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Lord Clement-Jones: My Lords, I rise briefly to support the amendment. As the noble Earl said, of course, it is good to see the launch of the Department of Health and the Health and Safety Executive sign-up campaign. That must be translated into action within the health service.

There are certainly a number of particular cases where occupational health services are badly needed and one only needs to read representations made in connection with the amendment, particularly from the Royal College of Nursing, to understand the need for occupational health services. There are areas where, because of the independent contractual status of GPs, GP practice nurses--there are 18,000 such nurses--have no access to occupational health services. Research by the University of Sheffield found that nurses in general are 40 per cent. more likely to suffer stress than are other groups of professional and technical workers. One could relate this to a whole range of professionals working in the health service. It is clearly important that all should have a high level of occupational health service available to them. I support the noble Earl in his amendment.

Lord Hunt of Kings Heath: My Lords, the noble Earl has raised a very important issue. In the past, perhaps the NHS has not done as well as it ought with regard to occupational health.

Legislation already exists in relation to the provision of occupational health services for employees. Section 2(1) of the Health and Safety at Work etc. Act 1974 lays a duty on every employer,

This is viewed by the Department of Health and the Health and Safety Executive, in their capacity as inspecting authority, as placing upon NHS management a duty to provide comprehensive occupational health services for their staff. This provision forms part of all inspections by health and safety inspectors and failure

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to provide an adequate service can result in the issuing of an improvement notice or result, where necessary, in prosecution.

The NHS Executive has further strengthened this line by including the provision of quality occupational health services for all staff as an objective in the new framework for managing human resources--Working Together, Securing a quality workforce for the NHS. This document sets out the framework for improving the health, welfare and working conditions of all NHS staff and raises these issues to the top of the management agenda where they should be.

Research carried out for the NHS Executive in March 1998 suggests that all NHS employees have access to occupational health services provided by their employers. The quality of provision varies and this is being addressed as part of the human resources strategic framework, Working Together.

The NHS Executive issued The Management of Health, Safety and Welfare Issues for NHS Staff in the spring of 1998 setting out details of what constitutes a comprehensive occupational health service and encouraging NHS employers to work towards this for their staff. This has been extremely well received by the field and is being widely used as the standard for negotiating provision by outside contractors.

I very much take the noble Earl's point about the importance of occupational health services in the NHS. I believe that that is a shared aim. I hope that I have explained that the Health and Safety at Work etc. Act 1974 lays down the duties that the NHS is already required to undertake. Taking that and the management action which I have described into account, I hope that the noble Earl will find this reassuring and will feel able to withdraw the amendment.

Earl Howe: My Lords, I am grateful to the Minister. I do find it reassuring, at least in part. By the noble Lord's own admission, the system across the country has been patchy: in some places it has worked reasonably well, although in others it has not. Clearly, there is work to be done. I worry that although, as the Minister rightly pointed out, duties are enshrined in law, there is not a tight enough system to enable shortcomings to be identified and corrected, as they should be. However, with those words, and in view of the hour, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 13 [Duty of quality]:

Earl Howe moved Amendment No. 24:

Page 11, line 8, after ("arrangements") insert (", including identifying adequate resources,").

The noble Earl said: My Lords, this amendment is designed to highlight one of life's simple truths--that in healthcare, as in any other area, you get what you pay for. If you believe in a quality agenda--clearly, we all do although we may disagree about the means to that end--you have to invest the money and the support staff to ensure that you achieve it. The commission for health improvement needs to do its job properly and it has a wide remit. I do not know--perhaps the Minister can

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tell us--what it will cost to set up and run the commission and how many employees the Government expect it to have; nor do I know what kind of additional funding will be made available to trusts to enable them to put the necessary systems in place to implement the new statutory requirements. Where is the money to be found and how much money will be needed?

I very much hope that the Minister will not say that each trust will need to find the necessary money from within existing budgets. That implies a knock-on effect to other parts of the service. We hear a great deal about the additional resources that the Government have committed to the NHS over the rest of this Parliament. If they mean business on delivering quality, I should have thought that this is one area that ought to have a call on that additional pool of resources.

The way that the quality agenda is supported centrally will have a very big impact on the degree of credibility carried by the policy as a whole once it is put into practice. Trying to implement the quality agenda on the cheap simply will not work because no one will have confidence in the results. The results will depend on assessments that have an objective basis to them. As I said in Committee, to judge the performance of a surgeon or of a specialist you need a reliable series of bench-marks which are themselves compiled from representative data on outcomes. It is a fact that at present very few specialist disciplines have such information available. Therefore, does the Minister agree that a great deal of data collection and analysis will need to be done in the first instance to enable the commission to do its work? If so, how is that to be funded and in what way will it be done?

My second quite separate question relates to the revalidation of GPs. The proposals for revalidation are not yet fully worked out, but it is already clear that testing the competence of a GP to continue practising will not be a cheap exercise. Revalidation is a concept which brings together two of the big issues in the Bill; namely, the quality agenda and the self-regulation of the medical profession. To what extent are the Government prepared to consider helping with the costs that this will inevitably entail? I beg to move.

Baroness Sharp of Guildford: My Lords, I rise to express my support for the amendment. As we on these Benches have made clear, we support the establishment of the commission for health improvement. As in education, we recognise that there are many ways in which the quality of service provision can be raised. Just as Ofsted in education is a mechanism for stimulating and monitoring improvements, so we see the new commission as having that responsibility in health.

