also provide for how the arrangements should take place—I will seek to reassure funding will be shared between parties. Funding could him that the procedures in place will allow for the usual mean a direct payment, arrangements to waive or set off and appropriate parliamentary scrutiny of the Bill. costs, or other arrangements to cover costs. Clause 3 is The hon. Gentleman talked about the powers being short but important. too broad. The Bill has a very focused purpose: to Question put and agreed to. ensure that the reciprocal healthcare arrangements, which Clause 3 accordingly ordered to stand part of the Bill. 29 Public Bill Committee HOUSE OF COMMONS Healthcare (International 30 Arrangements) Bill Clause 4 definition of “authorised person” in subsection (6). Mr Jethwa, representing the BMA, said in his evidence to this Committee that data DATA PROCESSING “has to be accessed on a need-to-know basis, and only when it is 12 noon in line with patients’expectations. Data sharing has to be transparent. We would be absolutely concerned that any safeguards meet those Julie Cooper (Burnley) (Lab): I beg to move criteria and principles. I do not think the details in the Bill make amendment 1, in clause 4, page 3, line 17, leave out that clear at the moment. We would like to see more clarity and paragraph (d). detail about that in future.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November It is a pleasure to serve under your chairmanship, 2018; c. 5, Q14.] Mr Stringer, and I am pleased to have the opportunity to speak to clause 4. At this time of great uncertainty, Mr Henderson, from the Academy of Medical Royal when the nature of our future relationship with the Colleges, said that although he recognises that there European Union is still unknown, we welcome the must be a “free flow” of data, intention outlined in the Bill to give some confidence to “individual patients’ data must be protected”, those who currently rely on the reciprocal health and that arrangements between the UK and the nations of the “it is slightly hard to say whether there is sufficient protection EU and EEA. We are only surprised that the Bill has thereornot”.––[OfficialReport,Healthcare(InternationalArrangements) taken so long to come before us. Public Bill Committee, 27 November 2018; c. 5, Q13.] The scope of the Bill is designed to cater for all He is correct: it is hard to see that there are sufficient possible outcomes of the UK and EU negotiations. The protections in the Bill. This is a hugely important issue intention is that, deal or no deal, the Bill will empower that needs to be fully addressed. the Secretary of State to negotiate future reciprocal With that in mind, we are of the view that healthcare arrangements between the nations of the subsection (6)(d) should be deleted, principally because UK and the EU, and any other such nation as is it gives the Secretary of State a power—to authorise desired. Providing for pensioners, visitors, students and private health companies to access patient data—that is workers to live, work, study and travel in EU member far too wide ranging. We believe that removing that states with complete peace of mind regarding the provision paragraph protects personal data and achieves a balance, of healthcare is a priority for Labour. We therefore giving more confidence to patients while allowing the recognise the need for the Bill. smooth transfer of data to designated qualified personnel. While understanding that any future agreement must The right to privacy and access to healthcare are rights allow for the smooth transference of data for the that we value, and the one should not be conditional on achievement of the best possible outcomes for patients, the other. We wish to ensure that the Bill gives UK we believe it is also crucial that the Bill provides robust patients, and patients from the EU, full confidence powers to protect personal data. Health records contain that their personal information will not be shared both personal and sensitive data, and access to such inappropriately.That remains the case whether healthcare information must be allowed sparingly and only for is received in the UK or overseas as part of a reciprocal medical purposes. Access to personal data should be healthcare agreement. As we leave the European Union, available to health professionals who are bound by a citizens accessing medical care as part of a reciprocal duty of confidentiality on the basis of need to know. health agreement need to be sure that their personal The Data Protection Act 2018 outlines the key principles data will not be shared inappropriately. Without that relating to the protection of data; compliance with the assurance, citizens may be discouraged from seeking spirit of those principles is fundamental to good data medical assistance. protection practice, and embodies the spirit of lawful, fair and transparent use of data. Currently, the General Data Protection Regulation Stephen Hammond: I thank the hon. Member for places restrictions on the transfer of personal data to Burnley for moving this amendment, because it gives countries outside the EU and EEA. As the UK leaves me the opportunity to set out clearly and in some depth the EU,we will not automatically enjoy existing protections; why we have chosen to include clause 4(6)(d) in the Bill. indeed, this Bill provides powers for negotiations to I want to lay out the reasoning for our concerns about take place with nation states across the world, to reach this amendment. I hope that I will be able to reassure agreement on a bilateral basis. That makes it imperative, her of the vital importance of paragraph (d), and that it in our view, that the Bill protects against potential is necessary and appropriate, because we will be unable misuse of personal data. to accept the amendment. Clause 4 outlines the detail of how data will be Reciprocal healthcare agreements are made possible processed for the purposes of the Bill. We have noted by close, consensual co-operation of different parties the wide-ranging powers to be given to authorised and bodies, such as the Department of Health and persons, who may Social Care, the Commissioners for Her Majesty’sRevenue “process personal data held by the person in connection with any and Customs, Ministers of devolved Administrations, of the person’s functions where that person considers it necessary healthcare providers and all their opposite numbers in for the purposes of implementing, operating or facilitating the EU and EEA countries. Since the Bill is about the doing of anything under or by virtue of this Act.” provision of healthcare, it would be remiss of Her We are not satisfied that sufficient safeguards are in Majesty’s Government to exclude healthcare providers, place when defining an authorised person for the purposes either those in the United Kingdom or those in other of the Bill. We have listened carefully to the concerns countries, from the list with authority and sanction to of the British Medical Association, and share that process and share data. Given that it is the Government’s organisation’s concerns about the lack of detail in the position that in the agreement with the EU, future 31 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 32 Arrangements) Bill arrangements for the provision of healthcare abroad Since our desire to continue existing arrangements will reflect existing ones, it is worth reflecting on the is shared by those on both sides of the House, I do not place of healthcare providers in these processes, to feel that the clause has inappropriate powers. To further illustrate the role they play in the commission and allay any other fears, I remind members of the Committee delivery of healthcare abroad. that the clause contains safeguards to guard against any misuse of data. The Bill gives powers to providers, Under the S2 route, a UK resident may decide to seek either in state healthcare systems or private ones, to planned treatment abroad. As part of the ordinary process solely where it is necessary for the limited procedure, the UK resident must visit a healthcare purpose of funding or arranging healthcare abroad— provider in the UK. The clinician would then provide nothing more. written evidence that the person has had a full clinical assessment, which must clearly state why the treatment All processing of the data by all parties must also is needed in their circumstances and what the clinician comply with existing data protection legislation. That is considers to be a medically justifiable time period within a crucial safeguard under UK data legislation. Data which they should be treated again, based on their concerning healthcare is personal or specific category circumstances. As is clear under existing arrangements, data. That can only be processed where specific conditions this function can only be served by a medically trained are met, namely that processing is necessary for the healthcare provider. This paperwork is then passed on purpose of healthcare and in the public interest. Members to NHS England or the comparable