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Baroness McFarlane of Llandaff: I rise to express briefly by support for Amendment No. 69, and others, dealing with extending the duty of quality to private healthcare institutions. It appears to me that this is probably the most important part of the Bill, dealing as it does with the quality of care that patients receive. I believe that every patient has the right to receive the minimum standards of quality, care and safety, irrespective of the sector in which treatment is received.

I wonder whether the Minister could clarify for the Committee whether the primary care trusts will be able to commission services from the independent sector. In any event, as has been stated, the independent sector already makes a tremendous contribution to the total care of patients. There are 230 independent acute hospitals giving approximately 20 per cent. of all surgical procedures performed in the UK and a further 67 per cent. independent psychiatric hospitals. Twenty per cent. of NHS psychiatric patients are treated in specialist independent sector clinics, and 55 per cent. of NHS patients needing medium secure facilities receive their treatment in the independent sector. Therefore, as I said, it is important that every patient should have the right to minimum standards of care, irrespective of the sector in which treatment is received.

Baroness Berners: I should like to express my support for the amendment. It must be sensible to use all available expertise and specialised facilities for the good of the health of the nation, and to have one overall high standard maintained throughout the whole country by the proposed commission for health improvement.

Lord Warner: I rise to express puzzlement about the group of amendments tabled in the name of the noble Earl, Lord Howe. The part I am puzzled about is the reconciliation of this set of amendments with a statement by the shadow Health Secretary on 18th October 1988 when, on the "Dimbleby Programme", she said:

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    "What I am saying is that the NHS can't do everything. There is now the question of whether or not we should expand that to include clinical services so that we get the private sector taking the risks, putting in the investment, paying the staff salaries"--
and this is the significant bit--

    "doing all the rest of it, under contract to the NHS".
I interpret "doing all the rest of it" as including quality assurance for the private provider. As I understand the position, the Bill provides for a quality assurance programme--not regulation--for the NHS. My interpretation of the shadow health secretary's approach is that the private supplier of services would provide and fund its own quality assurance programmes. It seems slightly odd that the amendments now appear to ask the taxpayer to provide and fund quality assurance programmes for private suppliers. I should be grateful if the noble Earl could reconcile those two points of view.

11.45 p.m.

Earl Howe: I am grateful to the noble Lord for giving way. I do not think there is any difficulty here. I think what my right honourable friend was talking about on the programme the noble Lord mentioned was essentially an extended PFI scheme. There is no suggestion in these amendments that the taxpayer should have to fund quality assurance in the private sector. That is a matter that would have to be addressed when the time came if the principle was agreed by the Government. I do not see anything too horrendous in the thought that the private sector should pay for what it gets.

The point I sought to make through the amendments is it makes total sense, I believe, for there to be a unitary framework of regulation covering both the private and public healthcare sectors. That really does not relate to the point that my right honourable friend mentioned when she was trying to address the question of how we can meet demand for healthcare in the country, which is a separate issue.

Baroness Hayman: We have had a useful debate on a set of amendments which, if taken in total--if I may summarise the position broadly--would make the provisions in relation to the duty of quality and clinical governance and the role of the commission for health improvement, apply equally to the independent sector and to the NHS. I recognise the concerns that have been expressed about ensuring quality in the independent sector, in particular the concern about the protection of vulnerable groups of patients who for a variety of reasons look to that sector for their care.

It is quite apparent--I make no apology for this--that the Bill takes quality in the NHS as its starting point. It provides an overall quality framework which we can pursue in the context of a national managed service, setting standards through the national institute for clinical excellence and national service frameworks. It seeks local implementation through the duty of quality on providers in clinical governance. It improves and strengthens professional self-regulation and continuing professional development. It seeks national monitoring by the commission for health improvement, through the performance assessment framework that we talked about

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earlier and through the national patients survey. It is not easy to transfer some elements of this total package, which has been built and put together for a managed service, into the independent sector.

There are, however, certain areas in which there is a clear overlap. I think it was mentioned earlier that the duty of quality and the clinical governance arrangements in NHS trusts apply to an institution as a whole and therefore would apply to private practice and those in pay beds within those institutions. On an analogous point--in answer to the noble Baroness, Lady McFarlane--primary care trusts can (as can health authorities) commission from the independent sector, although, as with health authorities, we would expect them to make maximum cost effective use of the NHS first. But when we are dealing with NHS patients being treated in private or non-NHS facilities, I think everyone recognises that there is a wide range of providers outside the NHS. They range from the straightforward, if you like, acute private hospital, right through to voluntary and charitable organisations such as hospices; a very wide range is covered. We have made it clear that when NHS patients are being treated within non-NHS institutions, the commissioning authority will ensure that the same standards of quality apply; there would be, for example, the ability for the commission for health improvement to look at the services provided within the independent sector.

As noble Lords have pointed out, that leaves us with the issue of the future regulation of the private and independent sector as a whole--particularly in the light of the new arrangements being made for the regulation of social services, a provision which brings this matter into sharp focus. We recognise that this is an issue which we need to address. I think the noble Earl pointed out that we have the present arrangements of regulation at health authority level, although I share with him some the concerns that have been voiced about whether that will be the most appropriate and effective way of regulation in the future.

I suggest to the Committee that we should recognise that we are at a time when the appropriate way forward is being carefully debated and studied. The Select Committee on Health in another place is currently addressing exactly these problems. The Government are committed to consulting on the regulation of the independent sector, which was covered in the social services White Paper. It is a subject on which we should listen carefully to a range of views. Some views have been expressed in the Committee tonight but, with respect to the Committee, we should go wider rather than simply take this legislative opportunity to transpose the system. As I have said before, the system is very much directed towards the nationally managed service that is the NHS, and it may not be appropriate to what the noble Earl categorised as the tigers and jaguars of the independent sector.

The purpose of the consultation, on which we plan to embark before too long, is precisely to explore, for example, better options than the current position of health authority regulation. I would suggest to the

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Committee that the right time to return to this subject is after the Select Committee on Health in another place has reported; after we have launched our consultation and had the responses to that; and when we have proposals for a way forward to deal with the very real issues that have been raised in the course of today's debate.

Lord Clement-Jones: I thank the Minister for her thoughtful reply. I am not quite sure that it demonstrates, perhaps not quite so much the urgency, but certainly the importance of the issue before us. She is absolutely right that the Select Committee on Health in another place is carefully considering the matter. I would hope that if the Select Committee does come to conclusions--and it is taking a very wide range of soundings in its deliberations--there would be a possibility of considering the matter afresh in another place when the time comes. It would be a massive lost opportunity if, when we were setting up the commission for health improvement, we failed to include the independent sector and then had to wait several years for legislative time to include the independent sector.

A number of noble Lords have underlined the question of minimum standards and whether or not patients are treated in the NHS or the private sector. I recognise the Minister's point that it is perhaps inappropriate to have a blanket coverage by the commission for health improvement right across all its functions in relation to the independent sector. That is why we limited our amendment to the investigation aspects. It may be that one could go slightly wider than that, but not a great deal.

I shall not withdraw the amendment at this stage because I believe the noble Earl wishes to speak. I shall come back to it after he has done so.

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