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Mr. Lammy: The hon. Member for West Chelmsford (Mr. Burns) has more or less made the points that I wanted to make. The intentions of the hon. Member for Oxford, West and Abingdon are honourable, and the Committee would agree with them, but the word ''wellbeing'' would add nothing to the duty of quality under clause 40. That amends the current duty of quality in section 18 of the Health Act 1999 to include a duty on all NHS bodies to ensure that appropriate arrangements are put in place to monitor and improve the quality of health care that they provide or obtain. Clause 118 allows CHAI and CSCI to assist any other public body in its work, which would include the Health Protection Agency.
I commend the intention behind the amendment, but for the reasons that I and, indeed, the hon. Member for West Chelmsford have outlined, I hope that the hon. Member for Oxford, West and Abingdon will see fit to withdraw it.
Dr. Harris: I thank the Minister and, in the spirit of charity, his able assistant, the hon. Member for West Chelmsford—who speaks for the Conservatives!—for their constructive comments. I am glad that the Minister understood the motives behind the amendment. I listened carefully to what he said and, in light of that, I am more than happy to beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 40 ordered to stand part of the Bill.
The Chairman: Before we move to clause 41, I have a quick housekeeping point. If there is a Division in the Chamber, I will suspend the Committee for 15 minutes. If there are two Divisions, I will adjourn the Committee for 30 minutes, and so on. Clause 41
Standards set by Secretary of State
Mr. Burns: I beg to move amendment No. 189, in
The Chairman: With this it will be convenient to discuss the following amendments: No. 108, in
clause 41, page 14, line 17, leave out 'Secretary of State' and insert 'CHAI'.
No. 109, in
clause 41, page 14, line 20, leave out 'Secretary of State' and insert 'CHAI'.
No. 110, in
clause 41, page 14, line 21, leave out 'he' and insert 'it'.
No. 111, in
clause 41, page 14, line 22, leave out 'Secretary of State' and insert 'CHAI'.
No. 112, in
clause 41, page 14, line 22, leave out 'he' and insert 'it'.
No. 113, in
clause 41, page 14, line 25, leave out from beginning to 'effects' and insert 'its opinion'.
Mr. Burns: The amendment seems to copycat the subsequent amendments. The hon. Member for
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Oxford, West and Abingdon will have an opportunity to make his points when he speaks to his amendment. I assume that the main thrust of his argument will be similar to mine, because all the amendments seem to dovetail.
The clause is important, because it is all about the Secretary of State setting standards for the NHS. The Government, from the Secretary of State downwards, have said on numerous occasions that they want to take the politicians out of the health service. I suspect that they have copied that philosophy from my hon. Friend the Member for Woodspring (Dr. Fox), because the Conservative party also believes that we should take the politicians out of the health service.
It is up to the clinicians and medical practitioners in the health service to run it to the best advantage with the best provision of health care to meet the local needs of local people. That is why I am surprised that despite the rhetoric, the Secretary of State will set the standards and will be given powers to ensure that targets are met through the standards that he will set. My hon. Friends and I believe that CHAI would be the more appropriate body to do that. That would set the NHS free from politicians and from political interference and control, because, under this fundamental part of the Bill, they would have their hand on the tiller.
I hope that the Minister will appreciate the validity of that point, given his comments about CHAI in previous debates. It would kill two birds with one stone. It would help to meet the aims and aspirations of the Minister and his right hon. and hon. Friends in de-politicising the NHS, and would give it a rational, independent body that could set the pace of improvements and standards so that we can continue to make progress and improve the quality of health care that the NHS provides for the citizens of this country.
Dr. Harris: The hon. Member for West Chelmsford is right that we are seeking the same thing. The order of the amendments on the amendment paper suggests that ours were tabled a little before the hon. Gentleman's. However, they would achieve similar things. His amendment talks about stating that CHAI should be the principal guardian of standards in the NHS, and I am more than willing—indeed, keen—to support that proposition, but that needs to be backed up with some specific measures that are found throughout amendments tabled by the Liberal Democrats and the Conservatives to subsequent clauses to make it clear how the intention behind amendment No. 189 should be implemented.
