Previous Section Back to Table of Contents Lords Hansard Home Page

Baroness Finlay of Llandaff: My Lords, will the Minister clarify for me that the inspection process for patients who have a lot of clinical input as well as a lot of social care input will be conducted only by CSCI? Alternatively, is he saying that, for patients for whom there are big outreach services from hospital, there would be a joint inspection process to make sure that there were not gaps in provision and that the patient did not miss out on high quality services on both sides of their spectrum of need?

Lord Warner: My Lords, I am saying exactly that—that the two inspectorates would work together, but who would lead would turn on where the balance of post-hospital care was being provided from. It would depend on whether there were, in effect, an outreach of the hospital or a transfer largely to the supervision of the social care agency.

Baroness Barker: My Lords, I thank the Minister for his answer, which served to strengthen my argument. There is still a tremendous lack of clarity about who will inspect medical services provided in the community. I agree with the noble Baroness, Lady Howarth, about the importance of social care and social rehabilitation. She and I have no argument on that at all. My concern remains about the quality of medical services, no matter how few or incidental they may be, to people cared for primarily in a social care service. I do not think that CSCI will ever be in a position to make clinical judgments about care of people in the community; that is the concern behind the amendment.

The comments of the noble Baroness, Lady Finlay of Llandaff, are helpful and have got us somewhere. Clearly we shall not get much further on the matter at this stage. We may not return to the issue, but professionals certainly will, time and again. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

10 Nov 2003 : Column 1115

Earl Howe moved Amendment No. 284:

    After Clause 44, insert the following new clause—

(1) The CHAI stall be the principal guardian of standards in the NHS and shall prepare and publish standards in relation to the provision of health care by and for English NHS bodies, Welsh NHS bodies and cross-border SHAs.
(2) The CHAI must keep the standards under review and shall publish amended standards whenever it considers it appropriate.
(3) The CHAI must consult the Secretary of State, the Assembly and such other persons as it considers appropriate before publishing a statement or amended statement under this section.
(4) The standards set out in statements under this section are to be taken into account by every English NHS body, every Welsh NHS body and every cross-border SHA in discharging its duty under section 45."

The noble Earl said: My Lords, in moving Amendment No. 284, I shall speak to Amendments Nos. 286, 287, 288, 333, 340 and 342. We come to an issue that, perhaps par excellence in this part of the Bill, points out the major gulf between the Government and ourselves, which is the question of who should carry responsibility for setting the standards in health and social care that CHAI and CSCI are to police. The Government say that if standards are not set by Ministers, that is an abrogation of ministerial responsibility and that, furthermore, it is wrong in principle for CHAI or CSCI to be both standard setters and the judges of whether those standards have been complied with.

I fundamentally take issue with those propositions. If there is one overriding problem with the NHS, it is the tendency of Ministers to second guess the clinicians and managers working in the service by setting them objectives that are, at root, political. They do it for understandable and well intentioned reasons, but it is a mistake. As the noble Earl, Lord Russell, shrewdly observed in Committee, benchmarks set for the NHS by politicians contain hidden clinical judgments, which politicians are in no position to make. If we are serious about de-politicising healthcare, Ministers have to stand back from the whole business of dictating targets and standards. They need to do that in order that the patient can be quite certain that the health service is being assessed, not in terms of what Ministers believe that patients should want, but in accordance with objective standards of quality devised by those professionally fit to devise them.

In making that case, I am not seeking to deny that the Secretary of State has a legitimate interest in the standards set in healthcare. He clearly does, and should be consulted accordingly. His views should count. Nor am I suggesting that CHAI and CSCI should not listen to anyone else in drawing up and interpreting the standards to which they work. Plenty of other people, not least patients themselves, have a legitimate role in that context. Clinicians, managers and voluntary organisations also have a role. But when we talk about who should have primary responsibility for the standards that operate, who should take ownership of them and who should be their chief defender and promoter, there can be only one answer: the two professional bodies themselves.

