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Lord Warner: The amendment is totally misplaced. It would be inappropriate for CHAI to review the Secretary of State against his public service agreements, as he is accountable to Parliament; so it is for Parliament to question him about his actions in implementing those agreements. If there is disagreement about how the Secretary of State has behaved over public service agreements, it is for Parliament to call him to account; it is not for CHAI to monitor the performance of public service agreements. It is always open to CHAI, should it so wish, to give advice to the Secretary of State, under Clause 53, concerning the relationship between the implementation of the agreements and the provision of healthcare by NHS bodies.

Strategic health authorities also have a key role in performance-managing aspects, such as the reduction of health inequalities, which are part of public service agreements. CHAI will also have a role in reviewing the performance of PCTs and acute trusts in tackling health inequalities. In several areas, specific parts of public service agreements will fall into the territory that CHAI will cover. But CHAI should not have an overarching duty to monitor the Secretary of State's performance against his public service agreements.

Baroness Noakes: Well, what a surprise! The Department of Health does not want to have its performance scrutinised. The amendment refers to CHAI publishing data relevant to the appraisal of whether the Department of Health had met its public service agreements. It is not about CHAI calling the Secretary of State to account; nor is it about giving an inappropriate role to a public body. Under the amendment, CHAI would have access of a very particular and privileged nature to the data that would enable judgments to be made.

The Minister talked about strategic health authorities having a role in the delivery of some of the targets related to health equality. That is absolutely

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fine. CHAI would be the best placed body to have access to the data held within the strategic health authorities on the achievement of their targets. It would be best placed to say whether the data were good or bad.

The Minister cannot realistically argue that the Department of Health and the Secretary of State for Health can continue to escape with choosing the terms by which their own performance will be judged. It is a very serious issue. I shall not press the amendment now, but I give notice that I shall return to it on Report. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 280A not moved.]

Clause 48 agreed to.

Clause 49 [Annual reviews]:

Baroness Noakes moved Amendment No. 281:


    Page 17, line 35, after "English" insert "and Welsh"

The noble Baroness said: In moving Amendment No. 281, I shall speak to the other amendments in this group. It is a long group of amendments, and I am afraid that I shall take several minutes of the Committee's time to cover various aspects of the position in Wales and related cross-border issues. We have touched on some of them, but the amendments address slightly different aspects of the Welsh issue.

The amendments fall into two main groups. Amendments Nos. 281 to 306 together would ensure that CHAI is the inspection body for both England and Wales. Proposals in the Bill to limit CHAI to England are unacceptable, because in Wales reviews and inspections are to be carried out by the Assembly; that is, politicians in Wales. It is not only wrong in principle for the review and investigation functions in Wales to be carried out by a politically controlled organisation, it is also inefficient. How can Wales, with its much smaller health budget, begin to amass the competence and expertise that will be grown in CHAI? Why do the Government want to expose the Welsh healthcare system to a system of inspection that, by definition, will struggle compared with CHAI?

When this matter was debated in Committee in another place, the Minister failed to produce any example of Welsh diseases being different from those in England or how the provision of healthcare in each country would be different. He certainly failed to produce an example of how patient care would in any way be enhanced by separate inspection arrangements. Devolution was not meant to mean substandard.

The noble Baroness, Lady Finlay, who is unfortunately not in her place, referred to different incidences of disease, but that is a different matter from different diseases and different patient care solutions. The noble Baroness, Lady Andrews, tried to convince us that Wales was different when she spoke to the earlier group of amendments, but I was not convinced that they were not distinctions without a difference.

Amendment No. 302ZA is a probing amendment to try to discover what CHAI's responsibilities are for healthcare in Wales. Clause 53 gives CHAI a number

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of functions of keeping both the Secretary of State and the Assembly informed about healthcare. However, as we have seen, the Bill is at pains to ensure that CHAI has very little remit in Wales. Our amendment makes it clear that CHAI should report only on things that it has looked at in Wales. Without something like this, it is difficult to see how CHAI could be expected to comply with Clause 53.