authority in the will recognise that clause 4(6)(d) does not represent a devolved Administrations for further processing. Many deviation or new departure from existing arrangements of those organisations are provided for by subsection (6)(c). and simply allows for the Government to maintain or Members will, I hope, understand that the lack of improve those arrangements in whatever circumstances qualification around the term “provider of healthcare” we find ourselves in after exit. is appropriate and necessary at this stage, given that In closing, were the amendment agreed, it could risk future arrangements are not yet clear. patient outcomes by excluding providers of healthcare from the list of authorised persons. The hon. Lady If the Government are adequately to fulfil the purposes expressed some concerns, and I hope that my response outlined in clause 1, they need to be able to facilitate has allayed them. I offer to make my officials available and fund healthcare for UK persons, for whom they feel to provide a briefing on this matter to her and any other responsible, whether the provider is based in the UK or member of the Committee who should so wish, so that overseas. In that connection, I think it is worth pointing they can be completely reassured that the normal data out that the current reciprocal healthcare arrangements protection legislation will apply to the Bill. The exchange allow UK persons to access treatment from providers of of data may happen only for a limited and focused healthcare in another country that are not NHS bodies purpose. The hon. Lady was right to express her concerns, or comparable state providers in another country, as and I hope she will be reassured by my words and that defined by UK healthcare legislation. That might include she will not feel the need to press her amendment to a an optometrist or a dentist, many of whom fall outside Division. the state healthcare system. Subsection 6(d) proposes to ensure that other types of healthcare providers are authorised to process personal Julie Cooper: I am grateful to the Minister for those data under the Bill, but most importantly that NHS explanations, and I welcome him saying it is a very bodies are able, where necessary, to share personal data limited and focused use of the data. I would be happy to for the purposes of the Bill with healthcare providers take a briefing from his officials, but further to that, to based outside the UK. Simply, if such providers were give assurance to our side, I would be grateful if he will not also considered authorised, it would be impossible undertake to go further on Report and outline the for healthcare commissioned, implemented, facilitated scope of the subsection. If he will do that, we will not or funded by the UK to be authorised to be rendered press the amendment to a Division. abroad. The hon. Lady is concerned that the clause will allow Stephen Hammond: We will carefully consider what private providers access to patient data and the powers the hon. Lady has said and her request for further to process it. She should be reassured that that is details on Report. I have listened and have offered that already legal and proper under existing arrangements briefing, and I hope that is sufficient for her to decide governed by EU regulations. Under existing reciprocal not to press the amendment to a Division now. healthcare arrangements, UK persons are able to receive treatment in another country on the same basis as a local resident of that country. That includes healthcare Julie Cooper: I beg to ask leave to withdraw the or other treatments given by healthcare providers other amendment. than those that fall within the scope of domestic UK Amendment, by leave, withdrawn. healthcare legislation. Question proposed, That the clause stand part of the After the fact and on return to the UK, the person Bill. would be able to seek reimbursement, where appropriate, from the relevant UK authorities. It is worth noting 12.15 pm that the person who sought treatment abroad would typically only be reimbursed up to the amount it would Stephen Hammond: I will try to limit my comments, have cost under the NHS. It would be for the person, given that we have already had discussions on the not the Department of Health and Social Care, to bear amendment. I am sure that will be welcome on this cold the financial risk of any additional cost. November day in a rather warm room. 33 Public Bill Committee HOUSE OF COMMONS Healthcare (International 34 Arrangements) Bill [Stephen Hammond] of data must comply with parts 1 to 7 or chapter 1 of part 9 of the Investigatory Powers Act 2016. The only Clause 4 provides a clear legal basis for processing purposes for which investigatory powers may be required personal data under the Bill for the purposes of UK are to investigate and tackle suspected cases of fraud data protection legislation. At present, the EU regulations and error relating to healthcare abroad. provide a lawful basis for processing data for the purposes As set out in subsection (1), the processing of data of reciprocal healthcare. Personal data is integral for under the Bill is limited to authorised persons who, as providing healthcare abroad. It is vital that authorised we have discussed, are defined in subsection (6). The list persons in the UK can process data for that purpose. reflects those persons and bodies currently involved in The clause ensures that, after exit day, there is a clear processing data, including personal data under existing and transparent basis for processing personal data for reciprocal healthcare arrangements. the purposes of providing healthcare abroad, as required I mentioned that, for clarity’s sake, subsection (6)(a) by UK data protection legislation. Clause 4 will ensure lists that safeguards are in place for that processing. “the Secretary of State, the Treasury, the Commissioners for Her Subsection (1) limits processing to that which is necessary Majesty’s Revenue and Customs, the Scottish Ministers, the Welsh for the purposes of the Bill. Subsections (2) and (3) Ministers and a Northern Ireland department”. ensure that any such processing must remain in compliance Healthcare abroad is entirely managed and operated by with UK data protection legislation and the Investigatory the Department of Health and Social Care in co-operation Powers Act 2016, and any other relevant restrictions. with the Executives in the devolved Administrations Finally, the persons who can process data under the Bill and their local healthcare systems. Although the Bill is are limited to those authorised in subsection (6), which about the provision of healthcare abroad, it is vital that we have just discussed. the Executives of the devolved Administrations are The safeguards limit the scope of clause 4 to what is considered authorised persons, since healthcare abroad necessary and proportionate to provide healthcare abroad. is often facilitated in co-operation with them. Under For reciprocal healthcare, personal data is required to subsections (6)(b), (c) and (d), healthcare bodies and process reimbursements to and from other countries, providers are considered authorised persons as they are and where reimbursement is made to a person as well. It directly involved in the provision of healthcare. is also sometimes necessary for healthcare providers to Finally, subsection (6)(e) gives the Secretary of State share medical information to facilitate treatment. The the power to add to the list of authorised persons, clause ensures that the Government can continue to which will ensure that the Government can respond process personal data as necessary, after exit day, in an appropriately, whatever the outcome of EU exit. It is effective and lawful way. Personal data transferred from also deemed necessary to allow the Secretary of State to outside the UK will remain subject to the need for respond to the changing demands of systems and safeguards to be put in place before it is transferred. operations. In future, duties may change and adding to Those safeguards will not be able to be contracted out the list will be difficult, so it is necessary to have the as part of any healthcare agreement with the EU or power in place. member states or third countries. Clause 4 is an important component of the Bill. It As I said a moment ago, subsection (1) provides for provides the Government with the necessary power to an authorised person to process data related to the process and share data that relates to healthcare provided provision of healthcare abroad. Personal data is defined abroad. Therefore, I recommend that the clause stand in the GDPR as data that relates to a living person who part of the Bill. can be directly or indirectly identified from the data. Specific category data is personal data containing health Question put and agreed to. and genetic data. At present, there are different routes Clause 4 accordingly ordered to stand part of the Bill. for providing healthcare abroad, such as the S1, S2 or EHIC routes, and each route requires different forms of Clause 5 personal data.

