Committee (2nd Day)
Clause 3: Availability, review and revision of NHS Constitution
24: Clause 3, page 3, line 21, at end insert “, who are eligible to receive NHS services or who have received NHS services within the past 5 years”
I express my thanks to the noble Baroness, Lady Thornton, for allowing us to up sticks slightly early on Monday. It enabled me to retire early with a dose of self-medication, and I think I will be a bit more fit for battle today. I thank her for her kindness.
Amendment 24 probes the meaning of the word “patients”, which the Bill defines as the people who will be involved in the review of the constitution. It may seem pedantic to raise the issue, but I think it reflects what will in future years be regarded as one of the Government’s biggest mistakes—the myriad different ways in which they have approached public involvement in heath. Since they have been in power, we have had no fewer than four major reviews of patient involvement. Some of us have been involved in the discussions on CHCs, PALs, patient and public involvement and LINks. I suspect that the conclusion in years to come will be that for all the good intent behind it, patient involvement, and the strategic involvement of patients in policy-making and assessment of the NHS overall, has been weakened. We return time and again, in different health Bills, to the question of how one can most effectively and meaningfully involve patients in the development of the NHS, and how one can best enable groups of patients to go beyond their direct individual experience of the NHS and provide input that not only challenges clinicians but is valid in strategic terms. That is the motivation behind the amendment.
The amendment widens the term “patients”, to make it clear that we are talking not only about patients currently involved with the NHS but also patients who have previously been involved with the NHS. Quite often, people have had an engagement with the NHS, recovered, gone off and thought about what happened to them, then tried to put that into context, and then come back with some of the most valid and challenging proposals. Our amendment is perhaps not perfect, but the intent is to ask the Government how they intend to meaningfully capture the involvement of patients in the review of the constitution, and, in particular, how they intend not to lose the experience of those who might have been involved but are no longer active patients seeing clinicians. I beg to move.
There is one additional point to make on this very sensible proposal. Patients who are currently patients often feel inhibited from saying what is really going on or what concerns them, because they are worried that they will antagonise the people who they are dependent on for their care. They do not know at that point in their illness how the rest of their illness is going to play out. It is only when they have been discharged from services that they may feel that they have the courage to speak out about some of the things that they found upsetting, or that they observed happening to other patients that they feel should not have happened. They then know that if they are going to go back into care they may be referred to a completely different service and can ask for that to happen.
I am delighted that the noble Baroness is better, and I am sure that it will be relevant to the discussion of the amendment.
The amendment proposes that the definition of “patients” in Clause 3 should be extended to include all patients,
“who are eligible to receive NHS services or who have received NHS services within the past 5 years”.
I understand the intention behind the amendment. I reassure the noble Baroness that recent and potential patients, as well as current patients, are adequately consulted in respect of any changes to the constitution. Clause 3(3) and 3(5) refer to the need to consult “members of the public”. That includes anyone who was eligible to receive NHS care, or who is currently receiving NHS care, or those who have received it in the past five years. I reassure the noble Baroness that these are all captured in the clause.
I further reassure the noble Baroness that it is fully our intention to consult extensively on any changes in the constitution. However, it is unnecessary to be prescriptive and to set up subcategories—another list, if you wish—of NHS patients in the Bill. I hope that I have demonstrated that the groups mentioned by the noble Baroness are already captured in the current drafting of the clause under the description of “members of the public”. I very much hope that she will feel able to withdraw the amendment.
I thank the noble Baroness, Lady Finlay, for her intervention and the Minister for his reply. It is good to know that the department intends to capture as much information as possible. I add to what the noble Baroness, Lady Finlay, said. Particularly when someone has had an acute episode, it is often only when they leave hospital and start to talk to other people and put their experience in the context of others’ experience, that they begin to appreciate why things were actually very good, even though they might not have appeared to be so at the time, or that there was something wrong.
I welcome what the noble Lord, Lord Darzi, said, but we continually run up against the problem of the definition of “patient” in all sorts of health legislation. Perhaps there is a need for the department to think about that and come up with a definition that is sufficiently wide that we can all understand it and agree it, and then we will not have to keep returning to these debates. His words were very helpful in this context, and on that basis, I am happy to withdraw the amendment.
Amendment 24 withdrawn.
Clause 3 agreed.
Clause 4: Availability, review and revision of Handbook
Amendment 25 not moved.
26: Clause 4, page 3, line 37, leave out “3” and insert “5”
It is unfortunate that this is the next amendment. Members of the Committee might think that I have a fixation with five-year plans, but I do not. There is a reason for this amendment. The length of time in which the handbook and the constitution should be reviewed has turned out to be interesting. Before I put down this amendment, I discussed it with a number of people. As I thought about it, I tried to note off the top of my head all the documents that have an impact on the NHS in a year. They include: NICE recommendations; new legislation; Healthcare Commission reports; CSCI reports and, in future, CQC reports; investigations into serious matters that have gone wrong; medical or surgical innovations; and documents outlining budgetary pressures. Every year, each of those will routinely have a clear impact on how the NHS responds to the needs of patients. It is within that context that the constitution and the handbook lie.
I therefore searched for an answer to the question: what would be a reasonable length of time within which to measure the impact of the constitution and the handbook and expect to see a change that would inform a new version? I felt that three years was not long enough. Three years does not seem the right length of time in an organisation the size of the NHS in which to implement something, review it and make a report of this kind. I then thought about other policy-led initiatives or documents around the NHS which are similarly reviewed, and I turned to the national service frameworks, which were developed as 10-year programmes with a built-in review after five years. It has certainly been possible with the older people’s NSF, which I know best, and with some of the others, to look at the detailed and strategic impact on the NHS of these strategic documents over five years.
In some ways, these are similar documents. The National Service Framework for Older People had within it eight or nine factors, one of which was about dignity and the way in which people were treated. Over five years, Professor Ian Philp and his team were able, working with clinicians on the ground, to note change and to come up with a realistic programme for the implementation of the latter part of the national service framework. I make it clear that my intention in moving this amendment is not to undermine the constitution in the national service frameworks or to push the frameworks off into the long grass. I am trying to find a timescale in which they can be reviewed in ways which are meaningful to the staff, who have to work with them, and to the patients who see the outcome. With that in mind, can the Minister say whether the department considered a timescale such as mine and whether it decided on this timescale for a particular reason. I beg to move.
Perhaps I may ask the Minister a specific question on Amendment 26. Will the data that are collected to inform whether there has been any change be routinely or additionally collected? If it is routinely collected, it will be easy to generate a report every year. If the data are additional, collected over and above the routine data, then all the points which the noble Baroness, Lady Barker, made are pertinent. You will weigh the service down with collecting data whereas you want to weigh it down with providing care and preventing disease, with data collection as a secondary matter.
I must declare an interest. As part of my role in looking at palliative care services in Wales, we have decided to pilot commissioning iWantGreatCare to produce a website which routinely collects data from patients and carers independently of the hospice and palliative care services. We will thereby have an independent rolling evaluation on which we can draw, with six very simple domains against which to make an assessment. As we have just been wrestling with this problem in Wales, I completely empathise with the principles behind the amendment. However, the crux is where the data to inform any kind of reporting and revision will come from.
I take a rather different view of the handbook. At the Committee’s last sitting, I asked a question about the handbook and who it was guiding. The Minister said that it was very much for patients. Having now read it pretty thoroughly, it is clearly a handbook for a whole range of people, giving them the guidance they need to carry out their tasks. We could have a debate about what is or is not “guidance”, but the handbook also contains clear specifics on matters such as the national social partnership forum. It deals also with other relationships and has other bits on legislation and health and safety.
In five years, those matters could change quite significantly. My concern is that the handbook should be constantly updated and somebody should keep their mind on the issues. As for whether there should be an overall review, which is what the noble Baroness, Lady Barker, is talking about, I absolutely agree. To get an overall picture, you need more information and a longer time period. However, my question for the Minister is how this document will be kept up to date. What is the mandate for its use? How will the Government ensure that everyone to whom it relates is quite clear about its status and their responsibility to use it? How much data do we need to review it? I apologise to the noble Baroness for using the debate on her amendment to ask a series of other questions.
Amendments 26 and 28, tabled by the noble Baronesses, Lady Barker and Lady Tonge, propose that the Handbook to the NHS Constitution be reviewed at least every five years, rather than every three years as Clause 4 provides. Amendments 30 and 32 propose that the Secretary of State report on the effect of the NHS Constitution on patients, staff and members of the public at least every five years, rather than every three years as Clause 5 provides.
The intention behind the amendments, as I understand it, is to give more time to vet the constitution before reporting on its effect; to provide more time to embed the handbook in the NHS; and perhaps to minimise unnecessary changes to the document. It might be helpful if I outline our objectives for the handbook and explain the thinking behind the current drafting.
The constitution, as we previously debated, is designed to be an enduring document. We therefore propose to review it every 10 years. The handbook, on the other hand, is an explanatory guide setting out the current law and policies underlying each right and pledge in the constitution. Our intention is to keep the handbook up to date. As the noble Baroness, Lady Howarth, has just mentioned, it would be useful to keep this up-to-date for patients, the public and staff. For example, if one of the Government’s waiting-time targets or commitments were to change, the handbook could be updated straight away to reflect that. Similarly, the Secretary of State has the power to make minor and technical revisions to the handbook at any time in line with changes in departmental policy or law.
Clause 4 provides a duty to review the handbook every three years. This would be a more general review of whether the handbook was still fit for purpose in its current format. We believe that every three years is a sensible interval for a major review, but earlier revisions might be needed. A more frequent review could create an administrative burden; any less often and we might lose the opportunity to ensure that the handbook remains useful and tailored to the needs of its audience. Finally, I should like to stress that the overwhelming response from our extensive consultation process was that every three years was considered the appropriate time to review the handbook.
I turn to Amendments 30 and 32. We do not wish the new duty for the Secretary of State to report on the constitution to create an administrative burden on the NHS. Perhaps I can set the noble Baroness’s mind at rest by confirming that we will work to ensure that local feedback and monitoring arrangements are aligned wherever possible with the constitution, working in partnership with others such as strategic health authorities, regulators and other stakeholders.
We also agree that the constitution needs to be given time to become embedded before we assess its impact, which is why we have set a minimum of three years for the report. There needs to be a balance between providing an assurance that the constitution is having an effect and giving it time to embed, as the noble Baroness so eloquently described it. We believe that reporting every three years will strike this balance. We need to know sooner than every five years what the effect of the constitution is.
Furthermore, it is logical that the timetable of both clauses—to review the handbook and to report on the effect of the constitution—should be the same. It means that the review of whether the handbook is fit for purpose can be set in the wider context of how the constitution has affected patients, staff and members of the public.
The noble Baroness, Lady Finlay, asked where the data will come from. These are routinely collected data from, for example, our patient surveys—which I very much hope noble Lords will see, as we talk about the quality accounts, will be much more sophisticated. These are much more sophisticated tools for determining the patient experience. The data will also include staff surveys which we have historically collected. We hope to assess the impact of the constitution using this baseline.
I hope I have been able to explain why we think that three years is the right period for a review of both the handbook and the effect of the constitution. I strongly believe that the reviews should be aligned. I would therefore ask the noble Baroness, if I have given enough assurance, to withdraw her amendment.
I thank noble Lords very much for their contributions. Perhaps I may reply to the noble Baroness, Lady Howarth, based on my understanding of the handbook. It is a document for patients and staff. I would like to call it a guide, and she will understand my aversion to using the word “guidance” in this context. It is also a snapshot in time of good practice underpinned by the current status of the law. That will change, but it will change at different points. Thinking back over recent years, I would say that the passage of the Mental Capacity Act brought about a fundamental change. Had there been a constitution and handbook at that time, that legislation would have changed them in a major way, as any pre-existing documents would not have made sense. That would have been less so in the case of other legislation. I do not imagine that the changes brought about by the Mental Capacity Act would have halted just because this handbook or this constitution had not been updated. That was what I was trying to get at.
I am not talking about technical revisions; I am talking about a review. Therefore, we are talking about the bringing together of good practice, legal developments, patient experience and developments in clinical practice, and putting them all together. It is possible to achieve a meaningful assessment of that only if you make that assessment over time. I say in response to the noble Lord, Lord Darzi, that three years is not even the length of a normal Parliament, never mind being long enough to monitor the effect of major policy changes. My amendments do not require that a review should take place only every five years, they say within five years. If there were an overwhelming case to do it at an earlier point, the Government would have the flexibility to do it.
I remain less than convinced about the need to do this within three years. I am somewhat sceptical about the degree to which the documents will change over a three-year period; it would be beneficial to take a slightly longer view. For the moment I shall not press the matter, but I hope I have convinced the noble Lord to think again before he dismisses it completely. I beg leave to withdraw the amendment.
Amendment 26 withdrawn.
27: Clause 4, page 3, line 38, at end insert—
“( ) The following must be consulted about the Handbook on a 5 year review—
(a) patients,(b) carers,(c) staff,(d) members of the public,(e) the bodies of persons listed in section 2(2), (4) and (5), and(f) such other persons as the Secretary of State considers appropriate.”
We may disagree about when people should gather to review these documents, but I hope that we will have a fair degree of unanimity about who should be involved in the review. The amendment seeks to clarify that the process of review will be meaningful to all involved. It sets out the different bodies which should be involved, differentiating the views of patients, carers, staff and other members of the public. To a large extent, it reflects the discussions we had on Monday about how those different groups are sometimes seen to have similar views, when in fact they could have very different ones. I hope the amendment does not irritate the noble Lord, Lord Walton, because it contains a list, but it seeks to set out a defined group of people and bodies which should be involved in the process of review. I do not think it is the kind of list that lends itself to being elongated further. There are self-evident reasons why every one of these bodies should be involved in that process of review, so I hope the proposal will be largely uncontentious. I beg to move.
My Amendment 29 is designed to say much the same as the amendment in the name of the noble Baroness, Lady Barker, only less prescriptively. Listening to the noble Baroness, I think that her approach might be better than mine. There is a good case for being prescriptive.
The central question is not at issue. It is whether the Secretary of State should have an explicit duty to undertake a consultation exercise on any revision of the handbook. My answer, like hers, is yes, he should. Why do I say that? We have touched on some of the reasons already. The handbook explains the NHS Constitution in greater detail and in so doing defines and occasionally limits or restricts the rights contained in the constitution.