The second group of amendments—Amendments Nos. 326 to 331 and Amendment No. 334—concern the interface between the Assembly and English NHS bodies. The amendments are predicated on the Government sticking to the Assembly keeping inspection functions and the focus of the amendments is alternative ways of keeping the Assembly out of the NHS in England. Amendment No. 326 is the most modest of the group. It amends Clause 68(1) so that the Assembly's function of reviews will be carried out,


    "where appropriate in conjunction with the CHAI".

Amendment No. 331 is similar and states that the Assembly may request CHAI to carry out a report on an English body.

Amendment No. 327 goes further and makes it a positive duty of the Assembly to request CHAI to do work that relates to English bodies. Amendment No. 330 restricts the Assembly's inspection rights to Welsh bodies only, coupled with Amendment No. 334, which removes the rights of the Assembly to enter premises outside Wales.

We incline towards Amendment No. 327, because we believe that hospitals should be subject to inspection that is free from politics. That has to mean CHAI rather than the Assembly, which is no more than a bunch of politicians. It would be a retrograde step to let politicians directly into the English NHS, even if devolution has given them a free hand in Wales.

The English hospitals that the Assembly might choose to review are already subject to review by CHAI. Indeed, CHAI would have the major inspection interest because of the dominance of English patients in English hospitals. Unless we do something positive in this Bill, English hospitals could become the subject of two inspections directed at the same issue. There is a duty to co-operate in Clause 141, which is better than nothing, but it does not take the Assembly clearly out of English hospitals.

I will now touch briefly on Amendments Nos. 328 and 329 which concern how the Assembly should conduct its functions when there are English interests at stake. Amendment No. 328 requires the Assembly to take into account the impact of its decisions on healthcare in areas of England that border Wales. Let us suppose that the Assembly decided to review coronary care provision with the needs of only Welsh patients in mind. Its decisions could have a big impact on English hospitals and English patients and so it needs to consider cross-border implications in its reviews.

Amendment No. 329 makes it clear that, if the Assembly is reviewing an English body, it must judge it against the standards set by the Secretary of State under Clause 45 and not the standards set for Welsh

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bodies under Clause 46—my noble friend has already referred to that issue. It cannot be right that English hospitals must follow both Welsh and English standards if they are different. That is burdensome for doctors and nurses who would have to inquire as to whether their patients were funded by England or Wales, which is simply nonsense. That is not the way that healthcare should develop. Much of what I have said applies also to the Assembly, CSCI and English local authorities. Amendments Nos. 361 and 399 repeat some of the CHAI amendments for CSCI. The principles are the same. I beg to move.

Baroness Andrews: This is a reprise of our earlier debate, although I take the noble Baroness's point that she has raised some different issues.

I shall take two points that the noble Baroness made right at the beginning. She deplored what she saw flowing from the function of the Assembly as the inspectorate in Wales. She said that it was a case of politicians doing the job of inspectors. I stress the independence of Health Inspectorate Wales, which is to be put in place under the Government of Wales Act 1998. I shall not rehearse the arguments for a devolved Welsh health policy; we have gone over it a lot today.

The new health inspectorate in Wales will enjoy exactly the same independence as other inspectorates established by the Assembly. In Wales, we already have a fine schools inspectorate, Estyn, which is completely free of the Assembly, and there has never been any criticism of its independence. The new inspectorate will be in that tradition. Likewise, the Social Services Inspectorate for Wales and the Care Standards Inspectorate for Wales have already proved their independence.

The independence of HIW will be clearly defined in the same way. The head will be appointed through existing senior Civil Service appointment procedures. There will be complete editorial control and the right to publish. The reports will be submitted to the Assembly's Minister for Health and Social Services and commissioned by the Assembly. There will be accountability to a senior Assembly director. There will be rights of independent access, an independent complaints procedure and so on. I hope that the noble Baroness is convinced by that, as the Assembly is convinced, and by the fact that the other inspectorates work extremely well in Wales and perform their functions independently.

