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Earl Howe: I am grateful to the Minister, but I am dismayed to hear that the department intends to promulgate an inordinate number of standards for CHAI to implement. I can only return to the concerns that I raised in a debate on a previous group of amendments. The provision is inordinately prescriptive. I am not sure how welcome the Government's approach will be to CHAI either, although that must be a matter for Sir Ian Kennedy to judge. Clearly, my amendment was a probing one. It has probed very successfully and we will have to reflect long and hard on the implications of what the Minister has told us. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 260A to 267 not moved.]

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Clause 45 agreed to.

Clause 46 [Standards set by Assembly]:

Earl Howe moved Amendment No. 268:


    Page 17, line 6, after "such" and insert "NHS bodies in areas of England adjoining Wales and cross-border SHAs and such other"

The noble Earl said: Even if the Government are unable to agree with the arguments that I tried to put forward earlier, I would strongly urge them to consider this amendment. It suggests that, before publishing a statement of standards, it should not be enough for the Assembly to consult such persons as it considers appropriate. It should be obliged, at the very least, to consult those hospitals and SHAs in border areas of England that may be affected by the standards that the Assembly sets in Wales.

English hospitals will be performance managed by English strategic health authorities according to standards laid down in England. If those hospitals accept Welsh patients, everyone must be clear about the standards to which doctors, nurses and managers should be working with regard to the care of those patients. If it is proposed for example, that Welsh NSFs, not English NSFs should apply to Welsh patients, not only do the English hospitals and their doctors have to sign up to that difference, the strategic health authority must also take it into account for performance management purposes. To take a hypothetical example, if beta interferon were the treatment of choice under Welsh standards of MS treatment but not English ones, that would have direct budgetary and clinical consequences for English hospitals and their staff.

Alternatively, the Assembly may accept that Welsh patients who are hospitalised in England should be subject to English standards of treatment. In that event, equally, consultation would be necessary with those English health bodies potentially affected.

Ideally, the standards laid down on both sides of the border would not differ from one another, but if that is to be made to happen—as opposed to being a fond hope—there is no possible argument for the Assembly failing to consult relevant health service bodies in England. Either way, with the greatest respect for our Welsh friends and colleagues, it makes no sense for Wales to treat itself as an island in drawing up its standards of treatment. It must bring into its deliberations all those across the border whom its decisions will affect. I beg to move.

Baroness Finlay of Llandaff: I have listened carefully to the debates about standards, and I have many questions for the Minister about the relationship between devolved healthcare in Wales and the situation in England. I seek some assurances.

My understanding was that, if the Secretary of State set standards in England, the National Assembly for Wales would have to pick up through CHAI only the standards that it thought were important for the population of Wales, particularly if there were thematic issues, such as apply to cancer care, or major cross-boundary flows, such as in cardiac surgery. That

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would allow the Assembly to benchmark services in Wales against services in England, and it would be able to establish local standards in Wales that would be monitored by the healthcare inspection unit in Wales, which will benchmark standards throughout Wales. The reason was that inspections by CHAI in Wales would not be as frequent as those by the healthcare inspection unit, whose role would be to run an ongoing monitoring process to drive up standards.

I seek clarification that the clause will ensure that that process will happen, that, as part of that process, cross-border issues will be covered and that, with thematic flows, there will be equity of standards for patients travelling across the border.

Baroness Andrews: Some of the issues raised by the noble Baroness, Lady Finlay of Llandaff, come up in a later amendment. I may decide to answer them in the context of the later amendment. I may also decide that it would be better to answer her specific questions in writing to ensure that there is clarity of understanding on the issues.

The noble Earl's amendment would place an obligation on the Assembly to consult English NHS bodies operating in areas that adjoined the Welsh border before publishing a statement of standards. I hope that I can convince the noble Earl that such an amendment is unnecessary.

The noble Earl said that everyone needed to clear about what will be inspected and against what standards and why. We have not had the clause stand part debate on Clause 46, so I simply refer to what my noble friend said about how important it was that Wales developed its own standards. He made the dual case that it was a devolution issue, as a matter of principle, and, secondly, that it was a practical issue because Wales was different. It would take me too long, even with the assistance of the noble Baroness, Lady Finlay of Llandaff, to explain why Wales is so different, but the Committee must take it from me that it is.

One of the things to be seen particularly in Wales is a different pattern of epidemiology. There is different social and medical geography, and there are different concentrations. Obviously, clinical standards do not vary, but the new Welsh health authorities are trying to deal with issues in a different way. Within what we might think of as a suite of standards—not simply a set a standards—clinical standards will be the same, but organisational principles will be different. For example, in Wales, one of the organisational targets that we might set is to have more work done through the medium of Welsh. We might also, for example, see a higher priority being given to primary care because of the relative quality of primary care. Therefore, there will be differences in the priorities that are set. When we are talking about Welsh standards, that may be the type of priority we are considering.

As regards the amendment, I want it to be clear that, under the Bill, the Assembly does not and will not set standards that apply to healthcare provided by English bodies for English patients: nor should it.

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Ultimately, it will be for the commissioning body—whether it be Welsh or English—to take responsibility for the provision of care to patients from its areas.

The Assembly's responsibilities for setting standards quite properly extend only to the NHS in Wales and to those English bodies which provide healthcare for Welsh patients under the commissioning arrangements already in place. Those commissioning arrangements have been in place for many years and they work. There has rarely been much contention attached to them.

In cases where English bodies provide healthcare to Welsh patients, they will be acting, in effect, as sub-contractors, as they always have done. As with any other contract, Welsh commissioning bodies would expect to be able to set the contract conditions, which, in this case, would be the standard to which healthcare is to be provided. In the same way, Welsh bodies contracting with English commissioning bodies to provide services to English patients in Wales would expect those services to match the standards set by the Secretary of State and CHAI to ensure that the terms of the contract have been complied with. Since those boundaries will be in place, there would be no reason for cross-border consultation because I am certain that it will be clear.

I stress, as I have before, that clinical standards do not and should not vary across the NHS in England and Wales. In setting standards in Wales which reflect the particular needs of Wales, as I have tried to illustrate, the Assembly will do that in the light of cross-border England and Wales bodies, such as the National Institute for Clinical Excellence and the Royal Colleges. With those reassurances, I hope that the noble Earl will withdraw the amendment.

Earl Howe: I realise that the noble Baroness has tried to be helpful. Patients in Wales and England do not expect two sets of standards that are roughly the same. They expect the same sets of standards, which, I believe, are quite a different matter from prioritising healthcare needs. The Welsh Assembly is entitled to prioritise the way in which funds are used to treat patients in Wales. I have no quarrel with that. The standards by which those services are delivered should not differ from those that operate in other parts of the country.

We might debate Clause 46 stand part to wrap up these issues. I sense that a number of Members of the Committee would welcome a return to this issue, albeit it a brief one. I do not propose to say any more on the amendment. I am disappointed that the noble Baroness seems to think that there is no need for a consultation requirement for the Assembly. I still believe that there is. I shall read carefully what she said and I will reflect on the matter between now and Report. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

On Question, Whether Clause 46 shall stand part of the Bill?


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