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Lord Roberts of Conwy: I support my noble friend's amendment and the thrust of the amendment moved by the noble Baroness, Lady Barker. I have received a very good brief from the Medical Technology Group, which points out that medical technology is transforming healthcare by achieving a higher return on resources allocated for improved patient health and health system outcomes. The group gives a variety of examples, saying that diagnostic imaging virtually eliminates exploratory surgery; lasers allow more rapid recovery from eye surgery and other procedures; minimally invasive surgery avoids lengthy hospital stays and long recuperation; and so on. I have no doubt that the group is correct in its assessment.

The group points out that medical technology not only benefits the patients but creates greater efficiency and savings in the health system, greater productivity, faster recovery times, a quicker return to work and lower absenteeism. Advances in technology have made exciting, groundbreaking possibilities a reality, and there are many examples of that.

The use of medical technology and the resulting cost savings to the NHS and improved patient outcomes will enable the Government to achieve many targets as set out in the national service frameworks and Department of Health guidelines. It will also enable NHS bodies to fulfil requirements laid down in technology appraisals published by NICE, and ensure that the statutory requirement that funding follow all NICE decisions is met.

Earl Russell: As an academic, I am used to the problems that arise when a government attempt to assess quality. I am very happy to support my noble friend's amendment, which I believe to be necessary.

I spoke recently with someone who had been in hospital for purposes of gender reassignment, who was very far from convinced that she was getting equal treatment to some of the other patients in the hospital. I remember on another occasion listening to a junior Minister, whom I will not name because, although he

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did not say so, I take him to have been speaking under Chatham House rules, who was very far from convinced that in the field of mental health patients received equal treatment.

There are big questions here that need addressing. The only trouble with tabling any amendment to any Bill is that it necessarily has to be cast in terms comprehensible to the Bill. That, I am afraid, one cannot get round; but it may be that it is the terms comprehensible to the Bill that we need to consider. All the Government's thinking on quality within the profession rests on two premises. One is that government are capable of recognising quality when they see it. The other is that quality is ultimately quantifiable. It is about time that the Government started wondering whether the two assumptions need double checking.

I remember reading a letter in the Independent from someone who had recently had a heart operation, from which, when he went in, his chances of recovery were approximately 50/50. He was being operated on by Sir Magdi Yacoub, who came to see him the night before, ran through a standard series of medical checks that he had to do, then spent half an hour sitting with him talking about Bach. The patient ascribed his survival to that half hour's conversation about Bach. We shall never know whether it is true or not, but I found it plausible. How do we quantify that in any form of performance indicator? Is that what distinguishes a great doctor merely from a very good one? If so, how an earth is the state ever going to recognise it?

Lord Warner: Although I applaud the sentiments behind the amendments and very much welcome many of the contributions made by noble Lords, I hope that I shall be able to provide sufficient reassurances to support our view that the amendments are unnecessary.

We believe that the significance of NICE and the national service frameworks will be adequately reflected by the provisions already in the Bill. I shall briefly refer to the remits and purpose of those two pieces of activity. NICE's formal remit is the promotion of clinical excellence and the effective use of available resources in the health service, as the Secretary of State may direct. It is therefore central to our plans to modernise the NHS and drive up standards. I should like to give an illustration of the amount of effort being put in. There are currently 48 guidelines and 41 technology proposals in simultaneous preparation, making it the largest programme in any country. It is respected throughout the NHS and, indeed, throughout the international community. The national service frameworks are another element of the overall programme of modernisation.

There is a set of arguments that I want to deploy from those two pieces of activity, which are designed to help us to improve health and social well-being by providing services to more people more quickly and to a higher standard; improving the patient experience, reducing variations in care across the country; and increasing compliance with evidence-based practice.

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The processes for doing that are enshrined in the Bill. The Explanatory Notes make it clear that it is envisaged that any statement of standards issued and published by the Secretary of State under Clause 45 of this Bill is likely to be informed by national service frameworks, NICE guidance and other relevant sources.