Subsection (2) disapplies the duty of confidence and REGULATIONS AND DIRECTIONS any restriction on the processing that would otherwise apply. The exemption ensures that data can be disclosed Justin Madders: I beg to move amendment 2, in where it is necessary for the limited purposes of the Bill. clause 5, page 3, line 44, leave out subsection (5) and The measure is necessary and appropriate. For example, subsection (6) and insert— authorised persons may need to share data if a person is unconscious and therefore not in a state to provide it “(5) Any statutory instrument which contains regulations themselves. Importantly, as expressed in subsection (3), issued under this Act may not be made unless a draft of the instrument has been laid before Parliament and approved by a data processing must continue to comply with the UK resolution of each House.” data protection legislation, which ensures there are further This amendment would make all regulations issued under this Act safeguards around data processing. The GDPR also subject to the affirmative procedure and require approval from governs data transfers between the UK and other countries. Parliament before they become law. All EU and EEA countries are bound by the GDPR, This amendment is probably one of the most important which means the relevant national data protection items that we will discuss in Committee. As I made clear safeguards in each country are adequate, allowing the when we discussed clause 2, there are widely held concerns free transfer of data between countries. about the scope of the regulations, which are exacerbated Subsection (3)(a) expressly requires that the processing by the fact that these extraordinarily wide powers, necessary of data does not contravene existing data protection as they may be in the circumstances, are subject only to legislation, and subsection (3)(b) requires that the processing the negative procedure. 35 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 36 Arrangements) Bill As I referred to earlier, the Delegated Powers and While there is scope for the affirmative procedure to Regulatory Reform Committee in the other place clearly be used in cases where Henry VIII powers are invoked set out the potential impact of my amendment not to amend primary legislation, I think it is pretty clear being accepted when it said: that potentially the most significant changes to reciprocal “If, without such amendment, the Secretary of State wished to agreements that could be enacted under the legislation fund wholly or entirely the cost of all mental health provision in are those that are subject only to the negative procedure. the state of Arizona, or the cost of all hip replacements in As we know, the negative procedure means that an Australia, the regulations would only be subject to the negative instrument is laid in draft and cannot be made if that procedure. Of course, these examples will not be priorities for any draft is disapproved within 40 days, normally via a Secretary of State in this country.” prayer against, which is usually by way of an early-day I hope that is the case, but we are here to look at how motion. If that does not happen, the legislation is then the powers could be used over,possibly,the next 100 years, passed. That is a 40-day process in the best-case scenario. and not just how we would expect them to be used in If I am correct, and if we leave without a deal, the the foreseeable future. Secretary of State will have to reach agreement with Nobody knows where this process will take us, and each of the 30-plus countries no later than Friday when examining legislation there is always merit in 15 February, assuming that Parliament does not sit on considering the unlikely as well as the stated intentions the following Sunday. At this stage, who knows where of the Government at the time. The Minister’s comments we might end up, but we will assume for now that the about wider objectives reaffirms the importance of our sitting days are as set out, so Friday 15 February will be scrutinising the regulations as much as possible. We find the last day that an instrument can be laid that will pass ourselves in an unprecedented situation in Parliament, before 29 March, assuming that it is not prayed against. and it is therefore important that we consider all Hopefully the Minister will be able to advise whether eventualities. my understanding of the timetable is correct. If Committee members need further persuasion that Will the Minister concede that, on a practical level, it the amendment should be carried, that Lords Committee would be better for regulations moved under the Bill to set out a devastating list of reasons why the negative be moved using the affirmative procedure? We could procedure is inappropriate. It said: then get them through scrutiny in both Houses much “There is no limit to the amount of the payments. There is no quicker than the 40-day procedure currently allows. limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions…on anyone anywhere. The regulations can delegate Stephen Hammond: The hon. Gentleman raises some functions to anyone anywhere.” important issues, including the issue at the heart of the The Committee concluded: clause—the appropriate, necessary and correct scrutiny “In our view, the powers in clause 2(1) are inappropriately wide arrangements for Parliament. Let me be clear at the and have not been adequately justified by the Department. It is start: the Government absolutely recognise the importance particularly unsatisfactory that exceedingly wide powers should of appropriate levels of scrutiny of the Bill and its be subject only to the negative procedure.” subsequent secondary legislation. It is clearly the hallmark The most significant reason why we do not object to of any effective parliamentary system that there are the legislation is that the biggest risk at this stage is that processes in place by which we draft, consider and test arrangements are made that do not safeguard the ability legislation. After all, that is what we are doing today. of our constituents, when they travel abroad, or of UK The appropriate parliamentary procedure for the scrutiny citizens who currently live overseas to access healthcare, of regulations made under the Bill that do not amend, as they do now. However, because of the way the Bill is repeal or revoke primary legislation is the negative drafted, we will find that we are unable to debate whether procedure. If I am not able to reassure the hon. Member those safeguards are in place as a matter of course. We for Ellesmere Port and Neston and he chooses to press have heard many references to the 190,000 UK expats the amendment to a Division, I am afraid the Government living abroad and the 50 million or so nationals who will resist it. travel to EEA countries every year. These are huge numbers of people, and the impact of the legislation on them is potentially huge. We owe it to all those people to 12.30 pm ensurethatanyfuturearrangementsareproperlyscrutinised. The powers in the Bill give the Government the We also need to consider the impact of any new flexibility and capacity to implement deeper, detailed arrangements on the NHS. As Alastair Henderson, and complex arrangements concerning healthcare abroad. chief executive of the Academy of Medical Royal Colleges, It is also clear that the regulating powers enable the set out in evidence on Tuesday: Secretary of State to make provision to fund that healthcare, “Both clinicians and health organisations are concerned that or to provide funding in connection with the provision we could end up with a system that is both administration-intensive of that healthcare, but that the subject matter to which and time-intensive.”––[Official Report, Healthcare (International the regulations relate is narrow.The remit of our regulating Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.] powers is tightly focused. They can be used only to give He went on: effect to healthcare agreements, or to arrange, provide for or fund healthcare abroad. Therefore, the subject “In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements matter is focused and provides the necessary reciprocal for 32 different lots of patients sounds pretty much like a nightmare arrangements for UK citizens. set-up.”––[Official Report, Healthcare (International Arrangements) Where the UK negotiates an international healthcare Public Bill Committee, 27 November 2018; c. 4, Q9.] agreement in the future, the most important elements If we do not agree to the amendment, Parliament could setting out the terms of the agreement will be included end up in that scenario without any voice. in the agreement itself, as I am sure hon. Members 37 Public Bill Committee HOUSE OF COMMONS Healthcare (International 38 Arrangements) Bill would expect. Those agreements are likely to contain all Justin Madders: I am afraid that I am not reassured. the detail that Parliament should consider, such as who The Minister has not really addressed the practical is covered by their terms. In contrast, the regulations issue about the 40-day waiting time for the negative implementing the agreement would not include anything procedure. If we enter a no-deal scenario after 29 March, fundamentally new. They would contain procedural, as I said earlier, all the instruments under the Bill would administrative and technical details, such as the types of have to be laid no later than 15 February. I am imagining document or forms to be used. Therefore, it is right that the Secretary of State whisking around the 30-plus those regulations issued under the Bill are subject to the countries that we would need to enter into bilateral negative procedure. I think most colleagues would consider arrangements with throughout the whole of January, that to be the right use of parliamentary time. and having to get that all signed up and put on the I hope I can persuade the hon. Gentleman and reassure Order Paper by 15 February. I am actually trying to the Committee further that when we strike a comprehensive help the Minister here by suggesting that if we do it by healthcare agreement with the EU or individual states, affirmative procedure, we can get these things through it will be subject to parliamentary scrutiny.Such agreements Parliament more quickly and with the appropriate level would come under the ratification procedure in the of scrutiny that these arrangements deserve. Therefore, Constitutional Reform and Governance Act 2010, which I will push the amendment to a vote. would provide an opportunity for parliamentary scrutiny Question put, That the amendment be made. of the substance of healthcare agreements that are The Committee divided: Ayes 8, Noes 9. given effect by regulations made under the Bill. Division No. 1] I remind Committee members of the Government’s AYES intention. I am sure all Committee members welcome reciprocal healthcare arrangements. We heard from the Cadbury, Ruth Madders, Justin witnesses who presented evidence to us that the Cooper, Julie Matheson, Christian administration of the current arrangements works well Day, Martyn Norris, Alex and is, on the whole, extremely popular. Regulations Debbonaire, Thangam Western, Matt made under the Bill will simply provide for the effective and efficient administration of those arrangements. NOES As I set out at the outset of my remarks, we will Burghart, Alex Morton, Wendy ensure that the affirmative procedure is in place for Costa, Alberto Quince, Will Hammond, Stephen anything that amends,repeals or revokes primary legislation. Robinson, Mary For technical regulations, it is appropriate that the Hughes, Eddie negative procedure is used. Given my remarks about the Masterton, Paul Throup, Maggie Constitutional Reform and Governance Act and my reassurances about how we intend to deal with the Question accordingly negatived. negative and affirmative procedures, I hope that the Question proposed, That the clause stand part of the hon. Gentleman is reassured and does not feel the need Bill. to press the amendment to a Division.