You cannot understand the constitution properly without also reading the handbook. In fact, the handbook could be regarded as much more of a source document than the constitution itself for practical purposes. The two are, indeed, complementary. Yet in the Bill, as we have already discussed, the handbook has no legal force or standing at all. It is a thing that is referred to but is not defined in any substantive sense. That still seems very odd indeed for such an important document. Surely the very least that we can do is to say that the Secretary of State should be under an obligation to consult key stakeholders whenever the handbook is revised. It should not simply be left to him alone to interpret the constitution, so I hope that the Minister will be able to provide some reassurance.
On the back of this, will the Minister say what the budgetary allowance is for the revision at three years? The size and extent of the consultation and the revision will determine its costing. If a small budget is allocated to do it, one risks having a tokenistic review, whereas if it is revised less frequently but is more extensive, the revision may prove to be more cost-effective in the long term.
I declare an interest as chair of the Care Quality Commission, and welcome Amendment 27 in the name of the noble Baroness, Lady Barker, at least in respect of the dreaded list. The list in the amendment replicates the list that is already in the Bill in terms of who would be consulted on the review of the constitution, and it is vital that that list is the same as the list for the review of the handbook, for the very reasons that the noble Earl, Lord Howe, outlined. In fact, the more important document is the handbook rather than the constitution, because it puts flesh on the bones of what the entitlements are.
I declared my interest because the amendment would mean that the Care Quality Commission, which under the Bill is already statutorily consulted on the constitution, would also be consulted on the handbook. It would be inconsistent if we were to be a statutory consultee on the constitution but somehow evaporated in the face of the handbook. We welcome the incidental implication of the amendment of the noble Baroness, Lady Barker.
I, too, support this amendment. I will not rehearse the arguments that I made on Monday about carers, but it is important that we all remember that, for many people, the handbook will be the way in to the constitution. We must therefore keep it as up to date and as widely known as possible.
I also want to discuss the concept of “widely known”. It is quite easy for us in Grand Committee, in your Lordships’ House and in the system to understand constitutions and handbooks. For the ordinary punter out there, however, it is a completely new concept. It will not be part of their daily reading or their daily lives, so we should all be in favour of having a greater opportunity to publicise its existence and its purpose. From the point of view alone of making the constitution more widely known, the consultation should be as frequent and as wide as possible.
Amendment 27, tabled by the noble Baronesses, Lady Barker and Lady Tonge, proposes that the same list of persons and bodies that are required to be consulted on the 10-year review of the constitution, with the addition of carers, should also be consulted on the regular reviews of the handbook. Amendment 29, tabled by the noble Earl, Lord Howe, addresses a similar point, but suggests that the Secretary of State shall consult,
“such persons as he shall consider appropriate”,
on any revision of the handbook.
I understand that the amendments seek to ensure that any reviews of the handbook to the constitution cannot be made without consulting those persons or bodies that might be affected by them. I have already set out my concerns about Amendments 26 and 28, so I will move on to the other amendments in the group. First, I would like to reassure noble Lords by restating our intentions behind the review of the handbook.
As I mentioned previously, the handbook is the explanatory guide to the NHS Constitution, to be used by patients, public and staff. The Secretary of State may make minor technical and legal changes to the handbook at any time, to reflect current departmental policy or changes in the law. We do not think that it would be proportionate to have to consult on such changes, and I think that most noble Lords agree. However, any significant changes to policy or law that affect the handbook are in themselves likely to trigger consultation requirements. We should bear in mind that if there is a policy change, that change itself will be consulted on. This debate is about the idea that there should be consultation on the policy change and then another consultation on the change to the handbook. I hope I have clarified that whatever change is to occur, there will be consultation on it. Requiring a second consultation on putting the change into the handbook would be a further burden and more bureaucracy. I reassure noble Lords that the Secretary of State is obliged to consult on any change in policy. The intention behind the regular reviews of the handbook is to assess whether the handbook continues to be fit for purpose for patients, public and staff. While the constitution is a formal document with formal consultation requirements, the handbook, as I said, acts more as an explanatory guide.
I hope that I have reassured noble Lords on these amendments. If there is still fairly strong feeling about it, I would be more than happy to look at the wording. Although I completely agree with the intention here, it is very important that, whatever we do, we do not increase the burden of consultation by requiring two consultations on a policy change that has exactly the same purpose.
I thank all noble Lords who contributed to this short debate. I say to the noble Baroness, Lady Young of Old Scone, that although the inclusion of the CQC may look incidental, it was entirely deliberate on our part. For the reasons she outlined, it makes sense for the regulator to be there.
I take entirely the Minister’s point about the burden of consultation. In the NHS and in social care we tend to swim in a sea of consultation, and, frankly, there are only so many sandwiches that can be eaten in the course of developing good policy. If he is suggesting that there should be only one opportunity to be involved in consultation then, on balance, my guess would be that most people would want to be consulted on the handbook, not the constitution. Not only is that when the detail of how the principle is to be implemented in the NHS is established, it is also the point at which people reading the documents get the sense of which principles are the really important ones and how all the different principles will interact in practice.
I have not spoken to anyone about this, but I know that many external organisations are very interested, and I would like to consult them on it. But that is my initial reaction to the Minister’s comments. I am very pleased that he has agreed that there is a degree of feeling about the issue. I am happy to look further at it and perhaps come back to it at a later stage.
I thank the noble Earl, Lord Howe, for his support. I do not want a never-ending list of people to be involved, but I do think that there is a case for this list, and possibly only this list, of people to be involved. I think it brings some welcome clarity. So, with the Minister’s assurances that he will not knock it out of court completely, I am very happy to beg leave to withdraw the amendment.
Amendment 27 withdrawn.
Amendments 28 and 29 not moved.
Clause 4 agreed.
Clause 5: Report on effect of NHS Constitution
Amendments 30 to 32 not moved.
Clause 5 agreed.
Clause 6: Duty of providers to publish information
33: Clause 6, page 4, line 13, after “containing” insert “(but not limited to)”
In moving this amendment I shall speak also to Amendment 36, and in doing so bring us to a subject that is particularly close to the Minister’s heart, namely quality accounts. I should say immediately to him that I see considerable potential in the idea of quality accounts. Nothing that I say when speaking to these or the next few amendments is in any way meant to be critical of the concept. There are, however, a number of aspects of the practical implementation of the policy that we need to explore.
The first question to be asked, as a number of noble Lords did at Second Reading, is what quality accounts are for. What audience are they to be aimed at? The answer is that they are for several different audiences. They are perhaps first and foremost tools for doctors and other clinical staff which, if used properly, will enable them to drive up the quality of their own performance. I buy into that concept completely. Any professional worth his salt is driven by a desire to do his job supremely well. That is what motivates him and gets him out of bed in the morning. Any benchmarking tool that helps him to do that, especially a tool which he himself has helped to devise, will be good news to him. So far, so good. Quality accounts are also for trust boards, as a means whereby directors can hold clinical staff to account for the quality of their performance. Again, I am supportive of that idea.
However, it seems to me that the data that will be of practical use to doctors are not necessarily the same data that a board of directors will find most informative; or if they are, the data may well need to be presented and explained in a slightly different way. Who will be responsible for ensuring that that process of presentation and interpretation is done properly and fairly?
The real question mark arises over the data presented for public consumption. The public do not need and do not want to have the same quality data as clinicians. The information that they get needs to be simple, easily understood and, above all, meaningful to enable them to make balanced and informed choices. In some areas they need access to the detail; in other areas, they do not.
There are several issues here. One is who will be responsible for packaging the data for public consumption. Another is who will decide what data are released into the public domain and what data are not. We know from what Ministers have told us, and from this clause, that some information in a set of quality accounts will be proscribed by government. However, a large part will not be. How are we to ensure that data published by different trusts are directly comparable? In various meetings, the Minister has spoken of the role of SHAs in acting as “quality observatories”. I would be interested to hear a little more from him about how these observatories will function. Equally, how are we to avoid the tendency, which a number of noble Lords referred to at Second Reading, for organisations to puff-up their successes but draw a discreet veil over their failures? In general, how are we to ensure that the information that is published does not mislead the innocent reader, however unintentionally?
One of the central features of any trust that claims to be a beacon of quality has to be that it is a safe place to be and to be treated in. The noble Lord, Lord Patel, will be speaking on this subject in a much more authoritative way than I can, and I will not steal his thunder. All I wish to say is that any areas of a trust’s performance where patient safety is decidedly lacking—and this could be in a whole range of areas, not just the ones that we immediately think of, like hospital-acquired infections—are not going to be things that a trust will naturally wish to advertise. Who will make them do so? There does not seem to be anything in the system to ensure that the public receive not just the truth but the whole truth and nothing but the truth.
The RCN has spoken very cogently about quality in nursing and made the important point that quality of care extends well beyond the success of this or that medical intervention; it is also about things like avoiding pressure sores and reducing patient trips and falls. One thinks also of good nutritional care and the efficiency with which drugs are dispensed on the ward. There are aspects of care to do with patient dignity that are of huge importance. One can think of a whole host of indicators in this general area. At the same time, it is not feasible to collect and publish more than a certain amount of data without it becoming unacceptably onerous. How is the right balance going to be struck?
I should like to ask the Minister to elaborate a little more than he did at Second Reading on innovation as a feature of quality. He said that there were all kinds of incentives for innovation already in the system, as well as innovation metrics which strategic health authorities will monitor. I hope that he can go a bit further than that because it seems to me that, when it comes to quality accounts, the public have an interest in identifying those providers where innovation and progress are high on the agenda. I do not know what metrics have been devised in this area. One could think of two or three reasonably good proxy measures, such as the number of clinical trials being conducted in a trust or the percentage of NICE-recommended therapies which the trust has actively adopted. I was particularly impressed with the Second Reading speech of the noble Lord, Lord Turnberg, who highlighted the importance of fostering teaching and research within the NHS and the need for patients to be aware that research is going on which they can take part in.
My main worry with quality accounts is the quantity of data needed to feed them month after month if they are to be of real use to the different audiences. As I mentioned a minute ago, the information appropriate to each of those audiences will be subtly different, which makes the task more challenging. At the same time, there is a distinct risk that if we start expecting too much from quality accounts and pile more and more information into them, we will dilute their effectiveness. It would be very helpful to hear something from the Minister on that aspect of the matter, which I am sure will not have eluded him. I beg to move.
With the clarity with which the noble Earl speaks, I would always be glad if he were to speak on my behalf. As he has forgone that privilege on this occasion, I will do my best. I am very much attracted to many of the noble Earl’s comments and hope the Minister will come back to them. My amendments would ensure that improving patient safety is given equal importance to the pursuit of quality in the NHS and seek to ensure that the potential of quality accounts to drive safety improvements is fully realised.
I should declare an interest as chairman of the National Patient Safety Agency, which has a central role in increasing the safety of healthcare. Improving patient safety is often cited by patients and policy-makers as the number one priority in the NHS. It has been estimated that one in 10 healthcare episodes results in patient safety incidents of some sort, and the NPSA’s national reporting and learning system—the NRLS—receives 3,000 patient safety incident reports every day. So the challenge is significant.
Over the past few years, much effort has gone into raising the profile of patient safety: establishing the national reporting and learning system, providing guidance and support to healthcare providers, putting patient safety systems into place and developing interventions to reduce the risks of known sources of harm. In the report by the noble Lord, Lord Darzi, High Quality Care for All, quality is defined as a combination of clinical effectiveness, safety, and patient experience. It seems to be taken as a matter of faith that that definition will become universally adopted. The difficulty with that assumption is that definitions of quality are notoriously variable and imprecise.
Within the report itself quality is sometimes paired with safety, and at other times it is mentioned alone or with clinical effectiveness and so on. I was interested to see that the Care Quality Commission used a different definition of high quality care in its recent manifesto. While I am pleased that safety is included in the definition, it highlights the risk that a lack of clarity in definitions will result in patient safety being sidelined as different bodies pursue their own ideas about quality.
“Quality” is currently left undefined in the Bill and the Explanatory Notes, and that, together with the fact that safety is not mentioned in the legislation, sends a message that patient safety is not important. Specific reference to safety in the legislation would send a powerful message to the contrary and help to mitigate the risks that I have highlighted. Failing to define quality adequately could lead to differences in interpretation of what should be included in quality accounts and to the exclusion of information related to patient safety. That would be a shame, because quality accounts have the potential to become powerful levers for the improvement of healthcare in the NHS.
I want to give some examples of how quality accounts could be harnessed to improve patient safety. “Never events” are serious, largely preventable patient safety incidents that should not occur if the available preventive measures have been implemented. Next year, PCTs will require healthcare providers to put in place preventive guidance in relation to a core list of never events; report the occurrence of events on the core list of never events to them; and, if events occur, put in place action plans to prevent recurrence. Requiring providers to report publicly the occurrence of never events would act as further encouragement to prevent them occurring in the first place.
Another example is safer surgery checklists. Earlier this year the National Patient Safety Agency issued an alert requiring healthcare organisations in England and Wales to implement World Health Organisation surgical safety checklists for every patient undergoing a surgical procedure. That was based on the results of a pilot which included the department of the noble Lord, Lord Darzi. The checklist is intended to strengthen the commitment of clinical staff to address safety issues in a surgical setting. It includes measures which will improve anaesthetic safety practices, ensure that surgery takes place on the correct site and reduce the risk of infections. The NPSA has a target next year to ensure that the checklist is used in all relevant healthcare organisations. Making organisations report publicly on whether they are complying with the checklist would be a powerful encouragement for organisations to do so.
The next example is Matching Michigan, a two-year initiative which will reduce the number of central venous catheter-associated bloodstream infections in intensive care units in England. It draws on lessons learnt from the successful Michigan initiative, called the Michigan study, on the same topic. If providers with intensive care units were required to report their rates of central venous catheter-associated bloodstream infections, I am sure that that would add to the success of the initiative.
Patient safety is a fundamental aspect of high quality care for patients. It is essential that healthcare organisations put in place all that is required to improve the safety of patients—such as local systems to record, investigate and respond to patient safety incidents; systems to report patient safety incidents nationally; and systems to implement national patient safety initiatives and interventions. They should also implement all national guidance and initiatives related to safety improvement. Making providers report on whether they are doing these things as part of quality accounts is a powerful lever in ensuring that they do. I hope the Minister agrees that patient safety is of paramount importance in modern healthcare and that we must not risk it being cast aside as we seek to improve the quality of healthcare in general.
My comments will be relatively brief, as the noble Earl and my noble friend Lord Patel have already expressed very clearly most of what I would wish to say.