10 Nov 2003 : Column 1116

In 1997, a standard was set for the NHS. That was to reduce waiting lists. That standard was no more sensible than that which was subsequently set by the Government, which was to reduce waiting times. Both those standards required clinicians and managers to do things that ran directly counter to their professional judgment. If CHAI and CSCI find themselves in a position where they are unable to defend to the hilt the standards they propound as being clinically and ethically well founded, they will not be seen as credible organisations. That is not to say that they should ignore the budgetary constraints within which the NHS must operate or set standards that are financially or practically out of reach. However, if the Minister were to speak to Sir Ian Kennedy, as I am sure that he has done, he would realise that Sir Ian has a clear idea of the domains of work in which CHAI will be engaged, and that those domains, which are relatively few, will embody the standards to which CHAI will work. I was dismayed when the Minister told me in Committee that the draft standards to be published later in the year would incorporate a multitude of subject areas. The Government seem to be in danger of making the same mistake as they have made for the past six years, which is to be far too prescriptive in their approach to healthcare.

I do not expect to persuade the Minister of my views, but I hope that other noble Lords will be persuaded. The work that we are discussing is directly comparable in its need for impartiality and professionalism to that of the Audit Commission. The idea that the standards to which the Audit Commission works should be set by politicians ought to fill us with horror. It is the same in this respect. CHAI and CSCI must be able to do their work without fear or favour, because only in that way will we fully trust them. I beg to move.

Lord Peyton of Yeovil: My Lords, I shall speak to my Amendments Nos. 285 and 287. I hope that the Minister will be a little more receptive than he was last Thursday, when he accused my noble friend, of all people, almost of obstructing the Bill, which was the last thing he was seeking to do. He was so ungracious that the only people who were indebted to him—although I do not suppose that they thanked him as cordially as they might—were the Opposition Whips. They enjoyed a successful vote largely due to some of the language that the Minister used.

The amendments reflect the muddle that the Government are in in having two horses, the Department of Health and CHAI. The Bill states that the Secretary of State "may" prepare and publish statements of standards. It is important that somebody should publish statements of standards. It would be difficult for practitioners to comply with requirements that have not been made absolutely clear to them. I notice that Clause 46, which deals with the standards that are to be set by the Assembly, states:

    "The Assembly may prepare and publish statements".

It goes on to state:

    "The Assembly must keep the standards under review".

10 Nov 2003 : Column 1117

My amendment would put the Secretary of State under a clear duty to do that. The preparation and publication of statements of standards should not be carried out on a voluntary basis. It should be an obligation. Clause 45(2) states:

    "The Secretary of State must keep the standards under review".

That is quite right, so why should he not be obliged to make them clear in the first place? I do not suppose that the Minister will accept the amendments, but they are tabled in the pious hope that he might perhaps be a little more receptive and not think that everybody on this side of the House is out simply to obstruct the passage of the Bill. We seek merely to help the Government. Some of us are hurt and upset that they appear to be as unappreciative as they usually are.

4.45 p.m.

Baroness Finlay of Llandaff: My Lords, the amendments are interesting because they draw out the distinction between clinical standards and service delivery targets. The latter are often called standards, but that is a misnomer.

Clinical standards are absolute. They are evidence based and they are the result of scientific inquiry—usually level one evidence from randomised control trials. Those standards are set within the context of national service frameworks. They are set according to NICE guidance; prescribing standards; the royal colleges' clinical standards; and the National Patient Safety Agency.

The second group are the targets: the service configuration standards, which vary according to political emphasis. They provide performance benchmarks such as waiting times. Clinical standards between England and Wales do not and cannot differ. It would be to fly in the face of scientific evidence to suggest that they could differ. However, performance standards inevitably will differ, because they will reflect policies, priorities, structures and circumstances on the two sides of the border. The Welsh Risk Pool, for example, has its own performance frameworks. The royal colleges' advice on service configuration will be interpreted slightly differently depending on the population to which it has to be applied. Service targets will arise from them that are within ministerial control.

I shall try to illustrate that difference with one clear example. The diabetes national service framework suggested that retinopathy should be detected early through a retinopathy screening programme. In Wales, that was instigated immediately, but there was a lag in England and Scotland. Nobody has disputed the clinical standard against which retinopathy should be screened, but the service targets varied on the two sides of the border. I am proud that England and Wales have now decided to follow the Welsh example.

That is a clear example of how distinct the clinical standards are. The amendments draw out that distinction and clarify that the guardian of the clinical standards cannot be within ministerial control. Those standards must relate to the bodies which conduct the background research and systematic reviews and

10 Nov 2003 : Column 1118

which produce the hard, often irrefutable evidence that dictates the direction in which the service should go.

Next Section Back to Table of Contents Lords Hansard Home Page