Stephen Hammond: Having failed to reassure the Justin Madders: I am afraid the Minister has not hon. Member for Ellesmere Port and Neston, I will have managed to reassure me, despite his best efforts. When a another attempt in this stand part debate. Clause 5 Bill would confer power on the Executive, we have to be supplements the substantive regulation-making powers very careful about giving that power away. It cannot be in clause 2. It provides detail on the parliamentary done without good reason, even in these extraordinary procedure, as we have already discussed, that will apply times. I have not heard any justification for giving such to regulations made under the Bill. Subsections (1) and sweeping powers to the Secretary of State without (2) introduce standard provisions, and are consistent adequate scrutiny. No matter how well-intentioned the with regulation and direction-making powers in many Minister is in his responses—I acknowledge his sincerity other Acts of Parliament, such as the Health and Social —we do not know who will be doing what in 12 months’ Care Act 2012 and the National Health Service Act 2006. time. As we said earlier, we could be handing a future Secretary of State the ability to enter into arrangements The clause is required to ensure that regulations and for hip replacements in Australia or such like. directions made under the Bill will be fit for purpose. As I have said, the powers in the Bill provide the Government As the Minister said, the regulations will enable the with the flexibility and capability to ensure and implement Government to enter into detailed and complex detailed and complex arrangements concerning healthcare arrangements on future healthcare. That is precisely abroad. For example, the Government may use regulations why we need them to be subject to the affirmative to confer different functions on different bodies, in procedure. I appreciate the point about the treaties order that they may implement and operate effectively possibly containing more detail, but this is about how what may be provided for in an agreed reciprocal healthcare Parliament will be able to scrutinise and challenge those agreement. Wedo that now in relation to the EHIC scheme, arrangements. which, as I said earlier, the NHS Business Services Authority administers on behalf of the Department. Stephen Hammond: The hon. Gentleman will have That administration includes the registering and issuing heard that the treaty arrangements will be subject to of EHICs and the processing of EHIC claims. parliamentary scrutiny in the normal way.Weare discussing Future administrative arrangements to implement the regulations as to how we enact those treaties. I was reciprocal healthcare agreements may reflect the current hoping that he might be reassured by that. situation, or may involve conferring different functions 39 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 40 Arrangements) Bill on other bodies, as appropriate. Once the arrangements The remit of our regulating powers is focused. They are negotiated, we will be in the best position to decide can be used only to give effect to healthcare agreements what the appropriate bodies to administer those or to arrange, provide for or fund healthcare abroad, as arrangements are. We will be able to provide for the is clear in the enabling powers found in clause 2(1). practical processes and implementation arrangements Where the UK negotiates a comprehensive international through the regulations. Clause 5 provides the Government healthcare agreement, whether multilaterally with the with the flexibility to ensure that any healthcare EU or bilaterally with EU members, the most important arrangements can be implemented effectively and efficiently. element that sets out the terms of that agreement would Subsection (3) provides that regulations made under be included in the agreement itself, as hon. Members clause 2 would expect. Regulations that give effect to such an agreement would likely focus on procedural, administrative “may amend, repeal or revoke primary legislation…for the purpose of conferring functions”, and technical details, such as the types of documents or forms that could be used to administer those reciprocal or healthcare arrangements, which is a point I made earlier. “to give effect to a healthcare agreement.” In a scenario where a comprehensive healthcare I want to try again to reassure the Committee about agreement is being implemented through regulations that. The Government are conscious that Parliament made under clause 2(1)(c), that agreement would be rightly takes an interest in this area and, of course, we subject to parliamentary scrutiny under the ratification share the view about the importance of scrutiny. procedure contained in section 20 of the Constitutional This is a consequential power to make amendments Reform and Governance Act 2010. That ratification to primary legislation, which is limited to three restricted procedure provides an opportunity for parliamentary uses: for the purpose of conferring functions, to give scrutiny of the substance of the healthcare agreements effect to a healthcare agreement and to make modifications being given effect to in the regulations made under the to retained EU law. It is not a free-standing power; it is Bill. It is for those reasons that I rejected amendment 2, a focused power to ensure that we can implement healthcare which the hon. Member for Ellesmere Port and Neston arrangements effectively. That may involve conferring moved a moment ago. functions on healthcare bodies, which could involve The final provision of the clause, subsection (7), sets amending primary legislation. out the definition of “primary legislation”. To reassure Subsection (4) provides that: the hon. Gentleman, and the Committee, the Government absolutely understand and appreciate the necessity for “Regulations under this Act may amend, repeal or revoke appropriate parliamentary scrutiny. The level of scrutiny retained EU law”, must reflect the substance of the piece of legislation. which is the body of existing EU law that the European That is what I believe the clause does, and I therefore Union (Withdrawal) Act 2018 will convert into domestic recommend that it stand part of the Bill. law, together with the laws we have already made in the UK to implement our EU obligations. It is vital that the regulation-making powers extend to amending, repealing Justin Madders: The Minister and I will not agree on and revoking retained EU law, because the bulk of the that, unfortunately. I will not repeat the arguments that existing provisions that relate to current reciprocal healthcare we have already gone through, but I will remind hon. arrangements with the EU will be EU retained law. Members that the Lords Delegated Powers and Regulatory Reform Committee described the powers and regulation Subsection (4) will ensure that domestic legislation in as “breath-taking”, and said that that area is clear and accessible. It will allow us to “There is no limit to the amount of the payments. There is no amend EU retained law, where appropriate, to give limit to who can be funded world-wide. There is no limit to the effect to new reciprocal healthcare arrangements. It types of healthcare being funded. The regulations can confer would be an oversight if the Bill did not provide for functions…on anyone anywhere.” such amendment, given that current reciprocal healthcare The scope of the clause is breath-taking. Although the arrangements with the EU are entirely bound up in EU Minister is trying to reassure us, as parliamentarians, law. we need the security of the affirmative procedure. I stress again that, of course, Parliament will be given the opportunity for the appropriate scrutiny of regulations made under the Bill that amend, repeal or revoke primary Christian Matheson (City of Chester) (Lab): I am legislation. As such, subsection (6) makes it clear that grateful to my hon. Friend and constituency neighbour regulations that contain provisions that make modifications for giving way.Would he have been a little more reassured to primary legislation will be subject to the affirmative by the Minister’s attempts at reassurance if this was not resolution procedure and, therefore, Parliament will part of a process and of a pattern of behaviour by the have the opportunity to debate them. That is the Government? There have been power grabs and the use parliamentary scrutiny procedure befitting Henry VIII of Henry VIII clauses throughout the Brexit process. powers, and one that allows for proper scrutiny. Regulations made under the Bill that do not contain Justin Madders: I thank my hon. Friend and neighbour provisions that amend, repeal or revoke primary legislation for his intervention. He is absolutely right. One of the will be subject to the negative resolution procedure. It is things that was stated during the referendum campaign our job—and I think it is only right—to ensure that was that Parliament should take back control, and that legislation is afforded the appropriate level of scrutiny. is what I believe should be happening following the Therefore, regulations that are made under the Bill that result. Parliament needs to make sure that, as much as do not amend, repeal or revoke primary legislation possible, the legislation that will be necessary in the should be subject to the negative procedure, as is normal. coming months is subject to full parliamentary scrutiny. 