Having established NICE and national service frameworks, it would be bizarre if the Secretary of State ignored all that work and those activities in setting the national standards that he will have to set and which will be made public later this year. As the Minister responsible for overseeing the work on national standards, I can assure Members of the Committee that the experience of NICE, national service frameworks and others will be reflected in those national standards. We are building up national standards that reflect those particular pieces of work and experience.

Clause 45, which relates to national standards published by the Secretary of State, makes it clear that any NHS body and cross-border strategic health authority is under a duty to take such standards into account in discharging its duty of quality under Clause 44. There are some strong mechanisms for building the work of NICE and the national service frameworks into the national standards.

The Bill then requires CHAI to produce criteria which the Secretary of State will ultimately approve which are compatible with measuring performance against those national standards. In our view those arrangements are strongly enshrined in this piece of legislation.

As I said, CHAI must take account of those standards when it undertakes its reviews. I remind the Committee that NHS bodies are also under an obligation to provide funding for treatments and drugs recommended by NICE within three months of guidance being issued. Of course, we know that there are some problems in some parts of the country with meeting that obligation but the obligation is clear and statutory. CHAI will therefore take account of statutory obligations on NHS bodies when carrying out its reviews. I suggest that we have a well-established set of arrangements which enshrine NICE and national service framework work in the standards that will be set under this legislation. The criteria that CHAI establishes will be consistent with those national standards. The work of NHS bodies will be inspected and reviewed by CHAI using those criteria. It will become apparent in the work done by CHAI where particular bodies are not operating in a way which is consistent with national service frameworks and with NICE guidance.

5 p.m.

Baroness Barker: I thank all Members of the Committee who took part in this extremely useful debate. I note particularly the comments of my noble friend Lord Russell who, as ever, takes us into the heart of a point very memorably.

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The Minister's response was encouraging but not sufficiently encouraging to dissuade me from returning to the matter at a later stage. Great Explanatory Notes of History is not a tome that I have read. The explanatory note that the Minister read out does not carry sufficient force to satisfy me or, I imagine, the noble Earl, Lord Howe. I believe that we agree that there is much good work going on, particularly in national service frameworks. The difficulty is that they do not have the force of statute and their implementation is therefore a matter of some randomness. That is the heart of the issue. The Minister's response did not go far enough to satisfy us that in future all that good work will be implemented. The question remains why the Government are running away from their own good work. I thank the Minister for his reply. I shall withdraw the amendment for the moment but I signal that this is a matter to which I am sure we shall return. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Barker moved Amendment No. 254:


    Page 16, line 20, at end insert "; and


(c) services to support independent living and rehabilitation"

The noble Baroness said: I turn to two other matters which again relate to quality in healthcare. The lack of definition of "quality" has concerned a great many organisations in different fields. The double whammy of a lack of definition of "quality" and the lack of clarity about the extent to which foundation trusts will pursue objectives which mesh with the rest of the healthcare system prompt these two probing amendments—Amendments Nos. 254 and 255.

Amendment No. 254 relates to rehabilitation and independent living. The amendment was no doubt drawn up in the wake of our discussions on delayed discharge. There is great fear that foundation hospitals, as bodies concerned principally with acute care which are at some remove from the rest of the healthcare system, will not place the emphasis that they should on the key factors in the lives of the largest number of their users—older people and other vulnerable adults.

Amendment No. 255 refers to the need to consult with patient representatives and clinical experts and tries to determine what quality standards are. In speaking to a previous group of amendments, I said that there was a great deal of emphasis on managerial matters such as response times and numbers of staff. However, there is much less emphasis on what could truly be described as qualitative matters, for example, cleanliness in hospitals. I was reminded of that in our discussions on patients forums. Patients and users had been aware of problems arising from lack of cleanliness in hospitals long before they reached

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Ministers' desks. The amendment seeks to include those people who have a slightly different perspective on the matter in the drawing up of the definition of "quality". It is important that we seek to widen definitions and to get away from number crunching as a way of determining whether foundation trusts will work and whether healthcare is of a sufficient quality. I beg to move.


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