The noble Earl highlighted the crucial importance of the education of staff in the NHS and research. I draw attention to principle 3 of the NHS constitution, which states:
“The NHS aspires to the highest standards of excellence and professionalism—in the provision of high-quality care that is safe, effective and focused on patient experience; in the planning and delivery of the clinical and other services it provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population”.
Yet on those particular aspects of the constitution, the handbook is almost completely silent. Bearing in mind that quality accounts must take account of the standard of service provided to patients, and of course to staff, I believe that these issues of education, research and innovation must in some way be mentioned and referred to. As the noble Earl said, my noble friend Lord Patel tabled a Question earlier today on clinical trials. The establishment of high quality in an era of evidence-based medicine is often based on the outcome of such clinical trials. I must say that I would wish to have specifically mentioned in this document on quality accounts the outcome of clinical trials and the evidence base on which quality services are provided. I hope that the Government will give attention to that.
I do not speak particularly to this amendment, but I believe that the issue is crucial to quality accounts as a whole. I am very firmly in favour of quality accounts being provided, if, as I said at Second Reading—the noble Earl highlighted this—the collection of the information will not be too burdensome on the staff who are required to provide them. For that reason, certain principles relating to the nature of the information to be included in these quality accounts is something to which the Government should pay very close attention, while bearing in mind throughout that the outcome of clinical trials and the importance of evidence-based medicine is highlighted.
Briefly, I once again express my anxieties about quality accounts. The concept of quality in the NHS goes without saying. Everyone wants quality healthcare; we would all accept that. What I find so difficult with Clause 6 is that without the regulations we have no idea what we are legislating for. We have no idea what we are creating here. We like the idea of quality accounts but we do not know what they are. This frequently happens in government legislation as Bills are going through both Houses. In this case, it really is crucial, as the noble Earl, Lord Howe, said, to know what we are going to measure. Patient dignity is probably one of the most important things of all. How do you measure patient dignity? It is going to take an awful lot of work to do that.
Safety, as the noble Lord, Lord Patel, said, is crucial. My concept of quality in the NHS has always been, as the noble Lord, Lord Darzi, said at Second Reading, the concept of clinical teams getting together on a regular basis to assess their progress, where they are going and how they could improve their performance. That has always been my idea, and I think that goes on all over the health service now, as I think the noble Lord said at Second Reading. We really do not know what these quality accounts are going to be. How can we insist on setting something up when we do not know how big it is going to be, what data we are going to collect, or what sort of organisation will be required?
I know that I am always beefing on about NHS bureaucracy, but we have an awful lot of it. Maybe the noble Lord cannot see this, but I can see a department of quality accounts and a director of quality in the next couple of years being embraced with delight by health service management. The fights will go on about offices and filing cabinets and who is going to be shifted where, and the whole concept will be absorbed into the health service as another branch of its bureaucracy. Who will collect the data? The data will be collected by the clinical staff when they should be attending to their patients. That is my anxiety. I am sure that the Minister is going to reassure me that this will not happen, that there will not be such a department and that clinicians will be left to treat patients; but frankly I do not believe it.
Finally, I do not want to labour the point, but I am not clear how quality accounts are going to be used. Are they going to be used internally? Apparently not, because they are going to be published. Are they going to form league tables? Are patients going to choose where they go based on the number of percentage points that a certain establishment gets for safety, or are we going to go more for dignity or for what percentage of patients live through a procedure? Has this been properly thought through? I hope that I am going to be reassured, but I had to reiterate my anxieties on the whole question.
I shall speak to the amendment tabled by the noble Baroness, Lady Greengross, which is grouped with this amendment. Although I am not particularly wedded to her wording about the domains, it is important that we have an understanding of what quality is and that we should make clear what areas we are looking to express data about.
Unusually, I profoundly disagree with the noble Baroness, Lady Tonge. I think that this is an extraordinarily welcome innovation, and I shall wax even more lyrical when I get to the next group of amendments—
I accept that, and I will be pressing those questions on the next group of amendments. There is a real risk that quality accounts will, as the noble Earl, Lord Howe, said, turn into what I call PR guff. The NHS is getting better and better. If you visit an American hospital as a manager, as soon as you walk through the door you will be handed its PR guff. It usually starts with the heart transplant programme and goes on from there. It talks about all the great things that the hospital does and tells you absolutely nothing about what really goes on in the hospital. I worry that there is a potential problem there.
I hope that patients are going to look at the website to see which orthopaedic surgeon they will choose out of those listed for a hospital, or whether they might go to another hospital because it has better outcomes. I certainly hope that that will happen eventually, but this is a start. I support the thrust of the amendments, which suggest that we need to be clear about what we include in the quality accounts that will make the difference to patients, clinicians and the system.
The noble Earl, Lord Howe, referred to hospital-acquired infections. I want to take that a step further. We all welcome the principle, but I want to put forward a scenario. What would happen in those conditions? I presume that in the regulations there will be a requirement to report on cleanliness in wards, because that is a very important issue for patients. I have spent months and months in hospitals, and some of the experiences that I can recall are pretty appalling—the state of the loos in hospitals, to start with.
Who is actually going to evaluate the state of the cleanliness of a loo on a ward in a hospital? I would have thought that all the hospital mechanisms would say, “Our hospital loos are clean. There are no problems. We hear good reports. The nurses tell us that they’re in good order”, whereas in reality patients often complain about them. It has been going on for years and is still going on. So who will write that report? If someone on a hospital ward complains about the condition of a loo, a ward, a mop under a bed or whatever, a row will break out within the administration about whether it should go into the report or whether it can be blocked. They do not want to see it.
Perhaps I can help the Committee by reminding the noble Lord, Lord Campbell-Savours, that there is now a very good hygiene monitoring system in addition to the hygiene code. People may fall short of the code, but very clear standards are established and they are well monitored and reported on. It is a good example of where, despite the horrors that we know still exist, a system is in place to try to address the problem.
I am aware of the code, but a hospital may choose to hide behind the existence of the code when it is writing its report. It may not wish to volunteer the information that, despite whatever codes exist, it regularly receives reports on a lack of cleanliness in loos and on wards in hospitals.
Perhaps I can provide some clarification on the new regime on healthcare-acquired infection that will come into place on 1 April. All NHS trusts will be required to register with the Care Quality Commission for their performance on healthcare-acquired infection. We will publish those registrations, including any conditions that we lay on trusts that fail to perform to the code. My understanding is that, as I am sure the noble Lord, Lord Darzi, will confirm, the regulatory performance of individual trusts will be a core part of the quality accounts. It will not be an optional ability to bury their bad news.
Perhaps I may add just one further bit of clarification on this crucial issue—and it is crucial, actually—which relates also to the point raised here about dignity. The fact is that there is now an extremely detailed patient survey: direct responses by patients about their treatment on a whole range of issues. If they are unhappy about the loos, they can make that clear on the patient survey. One of the greatest innovations over the past few years is the introduction of this patient survey. We trusts cannot wriggle out of that; it is all there on paper. You can benchmark across all the trusts and see exactly where you are. There is no way out.
I think that everyone is queuing to reassure me that there will be no problems. My noble friend tells me that she believes that the accounts will contain a reference to this. The question is: will they? I seek my noble friend’s reassurance that they will be there for all to see when the reports are published.
Perhaps I may speak very briefly to that point and also say one or two other things. Not only are cleanliness and the cleaning of loos addressed in the code of conduct; it is also to do with the accountability and authority within the organisation. Accountability should be clearly spelt out at the delivery end. As an NHS trust chairman, I had a battle when I found that the loos were absolutely filthy. I asked the chief executive whether he had been into a male toilet in a Little Chef. He said, “I hope you haven’t”. I said that I had not, but I had been into some of their ladies’ loos and there was a checklist in each one. It took me six months to get checklists into every loo in that trust. We have them here, too. So there has been movement. Some trusts probably have not moved forward, but it is not beyond the wit of man to do so. It comes back to the issue of accountability and the authority that comes from the board down to the first level.
That brings me to the list, which the noble Earl, Lord Howe, mentioned, from the Royal College of Nursing. I am aware that much work has been done to develop the metrics for measuring some of the quality issues that the Royal College of Nursing has raised. I agree that some things are more difficult to measure. That comes back to the dignity, care and compassion that are absolutely fundamental to the quality of care. I spoke to this at Second Reading. We must be aware of the danger of this becoming a tick-box system that does not take account of accountability at ward level or in the delivery of care in the community right the way through to the authority at board level. What was the problem at Stoke Mandeville and at Tunbridge Wells and Maidstone? The eye was off the ball. The accountability was there, but the authority had not been taken through. That issue is not recognised in the statement.
I take the point made by my noble friend Lord Walton of Detchant about education and training. I know that you can read here that education and training universities are contracted and commissioned through the PCTs, but I have considerable worries about the isolation of the universities. We only have to look back two to three years to the cutbacks in finance and the fall in the workforce. The education and training universities are set apart, and we need them to be in the Bill as very much part of the exercise in quality.
I support Amendments 34A and 37A. Only yesterday, I read in the Yorkshire Post that Leeds hospitals have been fined many millions of pounds because they have serious infections of MRSA and C. difficile. Also, no one knows better than the noble Lord, Lord Darzi, that safety in operating theatres is vital. I cannot imagine that he cannot include safety. Hospitals have become dangerous places. They should be as safe as possible. This definitely needs to be emphasised.
I was very gratified to hear this debate. It should reassure noble Lords to know that this is the type of debate that I wanted to create in the NHS. If you go out into the NHS, that is what it is talking about at the moment. I said in High Quality Care for All that I wished quality to be the organising principle of the NHS. I wanted to use any lever that I may have to create that debate. It is working here, and I have no doubt that it will work in the NHS, too.
Most noble Lords have expressed concern about what the quality account is. I will try in a fairly long speech—I will go sideways sometimes—to explain what the quality accounts are and how we envisage them improving patient care. I have no doubt that some noble Lords have said in the House that the quality of care that has been provided has not always been central to the discussion of the performance of the NHS or on the agenda of boards that lead NHS organisations. I have sat on a board for 18 months, and at every board meeting most of the discussions have been about the financial health of that organisation and intermittently about where the threats were from neighbouring organisations in relation to services. In the last half hour of these discussions, someone mentioned quality indicators, which were the minimum requirements that the regulator was required to measure. That is not what I see as quality in the NHS; I see the culture of every clinician, organisation and board as very much the driver of quality improvements for the future.
Some noble Lords asked why we have picked these three domains of quality, as there are seven domains of quality. We have picked safety because we strongly believe that safety is paramount. The noble Lord, Lord Patel, very eloquently referred to that. We also picked effectiveness. Clinicians have always been accustomed to that. The noble Lord, Lord Walton, referred to audits. Historically clinicians measured audits. The third one, which I believe is the most important and which historically we have not had much regard to as clinicians, is patient experience. I am not referring to patient experience as patient satisfaction surveys, as that is a tick-box exercise. It is not uncommon with patient satisfaction surveys not to get that information until about a year down the line. It is meaningless. It rarely gets down to those providing the service learning from that experience. Therefore, we are talking about sophisticated tools in which we will measure patient experience.
What about the other four domains? We need to start walking before we run. Other domains include productivity, cost-effectiveness and value for money, which I have no doubt are extremely important, certainly in the current economic climate. However, this is a good start to defining what quality is.
The next issue is what should be in the quality account. Whichever way you look at it, the regulator in this country has had a huge impact on improving the quality of services. I am not sure how many more weeks there are. The noble Baroness, Lady Young, always reminds me of the number of weeks, but I am sure she will refer to that later. The Care Quality Commission will maintain the wonderful quality improvements that have been introduced throughout the system. We have seen many quality improvements by the regulator and, let us not forget, we have also seen many quality improvements on the back of the operating frameworks. Some have described those as targets. Some of the high quality care targets have worked. You just have to look at the mortality rates for cardiovascular disease. We have had a 48 per cent drop in death rates following coronary artery disease.
The Care Quality Commission will measure all the indicators in the system as it stands, which will be part of the quality account that a provider will have to take ownership of and publish. Also, mostly tier 1 operating framework indicators will be in the quality account.
The bit that the Committee may feel is still blurred is the question: “What else?”. It is the “What else?” that excites clinicians. Clinicians come to work not because they think that they are meeting the core standards that the system requires them to achieve but because they want to excel. They are ambitious and really want to push the frontiers in the quality of care that they provide. They are the experts in what they measure. It is not for us sitting in this House to decide what these measures should be as long as the framework is correct. That framework is, as I described, for safety, effectiveness and patient experience.
In my line of practice, a number of well established national and international indicators reflect the quality and effectiveness of the care that I provide. I want to add newer indicators that reflect the experience of the patients receiving care through my team. That is also very important. We should not forget the safety requirements when working in a very complex health environment in which the risks are constantly increasing. The legislation in front of us would create that broad framework. I hope I have reassured the Committee about the good work that the Care Quality Commission and the NHS operating framework have done together.
MRSA and other infection rates were also mentioned. That will be there. That is a must, but that is not what we are discussing here. We want to encourage further quality measures. We must ask why. It is not just an ambition; it is quality improvement, and there is a science behind quality improvement. People measure things not only for the sake of measuring them but for the transparency that comes with that, which is what drives people to improve the services that they provide.
When we come back in the autumn with the secondary legislation, we will debate what will be in the quality account. I remind noble Lords that a component of the quality account will not be discussed in this House. This will be discussed on the front line, where people are delivering those indicators, which could include audits and other parameters. Some noble Lords have suggested—
Before the noble Lord moves on, I want to ask a question for clarification so that I really understand this. I did not speak earlier. Is he indicating, as in some areas, that the various groupings will have a self-evaluation within their particular clinical setting—I am more familiar with that in the setting in which I work—which the CQC could measure in its regulatory evaluations? Is that the kind of concept that he means?
It will definitely include all the comparative information that the Care Quality Commission will be measuring. That is one of the parameters. The Thames Cancer Registry, for example, has a large amount of data and information that most cancer units in the NHS may wish to start taking ownership of and publishing. In the NHS, we collect large amounts of information. It does not have the ownership of the clinicians who are providing the services, and I want to close that loop. That is the purpose of the quality accounts. We need to make that culture thrive, and that is why I am slightly concerned that we should not surround that space area with the words of legislation.