41 Public Bill Committee HOUSE OF COMMONS Healthcare (International 42 Arrangements) Bill [Justin Madders] (e) any and all outstanding payments owed to or by the government of the United Kingdom in respect of That is why the affirmative procedure should be included healthcare arrangements made before this Act in the clause, which we cannot support as it currently receives Royal Assent; and stands. (f) any and all administrative costs faced by NHS Trusts in respect of healthcare arrangements. Question put, That the clause stand part of the Bill. (3) The information required under section 2(a) and 2(b) The Committee divided: Ayes 9, Noes 8. above must be listed by individual country in every annual Division No. 2] report.’—(Julie Cooper.) Brought up, and read the First time. AYES Burghart, Alex Morton, Wendy Julie Cooper: I beg to move, That the clause be read a Costa, Alberto Quince, Will Hammond, Stephen Second time. Hughes, Eddie Robinson, Mary I should stress that we support the intention of the Masterton, Paul Throup, Maggie Bill. Providing that UK citizens can live, work, study and travel in EU member states with complete peace of NOES mind with regard to the provision of healthcare is a Cadbury, Ruth Madders, Justin priority for us. We are aware that, under existing Cooper, Julie Matheson, Christian arrangements, the healthcare of 190,000 UK state Day, Martyn Norris, Alex pensioners living abroad, principally in Ireland, Spain, Debbonaire, Thangam Western, Matt France and Cyprus, and of their dependent relatives, is protected. Question accordingly agreed to. In addition, we seek to ensure that the health benefits Clause 5 accordingly ordered to stand part of the Bill. currently enjoyed by UK residents who visit the EU on holiday or to study continue, so that they may use the European health insurance card to access healthcare Clause 6 and emergency treatment for healthcare needs that arise during their stay.Wealso seek to continue the arrangement EXTENT, COMMENCEMENT AND SHORT TITLE under which EU nationals receive reciprocal provision Question proposed, That the clause stand part of the when they visit the UK post Brexit. Bill. We note, however, that the Bill is intended to provide for all reciprocal healthcare arrangements in the future, Stephen Hammond: I wish to introduce this short even though we still do not know—even at this late clause, which I suspect will be somewhat less contentious stage, two and a half years after the referendum—whether than the previous one. Subsection (1) provides that the a satisfactory Brexit deal will be approved by the UK Bill extends to England and Wales, Scotland and Northern Parliament. Given the possibility of a no deal scenario, Ireland. Subsection (2) provides that the Bill will come where the UK crashes out of the EU and potentially into force on Royal Assent, which reflects the need to enters a period of unprecedented uncertainty, we are respond to the range of possible EU exit scenarios in a extremely concerned. timely manner. Subsection (3) establishes that the short Weunderstand and support the Government’spreferred title of the Act will be Healthcare (International policy position with regard to future reciprocal healthcare Arrangements) Act 2018. With that short explanation, I agreements, where the intention is to seek a wider recommend that the clause stand part of the Bill. agreement with the EU that covers state pensioners Clause 6 accordingly ordered to stand part of the Bill. retiring to the EU or UK and allows for continued participation in the European health insurance card scheme, together with planned medical treatment. We New Clause 1 want to ensure, however, that appropriate safeguards are in place with regard to costs, not least because the ANNUAL REPORT ON THE COST OF HEALTHCARE Bill provides the authority for the Secretary of State not ARRANGEMENTS only to facilitate a continuation of existing arrangements, ‘(1) The Secretary of State must lay before Parliament an but to enter into any number of bilateral agreements annual report setting out all expenditure and income arising with individual member states, with no provision for from each healthcare arrangement made under this Act. parliamentary scrutiny. (2) The annual report laid under subsection 1 must include, We also note that the Bill provides the authority to but is not limited to— strengthen existing reciprocal healthcare agreements (a) all payments made by the government of the United with countries outside the EU, or to implement new Kingdom in respect of healthcare arrangements for ones with countries across the globe, in line with the healthcare provided outside the United Kingdom to British citizens; Government’s aspiration to develop trading arrangements with countries beyond the EU. There is, therefore, the (b) all payments received by the government of the United Kingdom in reimbursement of healthcare provided potential for the establishment of multiple complex by the United Kingdom to all non-British citizens; agreements. (c) the number of British citizens treated under healthcare As it is not possible to know the detail of those arrangements outside the United Kingdom; agreements in advance, we cannot assess their likely (d)thenumberof non-Britishcitizenstreatedunderhealthcare costimplications.WethereforebelievethattheGovernment’s arrangements within the United Kingdom; impact assessment is woefully inadequate in that regard. 43 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 44 Arrangements) Bill The assessment suggests that the cost of establishing if there are multiple future arrangements with differential a future reciprocal healthcare arrangement would be terms. Subsection 2(e) will enable ongoing parliamentary £630 million per year, which is the same as the current scrutiny of performance levels. While respecting that agreement and takes no account of inflation or future urgent medical care is provided to any patient who medical developments. The impact assessment’ssuggestion needs it, the NHS and the Department of Health and that costs might actually be less than those we already Social Care must always ensure that money due to the incur is not credible. NHS is recovered. We need a system that is fair to We will be in uncharted waters, facing the prospect taxpayers and to patients who are entitled to free care of the necessity to negotiate multiple agreements, some either by virtue of being a British citizen or under a of which may be complex. As the former Secretary of reciprocal agreement. State said, It is clear that, even under current arrangements, the “It is perfectly possible to agree the continuation of reciprocal collection of moneys owed for healthcare provided to healthcare rights as they currently exist, but it is not possible to foreign nationals, together with the administration of predict the outcome of the negotiations.” existing reciprocal healthcare agreements, is an onerous Weagree that it is impossible to provide reliable estimations task for hospital trusts. As we leave the EU, it might be of likely costs in advance. We are therefore not prepared necessary for the UK to enter into multiple complex to give the Government carte blanche. arrangements on a bilateral basis. Indeed, the Bill gives New clause 1 would provide a sensible requirement powers to the Secretary of State to enter into any for the Government to report back to Parliament on an number of agreements, which would introduce additional annual basis.Subsection 2(a) would require the Government considerable financial burdens on hospital trusts whose to provide details of all payments made by the UK duty it will be to administer the collection of charges for Government for healthcare provided outside the UK to NHS services provided to foreign nationals who retire British citizens. Subsection 2(b) would stipulate a to the UK or who visit the UK under future reciprocal requirement to provide details of all payments received arrangements. It is likely to be a more onerous process by the UK Government in reimbursement of healthcare as a series of differential arrangements might be required. provided by the UK to all non-British citizens. Subsections The BMA and the Royal College of Paediatrics both (c) and (d) are straightforward and would require details agree that, should it be necessary to establish bilateral of the numbers of citizens treated under reciprocal reciprocal arrangements with EU nations, significant arrangements. Subsection 2(e) would write into law a additional costs would fall on the NHS. requirement to report on all outstanding payments Subsection 2(f) would introduce a requirement for owed to or by the UK Government. the Government to report the detail of all costs incurred The Bill provides an opportunity to monitor efficiency by hospital trusts in the pursuance of that duty. Cuts to in this area and may provide an incentive to address the real-terms NHS funding since 2010, together with increased concerns raised by the Public Accounts Committee in demand, have pushed many NHS hospital trusts into its 2017 report, “NHS treatment for overseas patients”. deficit positions.The NHS is underfunded and understaffed, It stated, and hospitals face all-year-round crises. It is therefore imperative that hospital trusts are not required to shoulder “the NHS has been recovering much less than it should”, additional financial burdens because of the costs of and, administering the collection of charges. It is absolutely “The systems for cost recovery appear chaotic.” essential that all agreements reached within the remit of That is not good enough and we would not want to see the Bill do not direct funds for the treatment of patients that poor level of performance replicated as a result of to administration. any new reciprocal agreements. Ordered, That the debate be now adjourned.—(Wendy Currently, the Public Accounts Committee reports Morton.) that there is no evidence that EU reciprocal health arrangements are being abused. However, there is an 12.59 pm increased risk of poor performance on collection targets Adjourned till this day at Two o’clock.