The noble Baroness's second group of amendments contains some contradictory alternatives to the measures in the Bill. As noble Lords have not given notice of an intention to oppose the Question that Clause 68 stand part, I assume that the amendments were exploratory. They go from one extreme to the other: at one extreme, the amendments extend CHAI's review and investigation function to Wales and, in so doing, duplicate the power in Clause 68 for the Assembly to review services commissioned for the people of Wales under the standards set by the Assembly. We have had that debate, and we have explained why it is important.

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The remaining amendments put a fence around Wales, leaving the Assembly to review services in Wales but requiring it to ask CHAI to fulfil the Assembly's review functions in respect of English providers of services to Welsh patients. At their most permissive, they simply allow the Assembly to invite CHAI to exercise its functions in England.

We have dealt with the more prescriptive approach. I have made the case for Health Inspectorate Wales. I hope that I have shown that it will be independent—necessarily so, as it will be locally based and sensitive to the different organisational structures and healthcare needs in Wales. The noble Baroness, Lady Finlay of Llandaff, gave us what I am sure we all agree was an astounding set of examples of why Welsh healthcare was different. The concentrations of disease are different; the morbidity patterns are different; the mortality patterns are different; and the rates of occupational disease are different. Wales needs its own sensitive organisation to deal with that.

I reassure the Committee that we are not saying that the independent inspectorate will be introspective or isolationist in its reporting. It will co-operate with other bodies operating in Wales, including CHAI and the social services inspectorate. I have already referred to Clause 141, which imposes the duty of co-operation. It is more than a start. It will be a duty that will be implemented and observed and it is a very important safeguard.

In relation to other issues raised—including cross-border issues—the Assembly has overall responsibility to ensure that appropriate healthcare is provided. A great deal of that is done under commissioning arrangements. The Assembly therefore needs the powers, as well as the functions, to review healthcare. Clause 68 gives the Assembly those powers. They are identical to those provided elsewhere in the Bill for CHAI, which will carry out reviews and so forth.

The problem with Amendment No. 334 is that it would make the exercise of the power impossible. It would deny the Assembly's health inspectorate access to premises in England. Let me be clear: Clause 68 is not a carte blanche. It does not mean that HIW will wander at will across the English countryside inspecting wherever it chooses. It is a closely constrained power to review or investigate where services are commissioned.

The border arrangements are based on years of experience. I shall not bore the Committee with the tale of my tonsillectomy when I was four years old. However, I can assure Members of the Committee that it was a very fine example of cross-border commissioning at the time, which can have only improved since then.

It is also important to bear in mind that HIW and CHAI will not arrive at the same hospital to do the same inspection in the same way. Obviously, they will work out who has done an inspection, whether an inspection is required in the near future, and who will carry out it out. There will be the dialogue that presently exists to ensure that those arrangements are sensible. The importance of co-operation is already

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recognised in the Bill. Clause 121 allows CHAI and CSCI to assist the Assembly in the conduct of their general functions. On the basis of those explanations, I hope we can agree that the amendments are unnecessary.

Amendment No. 302ZA is neither needed nor desirable. It would limit CHAI's ability to inform the Secretary of State or the Assembly about the provision of healthcare in Wales, except for national matters which it has reviewed or investigated itself. I cannot believe that this is in the interests of the NHS or patients because CHAI will have a focus on disseminating information. It will also be under a duty to co-operate and it must be able to access information that is necessary to undertake its functions. If it were denied opportunities to access relevant materials, it would impair and reduce its own function. Therefore, we know that there will be co-operation and sharing of information, not just with HIW, but with other bodies. It will be two-way traffic. CHAI will be in a position to add value to reviews—both those that it conducts and those conducted by HIW. It will not work in a vacuum, nor should the other bodies.

The reason that the Bill places duties on CHAI and others to co-operate is to ensure that the best information is available as widely as possible. As the noble Baroness rightly says, much of the work of CHAI and HIW will be of interest and value on both sides of the Welsh border. It would be wrong to constrain either body in the manner proposed in the amendment. With that explanation, I hope that the noble Baroness will withdraw her amendment.


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