The future will be different. We should also have the opportunity to develop future indicators. I mentioned that we should start walking before we run. That is the purpose of the creation of the National Quality Board. I am delighted to say that with the regulators—Monitor, the CQC, or patient groups or clinicians at a national level—we could develop further indicators in the future that may fall into any of these three categories. They may fall within the category of the regulator or the category of quality improvements. Quality accounts are not only for secondary care providers. We have a lot of quality to measure when it comes to community services and primary care. We know that we are measuring the quality outcome framework in primary care, but there is a hell of a lot more that we can measure when it comes to providers outside and elsewhere.
Research and teaching were brought up by the noble Lord, Lord Walton, and the noble Lord, Lord Patel, asked a Question in the House about this earlier. The noble Earl, Lord Howe, also mentioned it. I agree that there is a very close link between innovation and quality. You can improve quality only if you are innovating. I sympathise, and I declare an interest. It would be reasonable to consult the service, as most of these indicators will be developed with the service. I do not see this process as a top-down approach. I will not just sit down in the department with many of my very bright Civil Service colleagues and decide what the indicators are. We need to consult the service to see whether there are indicators that will reflect innovation, and the uptake by patients of clinical trials may be one of those. We should never underestimate patients’ sources of obtaining knowledge.
One of the challenges that clinicians have is the inaccurate information that patients have when they come to see clinicians as out patients. Most of that could be through some of the PR blurb to which the noble Baroness, Lady Murphy, referred. We want to be open and transparent to empower our patients in future, because most of us in this Room have exercised informed choice and that is where we need to head. I hope that I have reassured the noble Lord—
I am not a professional in this area, but a consumer of services. My noble friend referred to MRSA. I could produce data on a hospital from these accounts that would not indicate to the public what is going on. Let us take a hospital with 20 wards. One ward is the principal ward where there is a problem with MRSA. If there is reference in these accounts to the whole hospital, the public are no wiser. They need to know which ward. I know that it is difficult for many hospitals to provide that information because they believe that those wards then become vulnerable, but that is the only way to impose the disciplines on those wards to get higher standards. Will the MRSA data be collected across the whole unit or will they be localised so that the public can see what is going on?
On the question of patient experience, I have been a day patient. Even today, I have been a day patient. I seem to be in and out all the time, although I have not been a residential patient for some 12 months. When these patient experience information-requesting arrangements are made and the forms go out are we asking patients who may well be very low, just want to go home and not want to be bothered or is some other arrangement now in place for acquiring that information? If it is based on people who are down and not feeling too good completing forms, I do not think they are going to fill them in very honestly. I certainly would not.
I am grateful for that intervention from my noble friend. I have no doubt that the noble Baroness, Lady Young, will have a lot to say about this as it is in the domain of the regulator. As to which ward has MRSA, every organisation has a legally accountable board. We are trying to get the board to be accountable not only for the whole place but also for every ward providing services and to act upon that information. I have no doubt it is within the domain of the regulator to ensure that boards are held accountable. If the regulator feels that transparency should go down to every ward, that is an issue that it will have to discuss with the board.
It that not also a matter of policy? Surely, the Government must have a view on whether that is right. In representing the public interest in these matters, the Government must have a view about whether that information is available. Whenever I go into hospital, I would like to know which ward is difficult so that I can make a decision about whether I want to go into it, particularly if it is an orthopaedic ward.
That may have been Aneurin Bevan’s vision when he said that the echo of a bedpan falling in Wales would be heard in Whitehall. I see the NHS having that accountability at a local level in years to come. I sympathise with what has been said. I can even go further and say what is happening, certainly with some of the suggestions from another regulator, Monitor, about developing the service line reporting to get that information-based service. The noble Lord could get that information on orthopaedics and figure out where the orthopaedic wards are. Rather than basing it on wards, we want to measure services. The experience, effectiveness and safety should be around either a disease entity or a specialty interest. That has been successful in certain lines; for example, in cardiovascular mortality rates with the transparency of reporting of mortality following coronary artery bypass graft. We have seen that before.
Amendments 33 and 36, tabled by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, appear to open up the scope of quality accounts to include any information that can be published. I appreciate that the noble Earl wishes to see NHS healthcare providers given as wide a latitude as possible in drawing up the accounts—I share that aim—but my slight concern as we try to focus on quality is, for example, that we do not want financial accounts to be part of quality accounts. I would like to keep them within the framework of safety, effectiveness and patient experience.
Perhaps the noble Lord could expand on why. He will be aware that the issue of private provider involvement in the NHS and comparisons between private providers is something that crops up quite frequently. I am interested to know why he wants to separate quality from cost and why, in the longer term, that is advantageous for the NHS.
I have already said that there are other domains in quality and that value for money is an important domain. We are starting here and, initially, within the quality account, we want to focus purely on the safety and experience parameters and then expand that to effectiveness. I agree with that. I just do not want a mixture of financial account and quality account with some other parameters that will diffuse or contaminate—if I can use that word—the purpose of the quality account as I see it and as it has been developed from the bottom up.
I hope I have reassured the noble Lord, Lord Patel, that safety is part of the quality definition. As I have described in the Bill, safety is one of the domains. I am very grateful to him for his contribution and to the National Patient Safety Agency for taking on some of the outputs of High Quality Care for All. A few have already been mentioned, such as the never events, which we see as part of quality improvement, rather than the quality accounts, and the reference to the checklist.
I turn to the point raised on the amendment tabled by the noble Baroness, Lady Greengross, which referred to the address by the noble Baroness, Lady Barker, on dignity and respect. That absolutely should not be an indicator because it is not something you can measure; that is part of the patient experience. There are ways in which one can measure that and it is not ticking the box while the patient is asleep or in bed receiving a treatment. Compassion and dignity—the way in which the patient has been cared for—are two indicators that are very much a part of the patient experience domain of quality improvement.
I hope I have reassured the Committee and explained what the quality accounts are. I hope, with that reassurance, that the amendment will be withdrawn.
I felt sure that we would be treated to an impressive and illuminating speech from the Minister in response to this amendment and so it has proved. For that, I thank him on behalf of the Committee. This has been an extremely good debate. However, I am left with one main question mark on a point to which many of us have returned: the burdens, which may, in practice, be placed on organisations. The Minister has indicated that this issue is live in the minds of many in the health service at the moment, and I am glad of that.
However, another area I wanted to touch on was private-sector healthcare providers—particularly pharmacies, which have not been mentioned much so far. The Bill’s impact assessment anticipates the cost of data collection for quality accounts being zero. That prediction may be premature for pharmacies. Until they and we know precisely what the make-up of a quality account will be, we cannot tell whether the information currently collated in pharmacies is in the format in which it will need to be reported.
As it is, the impact assessment estimates that the cost of analysis by a member of staff to produce the quality account in any given organisation will be between half a week and five weeks. The estimate that I have seen is that this will place a cost on the pharmacy market in England of around £20 million a year. That is a significant regulatory burden, and we must find ways of minimising it in a manner consistent with achieving the aims that the noble Lord has in mind.
On a point of detail, although an important one, has the Minister considered whether it would be possible to give companies the option of publishing a quality account within the timescale of their annual reporting requirements rather than necessarily adhering to the April-to-March reporting period that has been specified for the NHS? That is only one point that has been raised with me. The Minister may care to answer it now; on the other hand, we could go over this outside the Committee or come back to it at a later stage. However, I wanted to flag it up with him. For now, however, I beg leave to withdraw the amendment.
Amendment 33 withdrawn.
Amendment 34 had been withdrawn from the Marshalled List.
Amendment 34A not moved.
35: Clause 6, page 4, line 26, leave out paragraph (d)
I also speak to Amendment 47, and will continue the themes that we have been discussing in the previous group of amendments. I was buoyed up on a wave of enthusiasm by the Minister’s first speech in his response, but was then dashed against the rocks of disappointment when he said that this has nothing to do with regulation or regulators. I cannot then think what the regulators are meant to do. I will flesh that out a little later.
I have been surprised by reports in the healthcare trade press about my amendments, and therefore hope that the Committee will bear with me if I make clear my purpose in tabling them. I declare an interest as a member of the NHS foundation trust regulator, Monitor. Like my colleagues in that organisation, I feel pretty strongly about the clarity of processes of management, reporting and the regulatory system. This is not about adding burdens, but about being able to be clear in what information is available, not only for patients but for clinicians, Ministers and trust boards in managing their services.
These are probing amendments. I do not expect to return to them on Report, but I want to be sure that I understand the Government's intention on the purposes of the reporting system for quality accounts. Again, we go back to the issues so ably raised in the previous group of amendments about how they are to be developed and for whom. If I touch on some of those areas again, I hope that the Committee will bear with me.
First, where do those issues sit in the overall framework of the Government’s intentions for the healthcare services? I am a great fan of the Government’s declared vision of an affordable, devolved healthcare system in which patients receive excellent care and taxpayers get value for money through autonomous, well led providers responding to commissioners’ requirements and patients’ voices—a system, which is regulated in a clear, auditable way, using a toolkit of measures that allows performance to be monitored and encourages continuous improvement. I have taken these off other doctrines. I am pretty clear that that is what the Government are trying to achieve.
Everyone will agree that the introduction of quality metrics is vital to that task. This is why, at Second Reading, I expressed my wholehearted support for the introduction of quality accounts, recognising that we are introducing a potentially far-reaching mechanism for encouraging clinical care improvement. I congratulate the Government on taking this forward. We have been hoping for this for a long time.
The quality agenda is, of course, huge. There are dozens of players, not just the clinicians and clinical staff who deliver care and the vital support staff around them, but the many players in stakeholder organisations. It must of course be for the Government—in practice, the Secretary of State—to set the priorities in quality. They will be looking to organisations such as NICE to establish guidelines for care pathways, and professional bodies to promote good practice including, of course, the input of individual clinicians and their teams. We look to the Care Quality Commission to not only set basic and registration requirements, but also to use available information to monitor overall quality standards. I have listened to the noble Baroness, Lady Young, on this issue quite recently, and heard her aspirations to develop a culture emanating from the commission that is consonant with what clinicians want: one of hauling the worst up by their bootstraps and encouraging clinical developments and excellence. That will give us a national picture.
What is the role of quality accounts? We have already touched on the problem that at least part of them will need to be different for different audiences. The noble Earl, Lord Howe, talked about that quite a bit. If I am a patient, I want clear, understandable information. I hope that simple, comparative information will be available. We may criticise the material available to the education department and parents looking at league tables but, my goodness, they have worked. They have been extremely helpful in assisting parents to decide which schools they support and which need to improve. If we can get similar data then, of course, we should do that.
As a clinician, I share the Minister’s view: I want a set of metrics that are meaningful to me and my team, by which I can judge whether my team is as good as the best in the country or just the also-rans. You might say that that is rather difficult in geriatric psychiatry, but it is not. It is perfectly possible in mental health services to have measurements of how efficacious the service is for a particular family.
The Minister’s intention is for quality improvements to be driven through the availability of these clinical data, some of which, as the noble Lord, Lord Walton, has said, have been available from audit. They must be comparative and matchable across different teams, hospitals and GP practices. All this stuff must be comparable if it is going to mean anything to clinicians and, of course, internationally comparable in due course. Quality accounts would surely need to be prepared for that purpose, and they could be.
As a trust board member, I want data that tell me as much about the clinical realities of the care my trust is delivering as I learn as a matter of course every week from the finance director about the finances. That would allow the board to focus on what we all know really matters to patients—the clinical realities of care. I also want material which will demonstrate to the local population, and to my governors and members of the trust, what we are developing and how we compare with the other local hospitals. If we are to do that, quality accounts must be published in a way that serves performance management requirements, and the requirements of contracting commissioners and those discharging regulatory functions. I remind the Committee that within two or three years all trusts will be foundation trusts or something similar. There will be no direct performance management. It will be management via the contract and the regulatory system. The CQC, Monitor, the NPSA and many other bodies will need access to this information.
The Secretary of State has every right to collect and collate data to give a national picture of the progress of quality improvements. Will accounts be suitable for that? I have a clear picture of where the Minister feels that they are clinically, but will they serve these other purposes? If not, how will they be meaningful nationally? Again, I add my cheers, but if quality accounts are to be meaningful, they must be as measurable and obvious as financial accounts. Since finances and quality are integrally tied not only to the development of value for money but are very subtly intertwined, we must have a reporting system that enables them to be assessed together.
The intention in tabling these amendments is not to oppose or dilute the concept of these accounts, nor to remove the Secretary of State from the sight of them. I simply question the drafting of the legislation and the accountability route. If we are to move towards an NHS focused on quality, these accounts must have the same attention and scrutiny as financial accounts. They cannot be an add-on to any discussion of performance, but must be central to it. I believe that including this in the system of reporting would support clinicians within what they are trying to achieve.
Quality accounts and financial accounts should be presented together to allow a coherent view of performance to be assessed and should be fully integrated into the reporting and accountability arrangements for NHS bodies. They cannot be seen as part of a separate and less important process. At the moment, the foundation trust regulator collects very crude performance data, which is provided by the Healthcare Commission. It assesses performance against specific targets, such as MRSA, the 62-day wait and all those other things that are uppermost in the minds of most trusts. It gives a broad indication of the governance, efficacy and leadership of trusts. That is all the regulator has to go on in terms of assessing efficacy.
The regulator is often asked whether cost improvement demands on trusts impact negatively on the quality of care. We can usually say with confidence that in our experience they do not impact on performance against the specific government health targets but, at the moment, that is as far as we can go. We need far better data on the quality of care to be sure about the impact of financial shifts. Let us be clear that significant shifts are likely to come our way in the next five years. Does the Minister accept that quality accounts could have an important function in relation to this aspect of regulation? If not, I am not sure how quality accounts will be incorporated into a system that takes care of the whole system.
Briefly, the amendments are intended to achieve two goals. They would insert a requirement to produce quality accounts that establish reporting arrangements for foundation trusts, which would send a clear message that the quality accounts are central to the reporting regime. They would also establish a fully integrated approach that includes the information that the Secretary of State requires and agrees the form of quality accounts to the Secretary of State. This is very similar to the approach in the requirement for financial accounts, which are devised by Monitor but agreed by the Treasury. They would also allow quality accounts to be laid before Parliament in the same way in which financial accounts are, with both elements of performance being considered together. This appropriately reflects the devolved system that we are trying to develop as well as the future design.