PARLIAMENTARY DEBATES HOUSE OF COMMONS OFFICIAL REPORT GENERAL COMMITTEES

Public Bill Committee

HEALTHCARE (INTERNATIONAL ARRANGEMENTS) BILL

Third Sitting

Thursday 29 November 2018

(Afternoon)

CONTENTS New clauses considered. Bill to be reported, without amendment.

not later than

Monday 3 December 2018

© Parliamentary Copyright House of Commons 2018 This publication may be reproduced under the terms of the Open Parliament licence, which is published at www.parliament.uk/site-information/copyright/. 45 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 46 Arrangements) Bill

The Committee consisted of the following Members:

Chairs: †MR GARY STREETER,GRAHAM STRINGER

† Burghart, Alex (Brentwood and Ongar) (Con) † Matheson, Christian (City of Chester) (Lab) † Cadbury, Ruth (Brentford and Isleworth) (Lab) † Morton, Wendy (Aldridge-Brownhills) (Con) † Cooper, Julie (Burnley) (Lab) † Norris, Alex (Nottingham North) (Lab/Co-op) † Costa, Alberto (South Leicestershire) (Con) Quince, Will (Colchester) (Con) † Day, Martyn (Linlithgow and East Falkirk) (SNP) † Robinson, Mary (Cheadle) (Con) † Throup, Maggie (Con) † Debbonaire, Thangam (Bristol West) (Lab) (Erewash) Western, Matt (Warwick and Leamington) (Lab) † Hammond, Stephen (Minister for Health) † Hughes, Eddie (Walsall North) (Con) Mike Everett, Committee Clerk † Madders, Justin (Ellesmere Port and Neston) (Lab) † Masterton, Paul (East Renfrewshire) (Con) † attended the Committee 47 Public Bill Committee HOUSE OF COMMONS Healthcare (International 48 Arrangements) Bill risks the very thing that she seeks to avoid. She seeks to Public Bill Committee avoid placing an administrative burden on the public bodies, but that is exactly what the new clause might do. Thursday 29 November 2018 We believe that the frequency and detailed content of a financial report should be determined once the reciprocal (Afternoon) healthcare arrangements have been made and the technical and operational details of those agreements are known. At the moment, the collection of administrative data is [MR GARY STREETER in the Chair] facilitated by the registration and exchange of e-forms through the processes provided for in the relevant EU Healthcare (International regulations. As a result, the UK and other EU member Arrangements) Bill states are able to collect data and report both nationally and at an EU level, based on known processes. Current spending on EEA healthcare is reported as part of the New Clause 1 Department of Health and Social Care’s annual report— which the hon. Member for Burnley may wish to look ANNUAL REPORT ON THE COST OF HEALTHCARE at, or may well already know about—as well as the ARRANGEMENTS accounts that are presented to this place. The Department (1) The Secretary of State must lay before Parliament an also provides information to the European Commission annual report setting out all expenditure and income arising for its triennial report on cross-border healthcare, as from each healthcare arrangement made under this Act. well as providing an annual statement of financial (2) The annual report laid under subsection 1 must include, accounts to the Commission. but is not limited to— (a) all payments made by the government of the United The Department is currently negotiating with the EU Kingdom in respect of healthcare arrangements for and individual states therein with a view to providing healthcare provided outside the United Kingdom to UK citizens with continued access to healthcare in the British citizens; EEA, either through an agreement or through bilaterals. (b) all payments received by the government of the United In that case, we will have to agree how eligibility is Kingdom in reimbursement of healthcare provided evidenced; how, and how often, that information is by the United Kingdom to all non-British citizens; exchanged; and, of course, the reimbursement mechanisms (c) the number of British citizens treated under healthcare that will govern the new arrangements. Those agreements arrangements outside the United Kingdom; will have to take into account the operational possibilities (d) the number of non-British citizens treated under and limitations of each contracting party. That should healthcare arrangements within the United Kingdom; include how NHS trusts in the UK can evidence eligibility (e) any and all outstanding payments owed to or by the for treatment, and how that can be done in the most government of the United Kingdom in respect of efficient and least burdensome manner. I therefore say healthcare arrangements made before this Act to the hon. Lady that much of the data she requests is receives Royal Assent; and already published. There is no suggestion that the new (f) any and all administrative costs faced by NHS Trusts in respect of healthcare arrangements. healthcare reciprocal arrangements will change the administrative burden; in certain cases, it is a simple (3) The information required under section 2(a) and 2(b) above must be listed by individual country in every annual matter of looking at coding within systems. However, report.—(Julie Cooper.) only once the technical details are known will the Brought up, read the First time, and Question proposed Government be able to formally commit to any additional (this day), That the clause be read a Second time. reporting, if necessary. I am bound to say to the hon. Member for Burnley 2 pm that when I saw that the new clause had been tabled, I Question again proposed. remembered that 10 years ago, I was in the place she is in now. It is the traditional role of Oppositions to table these new clauses for almost every Bill; it is also the The Minister for Health (Stephen Hammond): Mr Streeter, traditional role of Governments to reject them when it is a pleasure to see you in the Chair this afternoon and they see them, as I remember only too clearly from to serve under your chairmanship. The hon. Member when I was sat in the hon. Lady’s place. I therefore hope for Burnley has moved the motion, and in responding, I I have gone some way towards making clear to her that will take the opportunity to deal with the important we are not trying to avoid any reporting requirement, or issues of financial reporting and facilitating parliamentary to shy away from any parliamentary scrutiny. There are scrutiny. already a number of reporting processes in place, and I will say at the outset that there can be no suggestion, we want to make sure that any future reporting processes nor is it the Government’s intention, that we should operate in a proportionate and considered manner. I have anything other than a commitment to transparency hope that the hon. Lady will accept the spirit of my and transparent use of public money. We are also remarks, and that she will therefore choose not to press committed to appropriate parliamentary scrutiny: we the new clause to a Division. have taken several significant steps to ensure that central Government data is published in a transparent way, including spending control. However, that needs to be Julie Cooper (Burnley) (Lab): It is a pleasure to serve done in an efficient and effective manner, and we need under your chairmanship, Mr Streeter, and to respond to know what data is available and is not available. I to the Minister’spoints.I appreciate some of his arguments, have problems with the hon. Lady’s new clause because but we are in unprecedented times. As the Bill will such a detailed reporting requirement is premature, and facilitate the arrangement of a diverse range of agreements, 49 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 50 Arrangements) Bill it must cover every eventuality. It is therefore perfectly (b) citizens of the Republic of Ireland can continue to reasonable to expect the technical agreements, once access medical treatment under a health agreement in they have been reached, to be reported back to Parliament Northern Ireland annually. Parliament cannot be expected to grant a if a withdrawal agreement between the United Kingdom and blank cheque. I accept that I do not have the Minister’s the European Union has not been ratified by exit day. experience in this place, but large amounts of money (2) In this section, “exit day” has the meaning given in will be spent on as yet unknown agreements, so it seems Section 20 (1) of the European Union (Withdrawal) Act 2018.” reasonable to request that, when the negotiations result —(Justin Madders.) in an agreement, it is reported back to Parliament once Brought up, and read the First time. a year. That is the first thing that concerns me. I should have thought that the Government would Justin Madders (Ellesmere Port and Neston) (Lab): I want to take the opportunity to report on the improved beg to move, That the clause be read a Second time. performance and collection of charges due to the UK in respect of all non-UK citizens seeking to access care in It is a pleasure to serve under your chairmanship, the UK. Mr Streeter. I recall that the first Westminster Hall debate that I secured was under your chairmanship. Indeed, Stephen Hammond: Indeed, and of course we are you were also in the Chair the first time I was the doing so. We have made that clear. As the hon. Lady Opposition Front-Bench spokesman in a Bill Committee. knows, over the past four years we have quadrupled the In these turbulent times, you are a consistent and familiar amount of income we are recovering. face—certainly to me and, hopefully, to many other hon. Members. Julie Cooper: I am grateful to the Minister for that Reciprocal healthcare is of most importance for those clarification, but my understanding is, as the Public countries where it is accessed most—none more so than Accounts Committee reported, that the Government on the island of Ireland. When the British Medical have still not met their own targets on improved collection, Association gave evidence on Tuesday, it was clear and there will potentially be greater barriers to protection about the success story that has been achieved, particularly if several agreements are negotiated. I therefore want in the border area, particularly with a dispersed population Parliament to have the opportunity to scrutinise the of around 2 million. It said: Government’s delivery on collection. “Given the population demands on the whole island of Ireland, I am concerned that the Minister does not think it both in the Republic of Ireland and Northern Ireland, there have fitting for Parliament to have sight of an impact assessment been some fantastic examples of where clinicians have either of the additional burdens that the collection resulting co-located services in a particular trust or facility where there is from the as yet unknown agreements would have on not the demand from the local population to warrant it, or travelled across the border to work on different sites.”