Amendments Nos. 108 to 113 are the beginnings of some of those measures and are crucial to the proposition made by the hon. Member for West Chelmsford that there needs to be an inspectorate-led guardianship of standards in the NHS, and that politicians need to be kept out of that as far as possible, except for when establishing the framework.
I am determined to make my remarks positive, so I will repeat what I have said on many occasions: this Government deserve praise for the quality framework that they have introduced. They have run the risk of
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being attacked for alphabet soup for the creation of many of the organisations that they have established, such as the National Clinical Assessment Authority, the National Patient Safety Agency, CHAI, and the National Care Standards Commission. There have been specific criticisms that we might have brought some of those issues together earlier. Nevertheless, the focus that the Government have put on mechanisms and inspectorates to safeguard quality is important.
Andy Burnham (Leigh): But.
Dr. Harris: There is no ''But''. The hon. Member for Leigh thinks that there is a ''but'' coming in this sentence and there is not. There is going to be a ''but'' at the beginning of a new paragraph, because clearly I have tabled amendments to the Government's proposals. Even in this constructive mood, I will obviously suggest that there are things that the Government could do better. It is important to put that on the record, because without the commitment that the Government have shown, both pre and post the Kennedy report on the Bristol infirmary, and without their interest in establishing quality mechanisms, we should not be having these debates.
One of the reasons for the Government's actions is that they know that they must have a tough inspectorate in health care. They cannot simply rely on patient choice to lever up quality, as might occur in the purchase of bread or some such producer-and-consumer analogy. It is much more difficult to obtain the desired effect in health care because of the inevitable differences in power between the consumer and the producer, given that it is a professionally delivered service.
It is also the case that the professionals are often not good at recognising quality problems, because of their essential conservatism and unwillingness to take advice from outside. That must be recognised. Nevertheless, the quality framework under this group of clauses is deficient, because there is too great a role for politicians. I have said that the Government have done well to set up a framework, but politicians should withdraw because we need to ensure that the health service is governed against objective standards of quality. Everything I say applies equally to the social care sector and CSCI.
With the best will in the world—I need not go into whether the Government have the best will in the world—it is hard for a political organisation or a politician, no matter how good his motivation, to ensure, first, that quality standards are objective and evidence-based. If they were, there would be no need for the Secretary of State to become involved. We could just ask someone with even greater expertise than him to recognise what the evidence supports to make those decisions.
Secondly, it is important not only that that process of identifying the right standards is done according to objective measures and an adequate evidence base, but that that is seen to be done, to command the confidence of users of the health service and those who work in the service. The Government are right to put in a tough quality inspection regime. It has been long awaited and I pay tribute to the fact that they
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have done that over the years, but it is important to keep people on board.
For those two good reasons, I urge the Government and other hon. Members present to consider how important it is that the amendments, in some form, are made. It is critical that it is CHAI that prepares and publishes the statements of standards in respect of the provision of health care by and for English NHS bodies and cross-border strategic health authorities.
There are other amendments that I have tabled for future debates in this Committee that put into legislation the basic processes of consultation that CHAI would need to undertake. However, it is a crucial measure of the true independence of CHAI that it is able to develop its own standards, not simply measure how well hospitals are jumping through hoops that are set by other people. I have made the point that if CHAI is inspecting the hospitals, it needs to be setting the hoops. It needs to be devising the standards against which hospitals are to be measured; otherwise it would not be independent. It is, by definition, a dependent process. If someone else, in this case the Secretary of State, says to the commission that it will have to measure performance, but that the Government will tell it what to measure it against and how to judge failure, then even if, by some miracle, the Secretary of State became a non-political person—health care is, of course, highly political—and came up with sensible standards, that would still undermine the commission's independence, by forcing it to measure standards that it had no power to set itself.