The amendments would remove the role of strategic health authorities in ensuring the accuracy of quality accounts. I am not sure how SHAs would do that. They have no relationship with foundation trusts; they have no supervisory role in any way. I am really worried that the current system will take us back to a centralised system that the Government have worked so hard for the past 11 years to break, and away from developing something new and responsive. Such a role would also divert the SHAs’ commissioning function.
I am not going to get hung up on individual amendments. They set down a challenge to remove the Secretary of State, and they are probing. They are worded to pose a challenge to the way in which the reporting system works in the Bill. I do not want to focus too much on that at the moment. Rather, I want to understand the rationale for the unusually retrograde reporting proposals, which could play such an important role. I wish the quality account processes every success, but we must understand where they sit in relation to the reporting of performance in the system that we are trying to develop. I beg to move.
I support Amendments 35 and 47. My noble friend Lady Murphy has outlined their purpose very eloquently, as she always does, but I hope that I can speak from a provider perspective. I declare an interest, of which most noble Lords are well aware, in that I have a paid post in a provider trust, the East London NHS Foundation Trust, which provides mental health services. We would be directly affected, albeit only administratively, by the amendments.
Let me say at the outset that I, too, very much welcome the idea of quality accounts. I would not want to dilute them in any way. I listened with great interest to the Minister’s explanation of how they will be put together, although I confess that I am not entirely clear even now. As I understand it, information will come from a lot of sources, and somehow there will have to be some rather succinct conclusions out of them so that the regulator and others can assess the performance of the trust against these three critical measures: clinical effectiveness, safety and the patient experience.
On the point about the patient experience, I will clarify what I meant by patient surveys in our trust and, I hope, in every other trust across the country. Not only do we have the national patient survey, we also have our own patient survey, which looks at the quality of service according to the patient’s experience by ward and, indeed, by consultant. Therefore, if we have some indication that consultants are not always explaining in detail the side effects of treatment and so on, we know which consultants on which wards are failing and we can pick that up in the normal course of the work of the trust. That was an aside, and the point I want to make is that, with respect to foundation trusts, Clause 8 does not take account of the normal reporting and accountability framework for foundation trusts; that is, we report to Parliament, to Monitor and to our boards of governors, which are often called members’ councils.
Since the noble Baroness, Lady Murphy, has focused on the Parliament and Monitor angles, I shall focus in particular on our local accountability arrangements and how I hope that the regime for quality accounts will dovetail into them. Local accountability arrangements are one of the most exciting developments introduced at the time of the establishment of the foundation trust model in 2002-03. Unlike NHS non-foundation trusts, we have boards of governors, and the majority of governors are elected by members of the public and key stakeholders from the community.
The majority of our governors, and I am sure this is quite normal, are users of services and are patients or carers of patients. There is no better person to assess and be concerned about the quality of services than a user or a carer. For example, one of our governors recently spent time in one of our inpatient wards. She had a hell of a lot to report to us about her experience, and not all of it was good. That feedback from somebody who spent—I cannot go into detail. That feedback is far more valuable for us in assessing how we are doing, what we are doing wrong and what we urgently need to put right than even an unannounced visit from a regulator or an inspectorate, and much more valuable than an announced visit. I can tell you that we work jolly hard before an announced visit. If somebody is sitting in your ward or experiencing your services for weeks or months, they know every detail, including the state of the lavatories and exactly how things are going.
More formally, we also report to our board of governors or members’ council on our annual plan and our annual assessment. Our self-assessment declaration goes to the board of governors for its comments and those comments go to the Healthcare Commission. We are coming into a new system, but local accountability is now very strong. I listen to chairmen up and down the country, and they are quite frightened of these boards of governors because they know exactly what is going on. That is the whole point. The proposed new clause would, by implication, require every foundation trust to present its quality accounts alongside its financial accounts to the board of governors at an annual general meeting. This brings quality accounts into the regular accountability framework of foundation trusts. If the Minister agrees with the principle that we are elucidating in this amendment, I hope that the Government will come forward with a government amendment that would incorporate these principles in the Bill.
I understand that the Care Quality Commission will be responsible for setting basic standards for the registration of some 27,000 health and social care organisations, but that in future there will be two sets of quality standards. The second one will be some sort of standards or guidance established by NICE, encouraging a general improvement in the quality of care and trying to raise standards above the basic registration level. That is what I understand, but the Minister will correct me if I have that wrong.
Boards of governors will be pressing for information about these higher level standards or guidance that the trust should be attempting to meet. I would be grateful to know whether these NICE-developed higher standards will be incorporated into the quality accounts in some way, or evidence against those NICE standards will be incorporated into the quality accounts.
An important aspect of the proposed new clause, as the noble Baroness, Lady Murphy, indicated, is that the strategic health authority would have no role in relation to the accuracy of the quality accounts for foundation trusts. The strategic health authority has a clear responsibility for the performance of non-foundation trusts. There is no quarrel about that, and the Bill relates perfectly coherently to the reporting arrangements for non-foundation trusts. In a non-foundation trust, the chairman is appointed by the strategic health authority, and the chief executive officer of a provider trust reports to the strategic health authority as well as to the chairman. All that stops as soon as a trust becomes a foundation trust. There is no reporting line to the strategic health authority. I feel that it is somewhat illogical and confusing for foundation trusts to be sending material to the strategic health authority on quality accounts but on nothing else. There would be no context for that work.
I hope the Minister will agree to clarify in the Bill the accountability framework for foundation trusts. I understand that some consideration is being given to dealing with these issues in regulations. My concern is that the primary legislation is over and above any regulations, and therefore strategic health authorities may feel that they should receive the quality accounts to check accuracy, if it is indicated in the Bill. I like clarity and simplicity, and it would be helpful to have a separate clause to set out the accountability framework for foundation trusts.
As a provider foundation trust chair, I strongly applaud the accountability framework that we have. It is not that we have any old accountability framework, so we might as well fit into it; rather this accountability framework, with Parliament, Monitor and our boards of governors, has provided not only a simpler but a more robust framework within which we have to work. When people are coming from your wards and your community services and they are sitting in front of you and saying, “But it is not like that. I have been there and I have experienced it, and it is not good enough. What are you going to do about it?”, the fact is that you get on and do something about it, if you have the money to do so.
I thank the noble Baronesses, Lady Murphy and Lady Meacher, for tabling the amendment. I welcome the opportunity to explore in more detail the implications of the quality accounts for foundation trusts.
First, I acknowledge the role of Monitor and the CQC in helping the department over the summer to bring a bit of clarity on quality accounts. In fact, some of the outputs from their joint working which most impressed me—they were sent to me in September or October—bring clarity to what we are talking about here. I tried to explain earlier that there are sets of indicators in the quality accounts that are set by the regulator, the CQC, which remain the same and which will continue to be the same. There are sets of indicators that are part of the operating framework to which Monitor holds its FT accountable, and those will continue to be the same. There is also the third part of the quality accounts which I referred to earlier, the purpose of which is quality improvement. That is where the confusion is arising.
I see no reason why quality improvement information should not be shared with the regulator. If people want that to be the case, and that is the relationship between the FT and the regulator, that is fine; I am not in any way challenging that.
It is also very important to reiterate the purpose of the quality accounts as we have described them and as we have debated them with Monitor and the CQC. As I said, some components of the quality accounts are the vehicles for upward reporting to the regulators, although the Department of Health sees no role in that. It is quite important to put that on to the record, as I have done in the past and will continue to do so.
I reassure the noble Baronesses about the purpose of the quality accounts. I sympathise with the intentions behind the amendment, which presents a helpful opportunity to set out how we propose to develop the quality accounts in a way that complements the foundation trust lines of accountability, which is the issue that has come up. Again, I reassure the noble Baronesses that we do not want to cut across the current reporting lines of foundation trusts and their accountability to their local communities or in any way to reduce their independence. This Government created foundation trusts and this Government want to see more NHS providers obtaining foundation trust status.
I also reiterate that there is no hidden agenda. I have said that before, and it is quite important that I say it again. I will come back to some of the points that have been raised. The purpose of sending the quality accounts to my right honourable friend the Secretary of State for Health is simply to get that information and to put it on to the NHS Choices website. The noble Earl, Lord Howe, asked how we will share this information nationally. We have made a significant commitment to the NHS Choices website, which is the portal through which we will inform our patients in the future about the quality indicators in the quality accounts. That is its only purpose. We do not see our role as in any way holding these organisations to account on the content of their quality accounts; we are simply using that information to display them on the NHS Choices website.
When patients look at NHS Choices, they rarely base their choices on whether a hospital is a foundation trust; they base them on the quality of care that is being displayed. It is irrelevant to them who the regulator is. Most patients do not know what Monitor is. That is the purpose of seeking that information, and I hope that I have reassured the noble Baronesses about that.
As for setting this out in regulation, I believe that Monitor is keen to publish the quality accounts alongside the foundation trust annual reports. The regulations and guidance should enable it to do that. It is keen, as I said, that foundation trust boards and members sign off their quality accounts. That is perfectly okay; they have every freedom to go ahead and do so. It is a good practice that might be shared by non-foundation trust organisations.
We are trying to set up the framework that allows Monitor to obtain the overview that it needs. As I said earlier, we are working with Monitor on the details of how the arrangements will work in practice, having regard to the role of the CQC in relation to the components of the indicators that are relevant to it. I hope that I have reassured the noble Baronesses. I certainly do not accept the amendments as they are, but if noble Lords feel that the wording in Clause 7 is blurred, my officials are still talking to Monitor’s leadership, and if there is better wording, the Government are always there to see that. I do not accept, however, that the foundation trusts should have a completely different reporting structure. I hope, on that note, that I have reassured the noble Baronesses adequately and that they will not press the amendments.
When the Minister says that he does not want to create a different reporting and accountability structure for foundation trusts, the reality is that there is a different reporting and accountability structure. As I have said, for foundation trusts it is Parliament, Monitor and the board of governors. For NHS trusts, it is the Secretary of State and the strategic health authority, not Monitor. The structure is already different, which is my concern. I very much take the Minister’s point that the Secretary of State is purely putting the information on to the website, but what about the strategic health authority? Why should any information on a foundation trust go to a strategic health authority, when in no other respect is there a relationship between those bodies?
Perhaps I may assist. I cannot remember in which clause it appears, but the SHA and the CQC are able to go back to trusts to correct information. It is an interesting idea. I am not sure that there would be any information to correct. However, one clause implies that if the SHAs have the information, they can go back and say, “You sort it out”, which would be entirely appropriate for NHS trusts. I think that that is where the problem has arisen.
If the wording can be changed to add more clarity, I am happy to look at that. The SHAs correct the data that commissioners receive because, ultimately, they are performance-managing the commissioners, the PCTs. We have not touched on some of these data. Many Members of the Committee have consistently said that we need to strengthen commissioning. Commissioning cannot be improved without high quality information. We need this information to go to the commissioners. In this debate, the SHA’s role is very small, namely to ensure that the commissioners are receiving accurate information. The CQC will do the same. Noble Baronesses may want more clarity on that, and I would be happy to bring that back to them.
In view of how the debate is emerging, I seek further clarity. If the Minister is minded to negotiate agreed words with Monitor, the one thing that we, the CQC, as the quality regulator, would be concerned about, on our behalf and on behalf of the public, is that we have a commonly agreed format for the basic core of quality accounts across foundation trusts and non-foundation trusts. If we end up with a different format between the two because it was agreed by Monitor for the foundation trusts and by the Secretary of State for the non-foundation trusts, that would be incredibly confusing to the public.
All of what the noble Baroness has suggested will be in regulation. I have consistently said that the content of the quality accounts will be brought back in secondary legislation, at the regulation stage, to determine exactly the whole system—the whole landscape—which includes the CQC, with its major leadership role in this area, and Monitor and the others. That is what we intend to do. I am trying to give further clarity to reassure the noble Baroness on her concerns about the strategic health authority and Clause 7.
I thank the Minister for that very helpful reply in respect of the three aspects of the quality accounts. It is now much clearer. I also welcome the statement that it is perfectly in order for us to encourage foundation trusts to report quality accounts with financial accounts along the accountability structure. That is very helpful. I now understand why SHAs are in the Bill. No one would guess that I was a former chair of a strategic health authority. They are a necessary part of the process, even though some people do not think so. I have every respect for the task that they do in developing commissioning. I understand that the commissioners must have the ability. Perhaps there could be some wording about accountability and who comes back, which might be the commissioners, the PCTs or whoever. I do not know, and I do not want to invent amendments on the spot. Perhaps there is some flexibility in how it is expressed.
I wholeheartedly agree with the noble Baroness, Lady Young, that we must ensure that the material that is presented to patients, clinicians, managers and the wider regulatory system is consistent and comparable. It would be crazy if anything else was the case. I wholeheartedly thank the Minister for that full response, and I beg leave to withdraw the amendment.
Amendment 35 withdrawn.
Amendment 36 not moved.
Amendment 37 had been withdrawn from the Marshalled List.
Amendment 37A not moved.
38: Clause 6, page 4, line 35, at end insert—
“( ) The Care Quality Commission shall, in a manner which the Secretary of State shall prescribe, review and report on the accuracy and completeness of any information contained in a document published in accordance with subsections (1) and (3).”
In moving Amendment 38, I shall speak also to Amendment 49.
These amendments share the same theme. They attempt to focus on what I see as a critical issue in the area of quality accounts, which is audit and validation. I mentioned in the last but one group of amendments my concern about the absence of any systematic check to ensure that information published by a trust does not mislead the public, either because it contains errors or because, intentionally or not, it conceals information that really matters and that would, if made known, cast a different light on the quality of that trust’s performance. At the moment, all that we seem to have in the Bill is a provision in Clause 7(3) which says that if the CQC or a SHA happen to spot something inaccurate, they can flag it up and get it corrected. That looks like a hit and miss approach, which does not seem to get to the heart of the problem.
I am proposing two ideas here. They are not mutually exclusive. One is that the CQC should be given an explicit duty to audit the accuracy and reliability of published quality data, as part of its inspectorial role. That would provide a measure of quality assurance that stemmed from an independent outside check, which I believe would give added reassurance to the public. The other idea is a bit more subtle. It is to suggest that we should try to embed in the NHS a system of quality assurance that relies on the accreditation of providers with professional outside bodies, such as the royal colleges. The attainment of accredited status would act as living proof that the services provided by a trust were of a high quality across the piece, because it would demonstrate that there were standards of training and professional attainment underpinning everything that the trust did. Equally, the quality of the information published by a provider would be shown as having an element of independent validation.