––[Official NHS hospital trusts’ general financial wellbeing. I will Report, Healthcare (International Arrangements) Public Bill press this new clause to a Division. I think it is sensible Committee, 27 November 2018; c. 4, Q10.] and reasonable, so there can be no cause to object to it. Fiona Loud from Kidney Care UK raised the example Question put, That the clause be read a Second time. of patients who currently cross the border daily for The Committee divided: Ayes 7, Noes 8. their care and treatments. She also mentioned organ Division No. 3] donation and organ sharing, and the need to ensure that the existing and very successful arrangements that AYES we have are preserved. Cadbury, Ruth Madders, Justin It is easy to talk about scaremongering when we raise Cooper, Julie Matheson, Christian the spectre of patients being turned away at the border, Day, Martyn and I am sure that we will all do our utmost to ensure Debbonaire, Thangam Norris, Alex that such circumstances do not arise, but we are talking about really important issues here. The healthcare NOES arrangements on the island date back to before the UK Burghart, Alex Masterton, Paul and the Republic of Ireland joined the EU, but they are Costa, Alberto Morton, Wendy now underpinned by EU law, so we cannot simply Hammond, Stephen Robinson, Mary revert back to the old arrangements, should a full Hughes, Eddie Throup, Maggie EU-wide deal not be reached. I was concerned about the lack of consideration Question accordingly negatived. given to the issue in the supporting documents and in the contribution from the previous Minister, the right hon. Member for North East Cambridgeshire (Stephen New Clause 2 Barclay), on Second Reading. If we do not get this issue right, the Bill will be a failure. The amendment would STRATEGY TO ENSURE CONTINUED ACCESS TO MEDICAL ensure that the provisions do not reach the statute book CARE IN NORTHERN IRELAND AND THE REPUBLIC OF until clarity on this hugely important issue is provided. I IRELAND appreciate that article 13 of the Northern Ireland protocol (1) Before this Act receives Royal Assent, the Secretary of in the withdrawal agreement indicates a desire to continue State must lay before Parliament a strategy containing a defined north/south co-operation in a range of areas, including process that will ensure that— healthcare, but that does not help us if Parliament does (a) British citizens living in Northern Ireland can continue not support the withdrawal agreement. That is why the to access medical treatment under a healthcare amendment asks for a strategy to be provided as a agreement in the Republic of Ireland; and matter of urgency. 51 Public Bill Committee HOUSE OF COMMONS Healthcare (International 52 Arrangements) Bill Stephen Hammond: The new clause deals with the Justin Madders: I am content with the Minister’s crucial question of healthcare on the island of Ireland. comments. I beg to ask leave to withdraw the motion. It focuses on reciprocal access to healthcare between Clause, by leave, withdrawn. Northern Ireland and Ireland, if there is no UK and EU deal, and would require the Secretary of State to set out plans for an agreement to protect medical access for New Clause 3 British and Irish citizens moving between Ireland and Northern Ireland. STRATEGY FOR SETTLING DISPUTES CONCERNING We agree that it is absolutely our intention to do two HEALTHCARE AGREEMENTS things. First, there should be a deal for reciprocal (1) The Secretary of State must, within one month of this Act arrangements between the UK and the EU, and secondly, receiving Royal Assent, lay before Parliament a strategy it is absolutely essential, in the unlikely scenario of no containing a defined process for settling disputes concerning deal, that essential access continues. The UK and Ireland healthcare agreements between the government of the United are committed to protecting reciprocal healthcare rights, Kingdom and either the government of a country or territory so that UK and Irish nationals can continue to access outside the United Kingdom or an international organisation. healthcare when they live in, work in or visit the other (2) The strategy under section 1 above must include country. We also want to maintain the co-operation information on— between the UK and Ireland on a range of medical (a) the body, bodies or jurisdiction that will be responsible issues, including planned treatment, public healthcare for settling disputes; and workforce. It is absolutely the intention of the (b) the process which will be followed by that body, bodies Government that people should be able to live their or jurisdiction when settling a dispute, including lives as they do now, and that our healthcare systems details of any further appeal mechanisms; and support one another. (c) anything else the Secretary of State thinks is relevant to If there is no deal—in that unlikely scenario—the such a strategy.—(Justin Madders.) UK and Ireland will want to set out how we both agree Brought up, and read the First time. to protect reciprocal healthcare arrangements, but it is also true, and the hon. Gentleman will know, that the Justin Madders: I beg to move, That the clause be UK Government are firmly committed to maintaining read a Second time. the common travel area and to protecting the rights currently enjoyed by UK and Irish nationals when in On Second Reading, I spoke about the importance each other’s states. The hon. Gentleman’s issue about of dispute resolution, and asked the then Minister the border is mitigated by the fact that the UK Government for Health, the right hon. Member for North East are committed to maintaining the common travel Cambridgeshire (Stephen Barclay), to set out how he arrangements, which allow full protection and maintenance envisaged it operating in both a deal and a no deal of the status quo for all journeys for individuals between scenario. Despite some prompting from me and my the UK and Ireland. It is currently estimated that there hon. Friend the Member for Weaver Vale (Mike Amesbury), are something like 110 million crossings. the Minister was not able to set out how dispute resolutions As I said earlier, as with other member states, we will be handled under the terms of any new agreement would expect to have a healthcare agreement between or even if the European Court of Justice will continue the two countries in the unlikely situation that there to represent a red line for the Government. The latter were no deal—an agreement that could be implemented point is particularly interesting, given the new role of into legislation that would provide the reassurances that the right hon. Member for North East Cambridgeshire. the hon. Gentleman seeks. The NHS charging regulations It appears that he did not provide detail on that point can already exempt individuals that are covered by because, at that stage, the Government were simply not reciprocal healthcare arrangements. We can also use the in a position to confirm what was in the draft withdrawal powers in the Bill to maintain aspects of our current agreement. co-operation, such as reimbursement for healthcare costs The Prime Minister categorically ruled out any and the sharing of data to support entitlements. I jurisdiction of the European Court of Justice very early therefore say to the hon. Gentleman that I do not think in the process, but I have yet to hear any serious the new clause is necessary, given the clear commitment suggestion about how disputes can be resolved, if we by both sides. I hope he recognises that commitment manage to reach a full reciprocal healthcare agreement and does not feel that he needs to press the new clause with the EU27 beyond the transition period, without to a vote. some reference back to the ECJ. The same concerns would apply if bilateral agreements were necessary in a 2.15 pm no deal scenario. Justin Madders: I am minded not to press the new Given the importance that the Prime Minister and clause to a vote if the Minister assures us that he will members of her Cabinet have placed on the ECJ following endeavour to keep us updated on the contingency plans, our exit from the European Union, it is curious to say if it looks like we are approaching a cliff-edge scenario. the least that we do not have a clear statement of intent That is really what we are trying to achieve. from the Government while we debate this Bill. If their position continues to be that we will not have truly left Stephen Hammond: Let me make the hon. Gentleman the European Union if we are not in control of our own the same offer that I made to the hon. Member for laws, as the Prime Minister put it in January 2017, it is Burnley. In that unlikely scenario, I guarantee that I will vital that we have clarity about the arrangement that make my officials available to give a briefing to the hon. will be used in place of the ECJ. If a new arrangement is Gentleman and any member of the Committee who established, what will the cost be? Who will the judges wishes to understand what our proposals are. be? Where will it be based? Will it be an open process? 53 Public Bill Committee 29 NOVEMBER 2018 Healthcare (International 54 Arrangements) Bill If, on the other hand, we look to the ECJ for dispute The hon. Gentleman challenges me on the role of the resolution after all, even if only in the limited area of ECJ. He is right that the ECJ has a role here, but its role reciprocal healthcare, would that not represent a significant is very clear and very limited. The role of the ECJ after political U-turn? This issue is fundamental to the the implementation period will be restricted to ensuring Government’s approach to Brexit. For example, they the correct interpretation of EU law.There is no suggestion decided that we could not continue to host the European that the ECJ will determine the dispute, or that we Medicines Agency, causing it to go to Amsterdam at the would ever agree to the ECJ determining the dispute. cost of 900 jobs in this country, and potentially hundreds That is the likely scenario and the processes that are of millions of pounds of investment. The Health Secretary’s already formally set out via the documents that I described sole justification for that was that the Government were earlier. In the unlikely scenario that the UK leaves the not prepared to accept the European Court of Justice’s European Union without a deal, the United Kingdom jurisdiction. Our purpose in tabling this new clause is to will arrange reciprocal healthcare agreements, and in get clarity from the Minister about whether the European those agreements, there will have to be bilateral dispute Court of Justice remains a red line for the Government. resolution. That would clearly have to be determined on Stephen Hammond: The new clause would place a a case-by-case basis as part of the negotiations to put duty on the Secretary of State to lay before Parliament those bilateral healthcare agreements in place, and, a detailed strategy defining the process for settling therefore, there is unlikely to be a single dispute resolution disputes concerning healthcare agreements after we leave process, which is what the new clause suggests, so while the European Union. No one in the room would dispute I accept the spirit of it, the wording would restrict the the spirit behind the new clause.As I have stated throughout ability for future reciprocal healthcare arrangements. our examination of the Bill, it is right that there should More importantly, the requirement for such a strategy be transparency