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Baroness Knight of Collingtree: I am a great believer in plain English. On those grounds, I have an objection to the name which has been given to the commission--namely, the commission for health improvement. Ought it not to be the commission for health treatment improvement, or the commission for healthcare improvement? Surely we are all in favour of health improvement, but I beg leave to doubt whether that will be achieved by setting up this commission. We are not very clear in what we are saying here.

When one reads the functions referred to in the amendment, it is very difficult to understand precisely what this commission will do and move it, so to speak,

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from the general to the particular. I have one brief question for the Minister. Does she envisage that what I believe to be the "great evil" of mixed wards in hospitals will be ended when this commission gets going? I ask that question because in some places they have been stopped, while in others they have not. It is impossible to overestimate the distress caused to some elderly patients--and, indeed, to others who are younger--by being placed in a bed next to one occupied by a man, if it is a lady, or in a bed next to one occupied by a lady, if it is a man. It is an issue which hospitals have not always understood. I believe that it is very wrong to impose on sick people something which could be avoided. Indeed, it ought to be recognised as a wrong way to treat people. Let us be clear in this respect. As regards this amendment and this part of the Bill, we are surely talking about healthcare and not just the rather vague concept of "health".

Lord Haskel: I did not recognise what the noble Earl referred to when he spoke about governance. I do not see governance as being laying down a rule book. It certainly lays down some basic rules, but the whole purpose of governance is to try to inform people what is best practice and try to persuade people to adopt it. It seeks to improve the mediocre, not simply tell people what to do by virtue of a rule book.

Baroness Hayman: I welcome the wide debate we have had on a specific amendment. I say to the noble Baroness who spoke about the name of the commission that if we refer back to the discussion we had earlier about the ambit of healthcare including prevention--which does, of course, concern health--we can see one of the problems of being specific and looking only at healthcare or services being provided. The whole intention of the Government's policy is not to adopt an artificial distinction between those things which encourage good health and those things which treat failing health, but to take a more holistic approach to both of them. Therefore I defend the name of the commission, but that is by the by.

In the debate on Amendment No. 81 the noble Lord, Lord Clement-Jones, suggested that we needed--if I can characterise it as the noble Earl, Lord Howe, described it--more of a rule book approach and an insistence that bodies act upon recommendations guided by the national institute for clinical excellence, whereas the noble Earl was worried about that. Clinical governance is certainly not the opposite of clinical freedom. I think I made clear earlier that one of the reasons one cannot be too prescriptive is because the individual treatment of an individual patient who may have complex needs must be individually decided as between the clinician and the patient. If he had said that the issue was the opposite of clinical licence and the licence to ignore authoritative evidence about proper treatment, we might be nearer to a working definition, but that again is by the by.

The noble Lord, Lord Clement-Jones, said--I think a little unfairly--that we had experience already of the problems and therefore we ought to move immediately to being prescriptive about enforcing the guidance set

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out by NICE, for example, and not allow it simply to be guidance. We have experience of the problems but we do not have experience of a rounded set of provisions aimed at improving quality, and of a kite-marked, gold standard, basic framework either provided by a national service framework or by national institute for clinical excellence guidelines. Then we have the duty of quality and of clinical governance and monitoring by the commission for health improvement, feeding back in turn, if necessary, to NICE and the guidelines. Therefore we do not have experience of how the whole system would work. However, I think that we have the balance right here.

Following a review or investigation what the commission recommends will be reported back to the organisation concerned, highlighting where there is need for change. The organisation itself will then be responsible for drawing up an effective action plan which will be shared with the commission, the regional office or the health authority, depending on whether it is an NHS trust or a PCT. Then the regional office or the health authority will supervise implementation of the action plan. Certainly the commission's recommendations will give added direction and impetus to that organisation in meeting its performance objectives checked annually through the NHS executive performance assessment mechanisms. Therefore I believe that the implementation of the commission's recommendations will need to be looked at in the light of wider objectives set, not just for the particular NHS body but, importantly, in the context of national priorities set for the NHS as well as wider local circumstances; for example, in working with other organisations to implement the local health improvement programme. Therefore despite the intention which lies behind these amendments--which I recognise--they may serve to be too restrictive.

We recognise the intention that organisations should move forward with recommendations made to improve the quality of services. Perhaps the noble Lord, Lord Clement-Jones, will be reassured to know that where there is unacceptable delay in making progress, the Secretary of State has a power under the Bill to give directions to the body under Section 17 of the 1977 Act, as amended by Clause 7 of this Bill, requiring it to take action to implement the commission's recommendations. Therefore there is no question of it being completely toothless. As I say, I think it important that the commission is guided not only by NICE but that it considers best practice in clinical care and treatment, and particularly national service frameworks. I do not wish to specify only NICE guidance as that which the commission should take on board and which it should ensure is being implemented. There will be a range of issues that the commission will wish to monitor and report back on and there will be a range of ways in which we ensure that institutions seek to implement improvements.

The commission will, of course, examine the take-up of NICE guidance as part of its work to assess the implementation of good practice across the NHS. However, I refer to the issue that the noble Earl raised. I say again that NICE guidance is not mandatory. It will

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provide guidance on which treatments are clinically and cost effective. It will offer doctors, nurses and other healthcare professionals advice and support in making complex decisions about individual patient care. However, final decisions on treatment will continue to be made locally in the light of individual circumstances.

The commission will have regard to a wide range of guidance in exercising its functions, including that made available through the national service frameworks and NICE. We expect the NHS to take account of this guidance in improving the clinical and cost effectiveness of its services to patients. Progress will be monitored by the commission. In those circumstances I believe it is unnecessary and indeed inappropriate to put specific provision as to NICE guidance on the face of the Bill.

Lord Walton of Detchant: I apologise to the Minister and to the Committee for joining this discussion a little late as I was momentarily distracted by some questions from another noble Lord. I assume that NICE will examine different areas of medicine and will then make recommendations upon their management. It is a matter of great concern, for example, that 3 per cent. of patients with multiple sclerosis in this country are receiving beta-interferon compared to 11 per cent. in Germany and 18 per cent. in Australia. CHIMP has been welcomed in principle by the major medical organisations in this country as being likely to make a major contribution to the improvement of health and the better management of disease. If it recommends certain measures based upon what NICE has proposed, am I right in understanding from what the noble Baroness said that should a particular body, a health authority or trust, fail to take account of that recommendation, the Secretary of State would have authority as a last resort to impose those conditions upon that body?

Baroness Hayman: Yes, the noble Lord is correct. When there is unacceptable delay in making progress on a recommendation by the commission which could well be based on the implementation of guidance, although it could be a specific local issue and not related to national guidance, the Secretary of State has a general power of direction which he could and, I believe, would use to take action to ensure that the commission's recommendations were implemented.

4.30 p.m.

Lord Clement-Jones: Before the Minister sits down, and before I respond, perhaps I may ask a question. Other health Ministers have indicated that if the experience of health authorities and NHS trusts in complying with CHIMP's recommendations in terms of the NICE standards was not a happy one, consideration would be given to tightening up on the enforceability of the NICE standards. Is that the Minister's understanding?

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