In other words, instead of relying completely on an ex post facto audit by the CQC, we should encourage trusts to attain the requisite standards of best practice and to be professionally accredited for doing so. This is what happens in industry. We need the equivalent of an ISO 9000 in the health service. It is the difference between ticking boxes or crossing items off lists and motivating staff and management to up their game and to focus on training and self-improvement. What affects quality adversely is staff errors and staff incompetence. Tick-box systems do not deal adequately with those things. In industry, you do not find tick boxes or lists of things which people have to do. You find that businesses work to accredit themselves with recognised independent bodies, to prove that they actually do what they boast of doing.
A system of accreditation in the NHS would avoid the need for the CQC to keep verifying minimum standards in a number of areas and would, I hope, generally make its job a lot more streamlined. I think particularly here of areas such as general practice, which I know is regarded by the CQC as quite a challenge in terms of the resources needed to register and regulate every GP in the country. A system of accreditation with the Royal College of General Practitioners might be an effective way of reducing this burden to a minimum.
There are other areas where, even with the best will in the world, the expertise of the CQC may be tested to the limit. I have in mind laboratory medicine. The CQC will be responsible for registering all providers of medical services, including diagnostic services. As regards diagnostics, registration will be based initially, we understand, on self-evaluation against defined standards, including intelligent use of quantitative outcome data. On-site inspections will be carried out according to perception of risk. They will not occur in all circumstances. In any event, registration will require only compliance with “bare minimum standards”. The CQC is using that phrase. I may be doing it injustice, in which case the noble Baroness, Lady Young, will tell me that I am, but it seems inherently unlikely that the CQC will have the capacity to assess the detail of specialised services such as diagnostics. It has said that it will be delighted to see organisations gain accreditation for the services that it provides, such as CPA accreditation for medical laboratories.
Contrary to the recommendation in the recent report by the noble Lord, Lord Carter, on NHS pathology, this accreditation will not be mandatory. I have to say that that concerns me, and one has to wonder how the performance of non-accredited laboratories will be covered by this system.
There is a perception, which I believe is quite widely shared, that those responsible for commissioning NHS services have a poor understanding of what represents quality in laboratory medicine. The noble Lord, Lord Carter, has called for better commissioning guidance and model contracts. He is surely right about that. I find it alarming that long-term contracts can currently be agreed for the provision of medical laboratory services without it being a mandatory part of the contract that there should be compliance with accreditation standards. I shall be interested to hear the Minister’s reaction to these ideas. I hope that he will agree that there are two genuine issues to be addressed. One is on auditing the validity of published information; the other is on verifying and validating the quality of a trust’s performance outside the relatively narrow sphere of its published data. Both are of key importance, and neither is dealt with in the Bill. I beg to move.
The Addison rule was written for a purpose, and this is the moment it was written for. I know it is intensely annoying for the Minister if the chairman of the Care Quality Commission keeps leaping to her feet and explaining things that really are in his provenance, but I cannot leave the amendments of the noble Earl, Lord Howe, unchallenged.
First, I shall say a couple of general things about quality accounts. The Care Quality Commission absolutely welcomes the initiative and very much recognises what the noble Lord, Lord Darzi, is trying to achieve. Indeed, it has been very pleased to have the supporting information from noble Lords on the implementation of quality accounts, which I think makes it very clear how CQC’s regulatory information will form part of the quality accounts and how CQC will be involved in determining the content of quality accounts. It very much welcomes that.
On Amendment 38, the noble Earl, Lord Howe, is right to say that the accuracy and completeness of the information in quality accounts needs independent verification. However, I do not think that it is a job for the CQC. The job that needs to be done is the equivalent to getting the bean counters in to make sure that your financial accounts are right. We do not want to be bean counters, even in a quality context.
The Care Quality Commission thinks that there is a job there, a good market niche, for the variety of account validators that has sprung up around accounts. For example, environmental accounts are now audited by environmental accounting auditors. It supports the view that the accounts need to be independently verified, but it does not want the job of doing it, thank you very much. Under Clause 7(3), if the Care Quality Commission spots something a bit off beam or not correct, it can challenge it and have it changed, and it welcomes that role. However, the Care Quality Commission does not want to be the comprehensive independent auditor of quality accounts.
I shall comment on the statements made by the noble Earl, Lord Howe, about accreditation. Accreditation has huge value and is an opportunity in a variety of ways to help encourage providers to take responsibility for the quality of the services that they provide. The Care Quality Commission has been having some interesting conversations with the Royal College of General Practitioners about how the college’s voluntary general practice service accreditation proposals could be used to reassure the CQC, as a regulator, that the service is of good quality. That will depend on whether the accreditation process can be made sufficiently comprehensive to cover all the bases that the Care Quality Commission needs covered, but it will be taking that forward with the Royal College of General Practitioners. If there was a good accreditation scheme generally in use across a service, it would encourage providers to take part in it. The Care Quality Commission would expect to spend more time with services that did not offer that accreditation reassurance than with services that did. For example, the pathology scheme, which is excellent, needs to get to a point where all providers of NHS pathology services are accredited under it.
I agree wholeheartedly with the view that accreditation should be a part of the regulatory toolkit, but please do not make the Care Quality Commission a bean counter. Since I have to keep the Minister happy, I should say that we are now 33 days away from the Care Quality Commission.
Amendments 38 and 49, tabled by the noble Earl, Lord Howe, discuss the role of the Care Quality Commission. I will consider each amendment in turn. Amendment 38 gives a formal role to the Care Quality Commission in auditing each organisation’s quality accounts. I share the desire of the noble Earl that quality accounts should be accurate; otherwise they would be meaningless. The most effective way in which we can achieve that is by working with provider organisations to develop assured indicators in the first place. That is where we are at the moment. We must ensure that we have an assured indicator across the system. We believe we have the tools to measure that. Our regulations and guidance will then set out options for producing a meaningful set of quality accounts.
Providers will be required in regulations to confirm that the content of their quality account represents a trustworthy and reliable view of the services they offer. There will be no requirement for the quality accounts to be formally audited, as the noble Earl pointed out, but we wish to encourage providers to seek external validation on a voluntary basis, perhaps from their local PCT, local involvement network or even the local authority. This is not a novel approach; anyone who has ever filled in a tax form will have come across it. Quality accounts are, however, not about the heavy hand of regulation but about adding to the drive for quality improvement.
The Bill provides that a provider must change its quality account if any errors are brought to its attention by the Care Quality Commission—part of the quality account is the indicators that the Care Quality Commission measures—its local SHA or Monitor, if it is one of the tier 1 indicators on the operating framework. So the data are already reported to the regulators and commissioners, and there is simply no need for an additional audit of that component of the data. On the other component, which is mostly about the indicators for quality improvement, most professional bodies and a lot of national audits that are currently in the system have an assurance framework to ensure that the data collected is accurate.
I turn to the role of the regulator. I certainly agree with the noble Baroness that it should not spend its limited resources on this quality assurance exercise but should channel its energy mostly into acting on what the data says. Any significant quality issues should already be clear to the CQC through the registration process and should merely be reflected in the quality account. Should any significant new issues be raised through a quality account, the CQC has powers to investigate.
Data being collected centrally is only a part of what quality accounts are to achieve. Our vision for quality accounts is to encourage the culture of measurements with the purpose of quality improvement. I do not believe that that should be a centralised performance management issue, but mostly about empowering clinicians, with the information that they collect, and helping them with quality improvements.
That is not in the legislation, but if a provider wished to share its quality account in a draft report before it is published, we would encourage that as an assurance exercise. It may share that with the commissioner, LINks or other organisations at a local level for that purpose.
Why should we not make it a requirement? Surely, PCTs or other local health-related organisations would be sounding boards in an area. Perhaps they might wish to qualify it, prior to submission to the Secretary of State. They might want to argue with the trust or the local provider that they have not necessarily got the facts right, or they might want to challenge something. Is it not better to have the challenge at that stage rather than when the Secretary of State finally makes the document available to the public?
The role of the Secretary of State is to get that information and to make it available on the NHS Choices website. That information would be made public by the board of the provider. The legislation would ensure that every board publishes its quality accounts locally for accountability and transparency reasons. We shall return to a few of the amendments later.
I understand that, but the issue is the wording that goes to the Secretary of State in the account. The provider might want to change something in the account prior to submission to the Secretary of State. I understand that it is made available later, but that might be too late.
If a PCT identifies a mistake in the information in a quality account or if the CQC identifies an issue in its indicators, the quality account has to be changed. If a provider does not wish to embarrass itself by publishing inaccurate information, we encourage it to check that information before publication or to be sure of it at a local level.
The underlying aim of Amendment 45 is to ensure that regulation does not impose an unnecessary burden on service providers. I am sure that all Members of the Committee can agree with that aim. I certainly can, as a clinician working in the health service. We have committed ourselves many times to ensuring that regulation is proportionate. That is why the Health and Social Care Act allows the Care Quality Commission to use any information that it wishes to use when determining whether a provider should be registered. It is also why Section 67 of the Act requires the commission to promote the co-ordination of reviews and assessments and the sharing of information. However, this does not mean that we need to prescribe exactly how the commission should carry out its functions or what place information from accreditation schemes might have alongside other relevant information in enabling the commission to reach a judgment.
Members of the Committee may remember the long debates that we had last year about ensuring that the Care Quality Commission is an independent body. We have to ensure that it can act independently, which means that its decision-making processes must be unfettered. It must be able to reach its own judgment on the suitability of a provider to be registered, and it can do that only if it has all the information that it judges to be necessary to determine whether that provider complies with the registration requirements and whether it should apply conditions to a provider’s registration.
Accreditation schemes may be developed for very different purposes from registration. As a result, they may focus on different aspects of performance from those on which the Care Quality Commission focuses, or even on driving improvements rather than ensuring that essential levels of safety and quality have been met. Many professional bodies, such as the royal colleges and others, have had a role in accreditations in the past.
We cannot expect the commission to use only one piece of information when reaching a decision. Nor can we put into place arrangements that mean that it registers a provider simply because another body, such as a royal college, may have provided that information for accreditation purposes. We must not prevent it from following up any issues identified as part of its data analysis. No matter how good the assessments of others might be, the commission must be free to use all the available information that it feels fit to use, and follow that up in whatever way it sees fit.
The commission is required under Section 4 of the Health and Social Care Act to work in a risk-based and proportionate way. It has already committed itself to working closely with partner organisations to develop an approach to registration that draws on existing systems of assurance and sources of information that are relevant to the registration requirements. It is already working with a range of stakeholders to develop its methodologies, as the noble Baroness pointed out earlier, and will consult widely on these in advance of implementing them.
I am grateful to the noble Earl for giving me the opportunity to clarify the role of the Care Quality Commission on those two important aspects. I also hope that I have reassured him on the quality assurance of data outside the context of the CQC indicators or the operating framework. If I have done so, I hope that the noble Earl will be able to—
Can the Minister clarify the Government’s perception of what have been the Healthcare Commission and Standards for Better Health returns from all these provider trusts? He focused closely on the CQC and the registration criteria. Does he envisage some sort of quality returns at this higher level to the CQC or elsewhere? I am not clear about that.
I do. The regulator has played an extremely important role in quality improvements and will continue to do so. Anyone who wishes to be involved in quality improvements should be encouraged to be so, whether they are regulators or clinicians working on the front line. This is an inclusive space. The exclusive role of ensuring that core standards are met will have to remain with the Care Quality Commission.
I hope that the Minister will agree that the purpose served by amendments of this kind is to enable us to look at issues, rather than to suppose that the wording of the amendments should literally be transposed into legislation. That purpose has been well served by this short debate and particularly by the Minister’s reply, which I found very helpful and largely reassuring. He spoke about assured indicators and the wish to see a voluntary audit, and I was glad of that.
The noble Baroness, Lady Young, endorsed the principle of an independent audit, even if she did bat back at me the proposal that the CQC should be tasked with this job. The fact that she did bat the idea back at me is helpful in itself. It will indicate to those who have been actively thinking that this might be a role for the CQC that they had better think again. I was grateful for her support on the role of accreditation, where all that she said indicated to me that we were speaking the same language. I very much welcomed what the Minister said on this area as well.
I take on board the Minister’s point about being prescriptive. I did not wish to imply that accreditation would or could be a substitute for proper assessment by the CQC or whether a body should be registered. The point of the amendment was to air what I know is a live concern in the CQC: how to make regulation proportionate and as unburdensome as may be reasonable in individual cases. I hope that the Committee will feel that we have broad consensus on this. I certainly do. I am happy to withdraw the amendment.
Amendment 38 withdrawn.
39: Clause 6, page 4, line 40, at end insert—
“( ) In this section to “publish” includes to make available to the public by means of a website.”
In moving Amendment 39, I shall speak also to Amendments 41 and 42.
These amendments all have to do with one thing, which is the need for NHS providers, as well as the Government, to make sure that information on quality and performance in the health service is readily available to the general public. One of the best ways of making information available to the public is electronically, through websites; but you have also got to let the public know that those websites exist. We cannot tell doctors, for example, what weblinks to set up with partners in the health service, what notices to pin up in their surgeries, or what leaflets and brochures to have on display; nor can we tell this to public libraries. It seems to me that trusts and secondary providers in the independent sector should be encouraged to broadcast the existence of their quality accounts in this sort of way; in other words, not just in their own waiting rooms but in the community as well.
When we talk about the community, we always need to bear in mind the hard-to-reach groups and those who most need to know where best to go for the services that they require. The elderly, the disabled and those with mental health problems all need to be empowered by quality accounts, and ways have to be found of ensuring that they have access to them. This means health providers being especially proactive on behalf of those groups in society.
The Government, too, will have a responsibility to ensure that the public know about and can easily access quality data published by the Secretary of State. Amendment 41 endeavours to address a particular issue that is relevant in this context and which I believe to be important. Unless people can relate the information in front of them to some kind of external comparator, its full meaning and significance will not be apparent to them.
The danger with a set of quality accounts published at any level, but especially at the national level, is that in setting out information about how a trust, a region or the country as a whole is performing, they may not show to the uneducated reader how creditable or poor that performance is when measured alongside relevant benchmarks. Those benchmarks could be either international comparators or indicators that are evaluated or devised by a body such as NICE and which endeavour to arrive at a gold standard of performance that could put the information contained in quality accounts into a meaningful context. If relevant comparators are not built into the outcome measures contained in quality accounts, there is scope for people to believe that quality is embodied in the performance of the best performing trust in the country. That may not necessarily be so.