regarding the UK’s future relationship to be laid before the House one month after the Bill with the EU and other countries after exit. It is right receives Royal Assent does not align with the aim of the that that transparency should apply to the arrangement Bill to provide future reciprocal healthcare agreements of future healthcare agreements, and the processes that with countries both inside and outside the EU. Clearly, underpin them, such as dispute resolution, but, although those agreements are likely to be negotiated over a I agree with the spirit of the new clause, I am not period of time and, as I have just mentioned, the entirely sure that it would achieve its intended aim. I dispute resolution mechanisms within them are likely to will give a number of reasons why. be different and may vary.It would therefore be arbitrary The new clause would confer a duty on the Secretary and unhelpful to produce a general strategy immediately of State to lay a strategy on the process for dispute after Royal Assent. resolution before Parliament. Both in a deal and a no I understand the intention behind the new clause, but deal scenario, such a strategy would be unlikely to it would place an unnecessary burden and duty on the provide information on the process for settling disputes Secretary of State. In a deal scenario, the procedures are concerning healthcare agreements that is not already already there. In the unlikely no deal scenario, it would available in the public domain. That is not due to a lack be likely to frustrate the ability to put in place future of endeavour; it is an issue of timing and consideration reciprocal healthcare agreements. of what is already publicly available. In the expected scenario that the UK agrees a deal with the EU, the I hope that, having heard that, the hon. Gentleman proposed process for settling disputes has already been will accept that, although we understand the spirit of confirmed in the White Paper on the future relationship, his new clause, its wording would be likely to frustrate the draft withdrawal Bill that governs the implementation the purpose of the Bill. I therefore ask him not to press period and, most recently, the political declaration on it to a vote. the future relationship between the UK and EU. The processes have already been confirmed. They are outlined Justin Madders: I am grateful to the Minister for in those documents and would apply not only to disputes, setting that out in more detail than we were able to elicit but clearly therefore to disputes in any reciprocal healthcare on Second Reading. Given that the withdrawal agreement agreement. had not been published at the time, I understand why The hon. Gentleman asks what the dispute mechanism the then Minister was not able to do that. The present is. I am sure that the Committee will be pleased that I Minister has been very helpful in setting out the process am not going to quote extensively from the withdrawal for leaving with a deal. He is right that, if we leave agreement, but it is worth putting on the record that the without a deal, we are in uncharted territory. I do not mechanism for resolving disputes will be through think I heard any confirmation that there are red lines, consultation at the Joint Committee, with the aim of in terms of the European Court of Justice, in that reaching a mutually agreeable resolution. If the parties scenario. That is really what the new clause was meant are not able to resolve the dispute in the Joint Committee, to establish. I beg to ask leave to withdraw the motion. either party can request the establishment of an independent Clause, by leave, withdrawn. arbitration panel to resolve it. The panel will be made up of five members, with one person being the chairperson. The UK and the EU will nominate two members to sit New Clause 4 on the panel and then mutually agree the fifth member, who will be the chairperson. The panel members will DUTY TO CONSULT WITH DEVOLVED ADMINISTRATIONS act independently and do not represent the party that Before issuing any regulations under this Act, the Secretary of nominated them. It is binding that the panel members State must consult the Scottish Government, the Welsh be independent and impartial and they must possess Government and the Northern Ireland Government and have specialised knowledge or experience of EU law and regard for their views on the regulations.—(Justin Madders.) international law. Brought up, and read the First time. 55 Public Bill Committee HOUSE OF COMMONS Healthcare (International 56 Arrangements) Bill Justin Madders: I beg to move, that the clause be read that we do so in a way that is collaborative and respects a Second time. the devolution settlement and the conventions for working I hope this is a straightforward and uncontroversial together. To that effect, to answer the hon. Gentleman new clause. Wehave already spoken about the importance directly, significant and ongoing constructive discussions of reciprocal healthcare arrangement to citizens in Northern are taking place with the devolved Administrations, at Ireland, and of course there will also be an impact on ministerial and official levels, on the Bill and the underlying patients in Wales and Scotland. The Scottish and Welsh policy. Governments have clearly and robustly articulated their The UK Government are committed to working closely support for a continuation of reciprocal healthcare with the devolved Administrations now and in the agreements, and why would they not? future to deliver an approach that works for the whole The Delegated Powers and Regulatory Reform of the United Kingdom. The Bill has a strong international Committee was clear in its recommendation that focus and is predominantly concerned, as we discussed there should be active participation of the devolved at length, with the welfare of UK nationals outside the Administrations in setting out the UK’s position in UK, including the making of payments and data sharing future arrangements, but I am not aware that there have to support that. We recognise that in some parts of the been any discussions. I would be grateful if the Minister Bill, however, powers may be used in ways that relate to could set out what conversations have taken place, because domestic healthcare. We are therefore seeking legislative we did not get clarity on that on Second Reading. consent motions to that extent only. The new clause repeats some of the issues that we raised We will of course engage with and consult the devolved this morning, which you did not have the pleasure of Administrations where regulations may relate directly hearing, Mr Streeter. It is about the scope and power of to devolved matters, but it would be inappropriate to do the Bill and the wide range of duties given to the Secretary so where regulations do not relate to devolved matters. of State, which will be subject to the negative procedure. Furthermore, as a measure of how important we consider We think it is important that, as part of the Bill, when this issue, we can and will only consider amendments to those wide powers are given to the Secretary of State, the Bill that concern the devolved Administrations where there must be a clear duty to consult with the devolved we have discussed those fully with the appropriate officials. Administrations before those regulations are enacted. In keeping with the spirit of the new clause, therefore, I The Fisheries Bill and the Agriculture Bill have dealt tell the hon. Gentleman that not only are discussions extensively with the need to involve the devolved ongoing, with constructive engagement with the devolved Administrations. I think this is the bare minimum that Administration, but we intend that to continue through the we need. It would represent a consistent and equitable Bill. We will continue to support in every way our approach across the devolved nations, in terms of our collaborativeworkingarrangements.Asapointof principle, future relationship with the EU. we guarantee to undertake meaningful consultation with thedevolvedAdministrationsonregulationsunderclause2, Stephen Hammond: It is a pleasure to respond to this whichIsuspectthatthehon.Gentlemanisconcernedabout, new clause, which addresses the extraordinarily important where they relate directly to devolved matters. The hon. issue of engaging and working with the devolved Gentleman’sconcern is to ensure appropriate consultation Administrations. We completely agree that regulations with the devolved Administrations, but that has happened, made under the Bill may relate to devolved matters, by is happening and will continue to happen. which I mean domestic healthcare. The Government I believe that the Committee is drawing to a close, so I will engage and meaningfully consult with the devolved will take the opportunity to thank all my colleagues, Administrations in line with our existing arrangements, and all hon. Members in the Opposition, for giving this as found in the 2012 memorandum of understanding small but important Bill the line-by-line scrutiny that it between the UK Government and the devolved deserves. I thank you, Mr Streeter, for chairing this Administrations, and the principles that underlie relations afternoon’s proceedings. between us. That reinforces the positive work that the UK Government continue to do with the devolved Justin Madders: The Minister has put on record Administrations daily for the benefit of the whole of pretty clearly his intention in respect of ongoing and the UK on this matter. continued engagement with the devolved institutions. I am forced to reflect that, though the hon. Gentleman’s He is right that we are concerned that the powers under new clause is not necessary, the sentiment behind it the Bill are wide. Those concerns remain, but in so far is shared by everyone in Committee, I suspect. The as they involve the new clause, his comments have done regulation-making powers in the Bill provide us with a enough to assure us that it will not be necessary for us legal mechanism to implement international agreements to press it to a vote. domestically. The Bill will ensure that we can broadly I echo the Minister’s sentiments, given that we are continue reciprocal healthcare arrangements, where agreed now making the closing remarks of this Bill Committee. with the EU, to the benefit of the residents of England, I thank you for chairing, Mr Streeter, and hon. Members Wales, Scotland and Northern Ireland. The powers for participating in Committee today. offer flexibility and can be used to implement comprehensive I look forward to Report. We need to continue to healthcare agreements with third countries in the future explore some important issues, but we must move forward for the benefit of all UK nationals. with this legislation, as is necessary in this uncertain time. I beg to ask leave to withdraw the motion. 2.30 pm Clause, by leave, withdrawn. The reciprocal arrangements, as governed by EU Bill to be reported, without amendment. regulations,predatethedevolutionsettlements.International affairs is a reserved matter, but domestic healthcare is 2.35 pm devolved. As we take the Bill forward, it will be important Committee rose.