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Earl Howe moved Amendment No. 289:

The noble Earl said: My Lords, in moving Amendment No. 289, I shall speak also to Amendments Nos. 324, 329 and 332. In Committee, we had a number of debates which drew attention to what one might term the "cross-border impact" of the Bill—that is, its effect on Wales as distinct from England and how, if we are not careful, one country will be directly affected by the provisions in the Bill which apply to the other country.

I admit that some of the amendments tabled in Committee were designed more to make a point about the perverse consequences of devolution than to offer up constructive answers to those problems. Nevertheless, the problems remain, and I regret to say that I do not believe that our debates thus far have resolved them.

The first issue relates to the standards which are meant to apply in English hospitals which treat patients under a contract from a Welsh commissioning body. On that issue the Minister said:

    "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".—[Official Report, 16/10/03; col. 1145.]

The question that arises from those statements is this: what will be the difference between the standards in force on each side of the border? The Minister said that, in practice, there would not be any difference. But she went on to say that in Wales things may well be done differently in an organisational sense and in relation to the priorities set there. She cited the example of more work being done through the medium of Welsh. Therefore, Welsh health bodies would be expected to work to a suite of standards, as I believe she put it—not simply clinical standards but others as well.

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That is where the difficulties arise. If it is the case that different standards are to operate on either side of the border, English hospitals which are located near the border with Wales and which treat Welsh patients will have two sets of standards in force—the standards set by CHAI and those set by the Welsh Assembly. I submit that that is not a sensible way to proceed.

Without any disrespect to Wales and its right to devolution in health matters, Wales should not be in a position to impose Welsh priorities, Welsh organisational standards or Welsh national service frameworks on English providers. If those in Wales attempt to do so, confusion will reign. A patient in one bed will be eligible for a different standard of treatment from the patient in the next bed with the same complaint. Clinicians will be expected to work to standards of which they cannot take ownership.

If that happens, how is the delivery of services to be assessed, and by whom? We cannot have two inspectorates, one from each side of the border, visiting the same English hospitals; nor can we sensibly ask the Welsh Assembly to delegate its overseeing role to CHAI because CHAI would be placed in the impossible position of having to police standards to which it did not itself subscribe. Yet one or other of those is the logical consequence of the Bill as it stands.

I stress again that in no sense am I seeking to turn back the clock on devolution. Let the Welsh Assembly decide on the appropriate standards and priorities for Wales. But, the moment we allow that jurisdiction to spill over into England, even by means of cross-border commissioning arrangements, we shall introduce unnecessary and inappropriate burdens that will do nothing but waste resources and place professional people in difficulties. The rule should be that if we have Welsh devolution, as we do, then its force should be felt in Wales and nowhere else. I hope that the Minister can be a little more reassuring on these issues than she was on the previous occasion. I beg to move.

Baroness Finlay of Llandaff: My Lords, I quake when I hear the noble Earl, Lord Howe, describe the differences between England and Wales. Offa's Dyke is not a Berlin Wall; it is an administrative boundary which is permeable and across which patients flow in both directions. I shall return to the figures of patient flow.

Because of that flow, the Assembly inspectorate, which will be Health Inspection Wales, and CHAI must co-operate and collaborate. I have already outlined why there can be no difference in clinical standards between England and Wales. However, there are, indeed, differences in the way that the service is being prioritised within Wales, and these are the standards which differ. For example, the National Assembly for Wales has set a 24-hour wait to be seen in primary care, not a 48-hour wait. Different priorities are set for emergency care. There is a priority for screening, immunisation and vaccination, all within Wales, and there are free prescriptions, which are meant to be for Welsh residents. I fear that there

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may be some abuse of that service at present but that will be addressed by a Question and not within this debate.

The demography in Wales differs from England, and across Wales there are vast differences. Overall 2 per cent more of the population in Wales are over 65, but in Cardiff 14 per cent are over 65 compared with 23 per cent being over 65 in Conwy. So, the Assembly has huge challenges in its devolved functions in delivering appropriate healthcare. Mortality rates vary enormously with Merthyr having a 50 per cent higher mortality rate than some rural areas.