Equally, it should not be open to the Secretary of State of the day to make out that quality consists of whatever he defines it to be. The system needs to have checks and balances built into it, and I suggest that NICE is probably the body that is best equipped to devise or to validate the comparator measures that are chosen for this purpose.
I hope that the Minister will understand what has prompted me to table these amendments. I beg to move.
The amendments laid by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, would require that duties in the Bill to publish quality accounts include publication on a website and set out defined routes for discharging these duties.
As I said earlier, the Bill requires providers to submit a copy of their quality accounts to the Department of Health for the explicit purpose of making the quality accounts available to the public. I reassure the noble Earl that this is the method through which information from the quality accounts will end up on the NHS Choices website. The website is the ideal place, because it will provide that comparative information from all providers at the local level, the regional level and even at the national level.
Subsections (6) and (7) of Clause 7 already make provisions to provide information on the manner in which patients and the public may access a copy of the quality account. However, we are also discussing with trusts, patient groups and regulators what else we can do besides publishing the information on the NHS Choices website and how we can ensure the effective public availability of quality accounts without overburdening the NHS. Our guidance will set out how this is to be achieved. It will, I hope, be reasonable and appropriate, which is exactly what the noble Earl, Lord Howe, wishes to see and, I think, seeks to achieve in Amendments 39 and 42.
Amendment 41, which has been laid by the noble Earl, would impose on NICE a role in helping people to understand providers’ quality accounts. Again, I appreciate his desire to see comparability between quality accounts, but I do not believe that NICE is best placed to do this. We put a lot of thought into this and consulted on it when we published High Quality Care for All. NICE has done a wonderful job in setting standards and in looking at the evidence base and making it available. I felt at the time that the best way of providing this comparative information was to work through the quality observatories at the regional level and at the national level through the National Quality Board, on which NICE, the CQC and Monitor are represented. In that way we can develop the systems and tools by which we will make that information much more comparable and digestible from a user’s perspective.
I refer again to what is in the quality accounts. I think I have said before that they will include some of the indicators that are part of the operating framework. MRSA infections were one such indicator. That will be there, and there will certainly be comparable data for the indicator, as measured nationally. The CQC’s data on safety and quality and measuring compliance against their registration requirement will also be available and will be comparable. There are numerous examples, one of which might be how providers are ensuring that any patients who need help with eating and drinking receive it and whether providers are ordering, handling, storing, administering and disposing of medicine safely.
The example I should like to bring in now, which is much more relevant to what the noble Earl said, is the role of NICE. One indicator within quality improvement will be the percentage of patients admitted with heart attacks who, on discharge, are prescribed an anti-platelet agent or a statin. NICE has the evidence base. In setting that, we need an assured indicator on which we can measure whether a provider publishes that in its accounts. We will encourage that. This is exactly the type of quality improvement measure that could be part of the quality accounts.
I hope I have clarified that it is our intention to get this information as widely, as accurately and as comparable as possible. Ultimately, we are trying to empower patients with the information that they need to make those choices.
Could the Secretary of State block a quality account before it is made available to the public under Clause 7(5) on the basis that he does not want particular information to be published in that report? I understand that there will be a series of regulations requiring what information can be made available. But once that is done and the account has been sent to the Secretary of State, does he have that power?
I need more clarification. The Secretary of State has no powers in withdrawing the quality accounts for foundation trusts. The different providers may have different rules in legislation. I will look into that and will get back to my noble friend.
I am reassured to learn that the Minister has every intention of seeing that relevant information will be published on the NHS website, which is an extremely important outcome. I agree with him. I do not think that NICE is the appropriate body to look at this issue. After all, NICE was established to look at physical, psychological and pharmaceutical interventions in the NHS and to work out the cost-effectiveness of these procedures in order to determine which one should be provided under the NHS. It is not NICE’s role to assess quality accounts or their outcome. However, will the Minister give us any information about the proposed constitution of the National Quality Board, which clearly will be very important in undertaking this monitoring task of the quality accounts when they are published?
There might be a difficulty if a hospital, a trust or whatever, which was operating under the auspices of the commissioning regime of a PCT, was not implementing NICE guidance—for example, in relation to particular drugs or therapies—and NICE then had to look at the quality of the outputs of the hospital. Does the Minister see the problem that might arise and how would that be dealt with?
I shall try to answer, first, the question about the National Quality Board. Membership of the board is within three major contributors: national bodies, including the Care Quality Commission, Monitor, the National Institute of Clinical Excellence and, I hope soon, the National Patient Safety Agency. I have no doubt that I have omitted one or two bodies. There will be expert groups in quality, which could be from academe or from international organisations. I understand that the appointments commission is going through interviews at the moment. Finally, there are patient groups and lay representatives, representing patients and the public.
On the question of the noble Baroness, Lady Barker, about NICE guidance: that is exactly what we are trying to achieve. You can get quality improvements only if you start looking at the evidence base, the guidance and guidelines. The bit of NICE that has never been openly debated is, mostly, the appraisal of drugs and devices. NICE has a much bigger role, which has been well recognised internationally, in the guidance and the evidence base. Through this process, we will encourage more uptake of NICE guidelines in designing pathways of care. That was the whole ethos of the next-stage review: eight pathways of care and 10 regions challenging themselves over what NICE has published on the latest evidence on patient care over the past decade.
Clause 6(1) refers to each body listed publishing a document; that is,
“publish in respect of each reporting period”.
Then, Clause 7(4) refers to:
“A copy of any document published”,
and goes on to talk about them being “available to the public”. Does that mean that both of these bodies will be in a position to publish? If a report can be blocked in the circumstances of one particular provider, how can it be blocked if the provider has the power to publish the material already under Clause 6(1)? It does not matter if my noble friend answers the question now; it is on the record. Perhaps officials could look at it and clarify the position on Report.
I welcome the Minister’s valuable assurances on this topic. I am glad that the noble Lord, Lord Walton, intervened to ask about the National Quality Board. Until the Minister replied, I had a feeling that there might be an in-house feel to the National Quality Board. That is clearly not the case, and I am grateful for that clarification.
I proposed NICE to be the body that proposed comparator measures because it is a widely respected organisation that works independently from the department and Ministers, the essence of its role being to assess evidence and its validity. Nevertheless, there are other mechanisms to achieve the same end, and we will watch with interest to see how the noble Lord’s plans progress. As with other areas in this Bill, there is a definite feeling of work in progress. I dare say that, when the Bill reaches another place, we may be a little further forward in knowing quite what the shape of things to come will be.
This has been a useful exchange. I am grateful to those who have taken part in the debate and beg leave to withdraw the amendment.
Amendment 39 withdrawn.
Clause 6 agreed.
39A: After Clause 6, insert the following new Clause—
“Quality accounts domains
(1) Each of the bodies listed in section 6(2) must publish information under the following domains—
(a) patient safety;(b) effectiveness of care;(c) patient experience.(2) Under the domain listed in subsection (1)(c), the Secretary of State must arrange for the development of measures to assess the dignity of the patient.
(3) Each of the bodies listed in section 6(2) must report on the dignity measures under the patient experience domain.”
I first apologise, because I did not notice that this was grouped earlier. I thank the Committee for allowing me to speak briefly.
This is a probing amendment: an attempt to clarify the information that needs to be published to ensure that we capture the deficit of dignity in care. I know that the Minister is committed to quality accounts focusing on the patient experience, but this is about ensuring that dignity is at the top of the agenda. It is a big concern for the charities Help the Aged and Age Concern. However, as a commissioner on the Equality and Human Rights Commission, I am concerned, under the banner of human rights, for any vulnerable person not having the dignified care that they deserve and which should be guaranteed under this constitution and the new approach that we are discussing. I hope that the Minister can reassure me that this will be looked at carefully and clarified so that it is available.
I am grateful to the noble Baroness for giving me the opportunity to address the Committee about the possibility of having a dignity, compassion and respect indicator within the quality accounts. To reassure the noble Baroness and noble Lords, if we look at the domain of patient experience, we have much more work to do than the historic patient satisfaction surveys. I strongly believe that dignity and respect should be part of the patient experience domain and should reflect the experience of the patient, not only in receiving care but in the way and environment in which that care was provided. The noble Baroness is aware of our major campaigns on dignity and respect. We can run any campaign, but the quality account is the way we measure whether we have achieved anything through them. I am very grateful to the noble Baroness for tabling this amendment, and I hope I have reassured her that the patient experience domain of the quality accounts will address those important aspects of care as we move into more personalised care and personalised provision.
I have always had a fairly radical view about this. I do not think anyone could work in health or social care without having the attributes of treating people with dignity and respect. If an issue arises, I do not think the quality account is the way for redress, but it provides information to the users of the service. Ultimately, any health or social care provider is accountable to its local population. If that information is captured through an independent assessment of the patient experience, where dignity and respect had been challenged in a provider, there are two ways patients can exercise their choice, but the complaint element could be addressed through other mechanisms.
I am sorry that I did not bring this up earlier. Patient experience is not purely information captured from patients; it is captured from their families, their carers and other people involved in their care. Patients and their relatives will have other ways in which they can capture that information. I could not agree more about some of the more senior citizens receiving healthcare.
I thank the Minister for that reply and for the commitment to this that he emphasised. My noble friend Lady Murphy indicated to me that she has raised these issues before. They are terribly important and have played an enormous part in my life over the past few years, emphasising the sometimes horrific lack of dignity of some of the most vulnerable people who need health or social care, particularly healthcare. I thank the Minister for his commitment. I beg leave to withdraw the amendment.
Amendment 39A withdrawn.
Clause 7: Supplementary provision about the duty
40: Clause 7, page 5, line 7, leave out “notify” and insert “notifies”
I hope the Committee will forgive me for descending into the realm of drafting detail, but Clause 7(3) contains the word “notify” as a plural verb applying to the subject of the sentence. Both the CQC and an SHA are singular entities in statute law. If they are separated, as here, by the word “or”, the verb should be singular. Equally, at the start of Clause 8, I cannot make sense of subsection (1) without adding the number “6” after the word “section”. I hope I am right about that, but if am not, I should be glad to know why. I beg to move.
Amendment 40 agreed.
Amendments 41 and 42 not moved.
42A: Clause 7, page 5, line 25, at end insert—
“( ) enabling the Secretary of State to require bodies to publish additional joint thematic documents.”
I shall speak briefly. The amendment is probing of an idea, which I hope will get some favour from the Minister and others. Some of it has already been addressed in a different way. As currently worded, the Bill will require both the trust and the primary care trust to produce separate annual quality accounts with indicators about how each is doing locally.
The amendment asks why not allow trusts and PCTs to work together to produce additional joint accounts on specific issues, for example maternity services. That would surely encourage NHS bodies to work together more collaboratively. Allowing for reports on specific themes could act as a tool for bringing both sides together to work on problem areas. It would also be potentially more useful to members of the public, many of whom are unlikely to understand why they are split.
In addition, the Secretary of State can require such documents to be used as a tool to secure service improvements in problem areas, particularly by making the commissioner and provider work together. If maternity service quality accounts were found to be problematical and deficient in some areas, the problem may lie in the commissioning process of the quality of services. Expecting PCTs in such circumstances to produce quality accounts of all maternity units, together with any others, might go a long way to identifying external bodies, including the CQC, and finding out whether the commissioning is a problem. I beg to move.
I shall speak to Amendment 43 in the group. It is a simple amendment about consultation and inclusiveness. I have no doubt that the content and format of quality accounts will evolve over the years as we get better at using them and discover more of what we want from them. At the same time, one of the things we want to avoid is for changes to the form and content of quality accounts to take place too often. When they do take place, they should be the subject of broad agreement among stakeholders or, at the very least, stakeholders should be given an opportunity to express their views about any proposed changes before they are set in stone. Part of the value of quality accounts will be derived from the trends they highlight over time. It would be highly regrettable if it becomes difficult or impossible to discern these trends because of frequent changes to the content of the accounts. I should be glad if the Minister could offer some reassurance to the Committee on that point.
It would also be helpful to hear from the Minister that healthcare providers will not be subject to constant chopping and changing in terms of the quality data they are required to supply and publish. Equally, they should not be required to collate a greater and greater volume of mandatory metrics and indicators. I am not in favour of having more than a certain amount of prescription from Ministers in this area, partly because on principle I think that we should keep prescription to a minimum and partly because I believe in clinicians and providers taking ownership of the data that they produce and making them relevant to them and to the patients whom they serve. With those thoughts uppermost in my mind, I look forward to the Minister’s reply.
I have some questions about the amendment of the noble Lord, Lord Patel. The issue of joint thematic data is extraordinarily interesting, particularly in mental health services and in care-of-the-elderly services, both of which I am the most familiar with. So much of the quality of what goes on in the healthcare domain is determined by the overall integration and co-ordination of health and social care. Sometimes it is quite difficult to extract the quality of care that an individual has received from information that is wholly documented in the NHS.
I know that the Care Quality Commission will have the powers to have joint thematic reviews and focused investigations across the domains, which is very welcome indeed. We all feel that that is one reason why it will be an advantage in this respect. However, I wonder how we might deal with the fact that care quality accounts will be healthcare-focused and whether the Minister and his team have thought through some of the more difficult issues in relation to mental health care and social care, which are so vital for long-term conditions.
The amendment moved by the noble Lord, Lord Patel, would allow my right honourable friend the Secretary of State to direct providers who jointly provide services to publish a quality account that looks at the quality of the service as a whole, regardless of their institutional boundaries. If I have read the noble Lord’s intentions rightly, this would enable us to compel, say, two trusts that regularly treated cancer patients on a single pathway to report jointly on a cancer services theme. I could not agree more. Ultimately, if we are measuring quality through the patients’ eyes, patients do not see these boundaries.
This is a challenging area, which is why I felt that we should have quality observatories. This is not just an analytical power. They could also, through that analytical power, see whether they could look at certain indicators in a more joined-up way. We are trying to achieve something similar. This certainly becomes extremely relevant for in-patients with long-term conditions and for in-patients for whom there should be more of a shift towards care in the community rather than in a hospital setting. That in itself is a reflection of quality. The prevention of readmissions and the acute exacerbation of chronic long-term conditions is a good example of that. We need to put significant thinking behind this. The purpose of the amendment is right, and we should do this.