However, as in education, the new quality framework is not costless, as the noble Earl made clear. Anyone present in the Chamber who has been a school governor will know the time and energy required from all teachers, especially the top management team, to prepare the necessary documentation for a full inspection. Exactly the same will be true of CHIMP. Sufficient time, money and, indeed, support must be

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invested to make it work properly. This amendment looks to the Secretary of State to allocate sufficient funding to meet these requirements. We fully support it.

Baroness Gardner of Parkes: My Lords, I, too, strongly support the amendment. I do so because I believe that resources are absolutely essential. I mentioned earlier tonight--and I repeat it now--that even at this stage when we are just getting to primary care groups, let alone to other issues with which we shall deal later, the resources are not there. I have in mind, for example, the Berkshire health authority. I mentioned Slough, which is an area with a great many single-handed practitioners and quite a deprived population. There is no communication between practices and many people have to work on their own. Others do not have a computer; indeed, some of them have non-matching computers. The debts being passed on from Berkshire health authority are enormous.

If things are so bad, and if something does not happen on 1st April, how will we know the outcome? Unless we can be confident that there is adequate resourcing for the next much more important stage after the PCGs, I believe that we need this amendment. It crystallises the whole issue as regards these necessary resources. I support it.

10.30 p.m.

Baroness Hayman: My Lords, we have had a brief but interesting debate on the link between resources and service quality. However, I should point out to the House that the amendment as it stands does not deal with the commission for health improvement; indeed, it deals with the duty of quality which is to be placed on primary care trusts. However, I would not wish that to stand in the way of debate on how quality is resourced.

As I say, I recognise that there are important links between resources and service quality, although perhaps a recurrent theme that I have been trying to put forward in looking at quality is that high quality services sometimes are also cost-effective services, and sometimes improvement and investment in quality lead to longer term savings. I believe that that was the point that the noble Lord, Lord McColl, made earlier; namely, that it may be more cost effective to employ highly qualified staff than to pay the costs of litigation that may arise if one does not employ them. That leads me to say that special funding for quality cannot be ring-fenced or handled through a separate stream of funds. The whole quality agenda of the Government is concerned with the way we use all resources, not just some resources that are earmarked for improving quality.

As regards revalidation, it is premature to consider the costing of that. The GMC has only recently taken a view on that issue. There is a great deal to do. It has not made any attempt to assess the financial implications of the proposals. Even if the individual clinician bore the costs of any assessment requirements, there would be implications for NHS employers in terms of providing locum cover and possible remedial training costs. We would not wish to attribute the ongoing costs of CPD,

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which would of course underpin the success of any revalidation system. There are important issues to be explored there.

As I say, this amendment is concerned with putting a duty on primary care trusts and NHS trusts to put in place arrangements to monitor and improve the quality of healthcare they provide to individuals. The amendment would require them also to identify adequate resources for this. It is, of course, important that the arrangements which trusts put in place are backed up by the appropriate resources. As I say, in some instances investment in quality may lead to a longer term saving.

However, in placing a duty on NHS trusts and primary care trusts to identify adequate resources, the amendment would appear to be giving them some responsibility for the size of the total sum of resources available to them. That would be to impose on them a responsibility which they could not reasonably discharge. It is, and has always been, the proper responsibility of government to determine the appropriate level of resources for the NHS. It is likewise the responsibility of government to make arrangements to promote the fair distribution of resources to health authorities and now for health authorities to arrange allocation to their primary care groups and their primary care trusts.

The roles which can properly be discharged locally include decisions through the health improvement programme process on how the resources available to the local healthcare system can best be deployed to respond to national and local priorities and needs. Our forthcoming guidance on clinical governance will make clear that if issues with significant resource implications emerge from that process, they should be explored in the context of the health improvement programme. In addition, NHS trusts and those primary care trusts with direct responsibility for providing services will, of course, need to have regard to the implications for service quality in deciding how best to deploy their own resources. That is already encompassed within the duty as drafted,

    "to put and keep in place arrangements for ... improving the quality of health care".
We believe these proper local responsibilities in the matter of deploying resources to maintain and improve service quality are already properly covered. So far as responsibility for securing resources is concerned, the Government have no intention of trying to confer their own proper role on others. Our recognition of the challenges facing the NHS informed the results of our comprehensive spending review when we committed an extra £18 billion to the NHS in England over three years. Noble Lords who can remember as far back as seven o'clock this evening will remember that I announced the investment this coming year of an extra £100 million into modernising A&E departments and improving rapid access to professional advice and help for patients. All those things are about improving quality within the NHS and providing the resources so to do. This time of night is perhaps not the best time for an extended debate on expenditure records or the pressures and opportunities facing the NHS. However, I suggest

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to the House that an amendment to this clause to confer on NHS trusts and primary care trusts a responsibility that they are simply not in a position to discharge is not the best way forward.

10.30 p.m.

Earl Howe: My Lords, I am grateful to the Minister for her comments on the amendment. I take her point that I am guilty of going wide of the amendment in addressing the issue of resources for the quality agenda generally, including the commission for health improvement. But the point that the amendment seeks to bring out is that, with a duty placed upon them to improve the quality of healthcare as the clause demands of them, primary care trusts and NHS trusts cannot just shrug off the issue of how that will be paid for. While they may not have a responsibility to provide those resources, they must address those issues. However, I shall read carefully what the Minister said and reflect further. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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