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Baroness Noakes: I thank the Minister for that comprehensive reply. I shall have to wait until I read it in Hansard to absorb it fully. For example, I am not clear whether or not he answered my question in respect of basic financial duties. That may be because of my lack of comprehension rather than the lack of an answer, but time will sort it out.

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I thank the Minister for the clarification in regard to the charging of local authorities. The Local Government Association will be very interested in that. I shall ensure that it is made aware of it because one of its considerable concerns is that local government will end up bearing additional costs through this route. I suspect that that is what it will involve.

The issue of financial independence was at the heart of the amendments, and the Minister did not give an answer on that. He answered that the Government wanted various powers to control CHAI and CSCI, and that that is the way in which the Bill has been drafted. It is directly contrary to the direction of travel in the amendments.

The Minister referred to borrowing being against Treasury rules because excessive debts could be run up. But one minute we are told that we can trust CHAI and CSCI because they are responsible bodies, with excellent chairs and members, and that all the Government need are reserve powers—to get rid of a recalcitrant chairman, for example—and the next minute the Minister argues that they have to have the most detailed powers to prevent those bodies stepping an inch out of line. His answer did not carry any real credibility.

The Minister often refers to the Audit Commission and Ofsted. The Audit Commission is quite different. It has extensive fee-raising powers, which is what drives its income and expenditure account. It is not constrained in the same way as CHAI and CSCI will be.

There are a lot of loose ends in this area. Financial independence is a key element of the independence we seek to establish for CHAI and CSCI. I shall read carefully the Minister's comprehensive response—for which I thank him—and in the mean time I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Warner moved Amendment No. 232A:


    Page 133, line 25, leave out "provided" and insert "proved"

On Question, amendment agreed to.

Schedule 6, as amended, agreed to.

Clause 41 [The Commission for Social Care Inspection]:

[Amendments Nos. 233 to 236 not moved.]

Clause 41 agreed to.

Schedule 7 [CSCI: Supplementary]:

[Amendments Nos. 237 to 253 not moved.]

Lord Warner moved Amendment No. 253A:


    Page 136, line 21, leave out "provided" and insert "proved"

On Question, amendment agreed to.

Schedule 7, as amended, agreed to.

Clause 42 agreed to.

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Schedule 8 [CHAI and CSCI: transfers of property and staff, etc]:

Lord Warner moved Amendments Nos. 253B and 253C:


    Page 136, line 32, after "to" insert "the CHAI or"


    Page 137, line 2, at end insert—


"( ) A scheme under this paragraph may contain provision for the payment of compensation by the Secretary of State to any person or body (other than one mentioned in sub-paragraph (1)) whose interests are adversely affected by the scheme."

On Question, amendments agreed to.

Schedule 8, as amended, agreed to.

Clause 43 agreed to.

Clause 44 [Quality in health care]:

Baroness Barker moved Amendment No. 253D:


    Page 16, line 16, at end insert—


"( ) It is the duty of each NHS body to put and keep in place arrangements for the purpose of monitoring the uptake of the following NICE approved technologies—
(a) pharmaceutical technologies, and
(b) medical devices."

The noble Baroness said: Clause 44 is, perhaps, the heart of the Bill in that it deals with quality of healthcare. It is a rather short clause, and my amendments would make up for the deficit in the description of what constitutes quality of healthcare.

Members of the Committee who have read the debates on the subject in another place will have picked up on the widespread concern that what passes for quality in healthcare is often measured in terms of management performance. That is particularly of concern under the framework of foundation hospitals.

The amendments would do two things. They would ensure that NICE guidance will be adhered to and that the task of monitoring it will be assumed by CHAI. Given the statement made by the noble Lord, Lord Warner, at Second Reading, in response to the noble Baroness, Lady Finlay, I am sure that he will be delighted to see that. The amendments also make it explicit in the Bill that national service frameworks, milestones and guidance are also to be the subject of scrutiny by CHAI and CSCI.

The difficulty is that, having taken what is regarded on all sides as a huge leap forward in bringing together the best evidence, best research and best practice in national service frameworks, the Government have fallen short of ensuring that, in some cases, their implementation is backed by resources and in gathering and monitoring the data which come from that implementation.

The amendments seek to make sure that the single most important source of information that will enable judgments to be made about quality in healthcare is a primary function of the new body. It is extremely important that information on the uptake of new technologies, new drug therapies and new clinical practices are gathered together, made available and fed back into the future planning of healthcare. For all that the independence of foundation trusts is to be welcomed, there is a genuine fear that there will be a

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dissipation of the gathering of data that will inform the development of future quality healthcare and, in particular, the innovation and effectiveness of new treatments.

It is perhaps a truism, but in some disciplines of healthcare novelty in itself is often taken to be a quality standard. If one were to go back to look at the provision of some treatments—statins, for example—perhaps novelty in itself is not a quality standard. Some very old treatments which have been around for a very long time are far more effective.

The coherence which these amendments would bring to the gathering of quality data by CHAI and CSCI is to be welcomed. I believe that there is a case for making this responsibility explicit on the face of the Bill. I beg to move.

Earl Howe: I am in complete sympathy with what the noble Baroness has said. I should like to speak to Amendment No. 274 in my name, which aims at very much the same goals as those of the noble Baroness.

There is considerable concern, as I am sure the Minister is aware, about the patchy implementation of NICE guidance around the country. NICE guidance is meant to be binding on PCTs and trusts, but there is considerable evidence to show that it is being quietly ignored where budgetary constraints get in the way. The review being conducted by Professor Trevor Sheldon will no doubt prove illuminating. But meanwhile, there is a strong case for ensuring that a systematic and transparent process is put in place to ensure that NICE-approved medicines and technologies are accessible to all who need them. CHAI is the body most obviously suited to this task.

Only last week we saw reported in the press the research by Glasgow Royal Infirmary showing that NICE guidance on statin prescribing is being widely ignored. Another example is atypical antipsychotic drugs; the Zito Trust has highlighted considerable variations in prescribing around the country. In some areas, atypical antipsychotics account for 70 per cent of all antipsychotics prescribed; in others, only 20 per cent. This is a concern in many areas. I understand the normal rule is for PCTs to implement guidance within three months. That is certainly not happening in many instances.

I have consciously mentioned medical technologies as distinct from medicines. Medical technologies, such as pacemakers, stents and implantable defibrillators are implanted into patients in specialist centres, and not all are subject to national registries or have audit databases associated with them. As a result, unlike prescription drugs, reliable data on the uptake of medical devices are not available, and it is unclear whether government and NICE targets are actually being met. There is anecdotal evidence that they are not, particularly in relation to some cardiac and orthopaedic treatments. The first step towards enabling CHAI to monitor effectively the uptake of technologies and to highlight regional disparities

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would be for appropriate data to be collected at PCT and NHS trust level. I very much hope that this will happen.

Hazel Blears, the former health Minister, was quite clear on the matter when she spoke in another place on 10th April. She said that it was the Government's view,


    "that the Commission for Health Audit and Inspection should be the principle external inspector of the implementation of NICE guidance . . . I expect that CHAI's work will cover clinical guidelines, as well as the appraisals that are integral to the clinical governance agenda in the organisation".—[Official Report, Commons, 10/4/03; col. 147WH.]

Noble Lords will note that I specifically mentioned in my amendment not only health technologies but the clinical management of specific conditions.

Hazel Blears' words seem unequivocal, but the Bill at the moment contains only an implicit duty for CHAI to monitor the update of NICE guidance. The duty ought to be statutory and the implementation of NICE guidance ought to be incorporated into CHAI's annual report to Parliament.


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