I do not feel that the quality accounts should be combined: I feel that we could have certain indicators that measure the whole pathway of care. In other words, we could include primary and secondary care. If we can get that right, I have no doubt that that in itself will align different providers to look at the processes. As we know from a patient’s perspective, 80 per cent of the problems occur because 20 per cent of the processes are wrong. We have demonstrated that on many occasions. The amendment is the right way in which to go, but I am not sure that combining the two quality accounts is the right way. We should first look at indicators that go across pathways and perhaps ask the two providers to report on them in their quality accounts.
Some work has been published on so-called aggregated indicators that look at different parameters and come up with what we call a lagging indicator that looks at the whole pathways of care. One of the other purposes of the National Quality Board is to have a sub-committee that is the technical expert committee that will look at the possibility of developing indicators that go across primary and secondary care or even health and social care.
The noble Baroness, Lady Murphy, referred to the National Quality Board also having a role in developing the indicators for social care. That is down the line. It is what the report said and is what we want to work. That is why the CQC’s presence and leadership on that board is very important.
I listened very carefully to what the Minister said. The fear that it set off in my mind is that where there is poor practice in an area—let us say a geographical area has poor practice in relation to maternity services—is there not a possibility, given what the Minister has just said, that the production of joint thematic reports simply enables the commissioner and the provider to reinforce whatever is the source or cause of the poor practice, rather than having two separate reports that can begin to flag up where the problems lie, in particular if care pathways are not working properly? There is a problem there.
I agree with that, but neither do I want to take the accountability off a provider by saying that it is someone else’s problem. That is the problem when it comes to the quality accounts. We need certain indicators that we can develop on the back of the quality observatories that would empower the commissioners with that information. The commissioner will then challenge the two providers in relation to the integration of care.
To seek more clarification, say that a maternity unit in a given area is found to have problems in the quality account, it may well be that the commissioning process is at fault and therefore that maternity department is not able to deliver to the required quality. The poor quality account in one maternity unit could act as a surrogate to identify that the problem exists in other maternity units too, and the root cause of the problem lies in the commissioning process being weak.
I am grateful for that clarification. Essentially, the noble Lord is asking whether a commissioner should have a quality account. The answer to that is that it should not have a quality account. There is a framework for assessing the quality of commissioning, which is the world-class commissioning framework. There is an assurance exercise that PCTs are going through. To reassure the noble Lord, there are now indicators looking at the performance of commissioning, which is something about which many noble Lords here have expressed concern. To be fair to the PCTs, as I said before, they are two and a half years old. We have in place the indicators that the noble Lord is referring to. It would be interesting to link the performance of the PCTs with the performance of their providers.
I do not wish to labour the point, but say there is a situation in which a practitioner in the provider trust believes that good practice is dependent on a practice, an innovation, a piece of technology or a particular drug therapy and the commissioners do not. How is the resolution of those two different things brought about by the production of the quality account? Or is it not?
That information, through the quality accounts, will be available to the commissioners. One statement about commissioners and providers which I have sometimes found challenging—we debated this before—is that the best services are usually provided by the commissioners and providers coming in to a strategic partnership and designing the quality of services that they wish to see. That is what I hope the quality accounts will allow, and they will drive that. If I can cite personal examples, I remember numerous cases when I started using robotic surgery. The commissioners were not happy with that, but I had the assurance of all my effectiveness and safety data, and certainly my patients did. Patients usually drive innovation if they are empowered with that information. They jointly sit with the commissioners and decide the quality of services they want to provide to their local population. Information is what brings people together to ensure that they are commissioning the type of services that the provider is able to provide.
I do not believe that that is what I said. The quality improvement also needs the support of the commissioner. I hope that, with the transparency of this information, if providers are embarking on a quality improvement exercise they should encourage their commissioners to be part of that partnership. To be honest, we have seen examples of this in social care. Best provision usually happens when commissioners are working with providers strategically and jointly. I do not think that providers would be critical of commissioners. It will encourage commissioners and providers to work closer and better together.
Thank you. The amendment tabled by the noble Earl, Lord Howe, places my right honourable friend the Secretary of State for Health under an obligation to consult bodies and persons he deems appropriate when preparing regulations that we will be drawing up later this year.
The Secretary of State is under existing duties to consult in the development of policy and secondary legislation. There will therefore be extensive and inclusive consultation in developing our ideas in this area. This has already started in relation to the assurance exercise. I appreciate the noble Earl’s vigour in reminding us of this important consultation, but I reassure him that development of policy in this area is very much a collaborative effort with our stakeholders.
I also agree with the noble Earl in his reference to changes indicators. I have reminded the Committee before that quality is a moving target, and we constantly need to challenge ourselves with finding the new indicators that we must develop to measure it. We hope to do so through the National Quality Board, some of whose main functions are to develop new indicators and even to assess some indicators which may not be valid in the future. I hope that it does so at a national level in consultation with the CQC, NICE—the standard setter—Monitor and other stakeholders, including patients. I hope that I have reassured the noble Earl.
I am grateful to the Minister. At the same time, he will recognise that there is an anxiety out there that bodies will be told to change the information that they are supplying from year to year and that no sooner than they get used to one set of indicators they will have to alter them and move on to another set. There is a value for the public, and certainly for Ministers, in looking at trends, as I mentioned. As we often say in these debates, there is a balance to be struck. I take on board that the Minister said that we will find newer and better ways of measuring things. However, I ask him to bear those points in mind.
Amendment 42A withdrawn.
Amendment 43 not moved.
44: Clause 7, page 5, line 34, at end insert “but does not include a private dwelling house or premises to which the public do not normally have access”
Amendment 44 can be dealt with briefly. Under Clause 7(7),
“the provider must keep affixed, in a conspicuous place at each of the premises at which the provider provides services … a notice stating how the most recent document published by the provider under that section may be obtained”.
Members of the Committee should note that the wording specifies “each of the premises”. Under subsection (8), we realise that the Government really mean business. Subsection (8) states:
“In subsection (7) ‘premises’ includes a vehicle or moveable structure”.
As you are being carted off in an ambulance wondering whether you are about to meet your maker, you will be able to berate the ambulance staff for not displaying a notice about how to access the ambulance trust’s latest quality accounts.
I am not necessarily critical of this approach, but it can be carried to unnecessary extremes. For example, it would be absurd and inappropriate for health visitors or members of mental health outreach teams to have to pin a notice up in the house of every patient they visit. It would be equally absurd for places where the public never go, but which nevertheless deliver services, to have to do that. In the latter category, I have in mind pathology laboratories or the control centres of NHS Direct. Perhaps the Minister will comment on this because the wording of the Bill seems to be a touch overly prescriptive. I beg to move.
I am grateful to the noble Earl. This amendment seeks to ensure that the duty to display a notice detailing how to access a quality account does not extend to each and every premise wherein services are provided—for example, a community nurse in a patient’s home. I appreciate the noble Earl’s effort to prevent an overextension of this duty and I can reassure him with his sentiment entirely. Our intention has been that the requirement applies to premises at which the provider generally provides services. We certainly do not intend that it should apply to a temporary or a one-off occasion. However, we wish to cover mobile premises, such as screening centres. Hence, the specific mention of a “moveable structure” under subsection (8). In the light of the points raised by the noble Earl, I am happy to take this point away for further consideration and to ensure that our shared aims are met. I need to seek legal advice and will come back to this matter on Report.
Amendment 44 withdrawn.
Clause 7, as amended, agreed.
Clause 8: Regulations under section 6
45: Clause 8, page 5, line 36, after “section” insert “6”
Amendment 45 agreed.
Clause 8, as amended, agreed.
Amendments 46 and 47 not moved.
48: After Clause 8, insert the following new Clause—
“Report to Parliament on impact of quality accounts
(1) The Secretary of State shall report to Parliament no later than 4 years after the coming into force of this Part on the impact of quality accounts.
(2) The report shall examine the way quality accounts reflect the varying demographic, social, economic and geographical areas served by the bodies listed in section 6(2) and (3).”
I imagine that veterans of the Committee will look at Amendment 48 and consider that it is one of the classic devices to which opposition Members resort when they are trying to probe the intentions of legislation or clip the wings of the Secretary of State. That was not my intention in this amendment. The request for a report to Parliament four years after “the coming into force” of quality accounts was not mechanistic. It is a way to offer Parliament the opportunity to evaluate the sorts of data which we have become much more accustomed to seeing as a result of CSCI and the Healthcare Commission.
Their annual reports to Parliament have become not simply events to which Members of Parliament turn up to find out how their local providers are performing in relation to others, in a kind of league table, but annual focal points which concentrate the minds of Members of Parliament on the impact of legislation on the NHS. Furthermore, they provide opportunities for regulators to put directly before Members of Parliament not only an overall comparative picture of the performance of the NHS but a themed analysis of parts of social care, in the case of CSCI.
I take this opportunity to put on record an appreciation of the work of Sir Ian Kennedy, Anna Walker and Denise Platt for the information that they have provided to Parliament during the existence of the bodies which they have led so ably.
The purpose behind this was to complete the circle of the work of the noble Lord, Lord Darzi. He went out with a mission, backed by the Government, to talk to clinicians, patients, users and so on, and he has brought before us a system, elements of which we have spent this afternoon probing. The intention behind this is to present an opportunity for those findings to be returned to Parliament. In future, Parliament will go on to base its legislative work and policy on much of the data which results from the work that the Minister is doing.
The second reason why the amendment is in this form relates to Clause 2. When the noble Lord, Lord Darzi, introduced the concept of quality accounts, he was at pains to stress that they would not be a crude league table, but that they would generate information which took into account the different population profiles in which individual clinicians and institutions worked. Therefore, it follows that it should be possible to look at the impact of quality accounts on health inequalities, which is a running concern of Parliament. For those two reasons, I thought that it was worth while tabling this amendment. It may look like a standard wheeze, but it is not; it has serious intent. I beg to move.
Normally I find myself supporting many of the amendments moved by the noble Baroness, Lady Barker, but I have a little difficulty with this one. I think that these reports will, in general, be boring and will not deal with the meat. Generally, reports which go before Parliament are left on the shelves in the Vote Office of the House of Commons, and I cannot see that they are of great interest. Those of interest are the reports which get into the hands of constituency Members of Parliament because they will go through them with a fine toothcomb to see what is going on in their local trusts and with their local providers. They will want to know where issues of controversy and difficulty are within those provider organisations, and they will want to concentrate on them.
In the event that one of these quality reports had come my way when I was in the House of Commons, I will tell noble Lords what I would have done with it. I would have gone into my office, we would have pored over it, and we would probably have gone to meet the chairman of the trust or a representative of the local provider. In current conditions, we probably would have sought a meeting with the chairman of the county council scrutiny committee to see whether it wanted to follow up any material that was provided in the report. Finally, in the event that there was something that clearly had wider implications than just the local area, I would have gone the chairman of the social services and health Select Committee in the House of Commons and asked him whether he intended to hold an inquiry. In the event that he said no, I would have lobbied within that Select Committee to ensure that the idea of an inquiry was raised within the membership of the committee.
Furthermore, in the event that the report had showed up areas of concern that arose out of the use of public resources and money, I would probably have rung up the National Audit Office to speak to the Comptroller and Auditor-General and asked him whether he intended to carry out an inquiry into the wider implications of that particular area of the report, which might be mirrored in the reports for other providers in other parts of the country. The National Audit Office, in the event that it carried out a report, would have reported to the Public Accounts Committee, which would have followed that up. I think that is a far better way of dealing with these matters than to have a report to Parliament which will be general and which, in my view, will have no effect whatever on what happens in these matters. I am sorry to say this to the noble Baroness, Lady Barker, because I agree with so much of what she says.
The noble Baroness, Lady Barker, has made a very sensible proposition, that the introduction of the quality accounts be reviewed to assess its impact on various sectors of society, including some geographical issues.
We thought very hard about the issue of publishing to Parliament. It is not in the Bill, but we have made a commitment that the National Quality Board will publish what we call a set of indicators at a national level—these are not the quality accounts but they will be built through the quality accounts—that will look at the progress of the NHS on a year-by-year basis. It is an opportunity that we have missed in the health service over the past decade in the investment that has been made. We may know, for example, that we are meeting certain targets, such as the four-hour wait or 18 weeks, but do not forget that that has had tremendous outcome improvements.
The example that I gave earlier of a 48 per cent reduction in mortality rates following cardiovascular disease is something that the NHS should be proud of. Parliament should be reassured that £100 billion of taxpayers’ money is invested in a service that is constantly improving. It is our intention to publish a report annually to Parliament, and it is also our intention to identify a set of indicators that compare us with some neighbouring European countries. It is important that we measure like for like, because they have different funding systems and other things. I hope that I have reassured the noble Baroness that we will be doing that. I agree that we need to risk-stratify this information and data, because the health of the population will have an impact on the outcomes of their healthcare systems. That is one of the functionalities of the quality observatories.
As for the wider assessment of this policy, the impact assessment exercise that was published alongside the Bill states that there will be a formal academic evaluation of the policy after it has been running for three years. It will assess the full effects of the policy, including the impacts on each of the six equality groups enabling any negative or unintended consequences to be addressed in the future. If a negative impact becomes apparent ahead of the evaluation, the department will take action to address that point. I am grateful to the noble Baroness for reinforcing this point and probing me to clarify the different reports and where we intend this information to lead us. I hope she will be able to withdraw the amendment.
I thank the noble Lord, Lord Campbell-Savours, for explaining why his constituents were so well served during his time down the other end and for initiating me into some of the black arts of MPs. Not having served down the other end, I was not aware of them. It is important to say that he is right about the way in which Members of Parliament and, to some extent, Members of your Lordships' House have traditionally dealt with information from the National Health Service. I am not going to deny that the NHS is still a particularly deep resource for political ammunition.
With the changes in the way in which the regulators have reported over the past couple of years and have gone about their business, we have managed to move on ever so slightly from that and have begun to receive data that look much more critically at these things. There is a long way to go, and the Minister’s major undertaking to try to measure quality will need different ways of reporting in future. Earlier this afternoon, the Minister mentioned that he does not propose to allow financial auditing into quality auditing yet, but in due course, he will. I am seeking, in a modest way, to try to find a way in which his proposal could be given a fair assessment by Parliament. In education, when comparative league tables came in, there was a period when Select Committees took apart that mechanism and subjected it to significant scrutiny. No doubt in years to come, the Health Select Committee will investigate quality accounts. If it does, I hope it will take this discussion into account and that the analysis we ultimately get is not unduly unfair to quality accounts and to what the Minister is trying to do.
Amendment 48 withdrawn.
Amendment 49 not moved.