I have said how the configuration of NHS systems differs. The local health boards took over the commissioning in Wales in March 2003. Health Commission Wales was established in April 2003 and commissioned specialist services. It commissioned 40 million worth of specialist services in England, which is 10 per cent of its total budget. It is specifically for that reason that there must be collaboration with CHAI and CHAI must be involved in setting thematic reviews; for example, of cancer services, diabetic services and coronary heart disease.

The reason that the Assembly needs to have an inspectorate is to have this strong focus on Welsh health priorities but it must in the process collaborate with CHAI. I hope that that is the spirit of the wording of the amendments tabled in my name. In Wales we have community health councils, which are able to identify gaps in provision. The Welsh NHS structure needs to be considered. Assembly Ministers also need to be able to respond to the intense scrutiny they are now under through robust, transparent, thorough and speedy reviews that can withstand that scrutiny.

I shall move on to why the chair of an inspection service in Wales must be independently appointed. The appointment of the head of Health Inspection Wales should be by an independent process. I understand that the Minister should not be able to veto the appointment of the individual but only the whole process and require that it starts again. Health Inspection Wales must have editorial control over its reports and those reports must go simultaneously to the Minister for Health and Social Services in Wales and to the Assembly Committee for Health and Social Services. They would also go simultaneously to CHAI.

The director should be accountable to a senior assembly director, who is not the director of the NHS in Wales and should have right of independent access to the Ministers and the Assembly Committee for Health and Social Services. Complaints should be dealt with by the Assembly complaints procedure and the Ombudsman. Delegation of functions will be through the permanent secretary, not the director of NHS in Wales.

Formal protocols are required for working between Health Inspection Wales and other parts of the Assembly, and formal agreements are required for working collaboratively between Health Inspection Wales and CHAI because of the cross-border flows.

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The inspectors should be made up of permanent inspectors and lay assessors. I hope that there will be an exchange scheme within the NHS within the whole of the UK including exchange with inspectors in the NHS Quality Improvement Scotland so that we establish methodologies and robust cross-border inspections as patients move across the borders.

For Health Inspection Wales the work programme should be generated by them and signed off by the Minister. Within Wales, co-operation and co-working needs to be with other bodies, such as the Audit Commission, the Care Standards Inspectorate for Wales and Social Services Inspectorate for Wales, all working with the community health council. That means that Health Inspection Wales will take over inspecting all services which deal with patients in Wales, including those that have home care teams that are currently subject to inspection by other departments. I am not sure that the noble Earl, Lord Howe, is aware that some teams have not been subject to health service inspections at present and have been inspected by bodies such as weights and measures, which is completely inappropriate. Health Inspection Wales will address all of that within Wales. However, when we come to the cross-border flows it must work collaboratively with CHAI as part of the contract monitoring process.

The simultaneous inspections will look at clinical and financial performance by all providers and that needs to be wherever the patients are cared for. The information from that process will be in the public domain and any inspections and information obtained by Health Inspection Wales will be fast-tracked back to CHAI.

I turn to the data. Last year 31,500 Welsh patients were cared for by English providers; 20,000 of whom were elective and 11,500 emergency treatment patients. However, the flow is also in the other direction. There were 11,500 English patients treated in Wales; 2,800 electively and 8,700 as emergency patients. So to try to separate the way that patients are cared for across Offa's Dyke does not become feasible.

The cost of Health Inspection Wales will be contained within the current envelope of 3.1 million and the collaboration should meet the criticisms of the noble Baroness, Lady Noakes, raised in Committee, that the Secretary of State needs advice through CHAI. Health Inspection Wales reports which are on the web will certainly be immediately available to everyone. But the collaboration that must be established—I sought to provide for that in Amendment No. 330 tabled in my name—is to ensure that the minutiae of detail of intelligence that is available to Health Inspection Wales would be fast tracked into CHAI through their collaborative working arrangements and they would develop joint methodologies.

The amendments standing in my name support how the inspectorates within Wales are driven by the Assembly but also support collaborative arrangements in both directions across the administrative divide between the Assembly and the Department of Health.

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5.15 p.m.

Baroness Carnegy of Lour: My Lords, before the noble Baroness sits down, is she saying that a hospital surgeon in a given hospital might have to operate different standards depending on whether a person came from Wales or England? That sounds as if it would be very difficult.

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