3.45 pm
I now refer to where the ''But'' comes in. The hon. Member for Leigh (Andy Burnham) said from a sedentary position that he did not think that the Secretary of State was anything other than perfect in such respects. I hope that he will be rewarded for that faith in due course, if he meant it seriously. The standards set by the Government, not under the national service framework—we must not confuse those two—are not true measures of the quality of health care, but of other things.
I shall contrast two different standards. The national service framework for coronary heart disease has several standards. They are clinically based and measure meaningful outcomes or the extent of interventions that have been shown on the evidence base to deliver meaningful outcomes. The proportion of people who are on aspirin for secondary prevention is obviously important. Stacks of evidence suggest that that relatively cheap intervention is hugely important and produces results.
The time from door to needle for thrombolysis is a standard set under the national service framework. It is not produced by the Secretary of State, but by the working group. It is a meaningful standard. It is clear that CHAI would measure the performance of health care providers against such standards when it is relevant, without the Secretary of State having a role
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in the process. There is no doubt about that. However, other standards may not have been subject to the national service framework, and CHAI needs to develop them. As I have said, the amendments would make it clear that CHAI needs to consult the profession, such as the medical royal colleges although consultation may not need to be limited to them, and local patient groups, such as the Commission for Patient and Public Involvement in Health, the closest that we have to a truly accountable body that represents the consumers of health care.
It is clearly unacceptable that something that is supposed to measure quality is doing so against standards that have nothing to do with quality of health care and clinical outcome. I shall pluck one topical example out of the air; it applies to all the so-called high-level standards that are in the Government's league table assessment. I am eager for the Under-Secretary to give me an evidence base today for any of the standards of waiting lists, waiting times, trolley waits and two-week waits. I offer him that challenge; we could probably use such standards as exemplars for the rest of the afternoon.
My example shows the damage that could be done if the Secretary of State were responsible for preparing and publishing a statement. Let us consider a standard under which 70 per cent. of patients in A and E are dealt with, from the moment of being admitted to their leaving the department, in four hours. I do not mean their having been seen by a doctor. That is a different issue. If a trust meets that target while another does not, does it follow that it is delivering better health care? Not only does that not follow, but there is every reason to suggest that it not only distorts the allocation of resources for clinical decision making, but acts against the best interests of patients in respect of demonstrable outcomes. It is counter-productive.
Anyone who has worked in an A and E department knows that about 70 per cent. of cases are people suffering minor injuries. The people are not brought to the hospital by ambulance and are relatively well. They can be dealt with quickly and processed—to use the Government's term—and either admitted or, as most usually are, discharged within four hours. That can be done if all the concentration is on that group, but what is to happen to the other 30 per cent.? They can be left for up to 12 hours before another quality standard kicks in, and it is likely that they will be left for longer because, in the first four hours, the only thing on which the accident and emergency department is measured is whether it can deal with the least sick patients more quickly. That is a potential perversion: a distortion of clinical priority. It is not just a question of potential, however. According to the majority in a survey of 30 per cent. of accident and emergency departments, it is actually happening.
It is disgraceful enough when the Government say, ''We shall measure your performance in the interests of patients by doing something that will be detrimental to them as a group, and will damage the individual interests of the sickest.'' It is unethical for doctors to co-operate in such intervention in clinical priority setting and decision-making. However, it is worse when such measuring is delegated to what the
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Government claim to be an independent commission to audit health care improvement. Clearly it is not independent. It is a charade of independence for a commission to impose the Government's standards for measurement, which have nothing to do with quality of care in terms of clinical outcomes.
It might well be that if one polled 100 per cent. of patients in an accident and emergency department, a majority would say that they would prefer 70 per cent. rather than 50 per cent. to be processed within four hours, but that is not how health care decision making works. It involves prioritising the sickest—those least likely to be able to speak for themselves—and ensuring that they are treated more quickly. Those are just a few of the problems with a single target.
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