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Standing Committee A
Tuesday 4 December 2001
[Mr. Alan Hurst in the Chair]
Duty of quality
Dr. Evan Harris (Oxford, West and Abingdon): I beg to move amendment No. 161, in page 17, line 3, at beginning insert
'(1) In subsection 18(1) of the 1999 Act (duty of quality), after the first word ''of'' there is inserted ''the Department of Health,''.
The Chairman: With this it will be convenient to discuss amendment No. 160, in page 17, line 5, at end insert
'including monitoring the provisions of health and safety legislation and infection control measures'.
Dr. Harris: Amendment No. 161 is a probing amendment to discover whether the duty of quality, which is covered by the Commission for Health Improvement, extends to the working policies of the Department of Health. I hope that the Minister will reassure me and other hon. Members who are concerned about the matter.
One of the key influences on the delivery of quality in the health service is Department of Health policy. To a certain extent, the practices of the Department and its agents are already covered by the CHI. The danger is that the commission will spend its time inspecting the work of hospital trusts and primary care trusts; but those trusts merely do what the Government have asked them to do. That may be an effective ploy for the Government, becauseunintentionally or otherwise, and regardless of whether the commission finds good or poor practiceits reports will let the Government and the Department off the hook. However, the subjects of those reports will be attempting merely to implement policies promulgated by the Department of Health.
In earlier debates, I mentioned the Liberal Democrats' concern that, however well-intentioned they may be, the central diktats of the Department of Health may distort clinical priorities. By that, I mean that patients may not be dealt with according to their clinical needs, and that the work of doctors and nurses will be based upon the need to fulfil political targets set by the Department. I do not say that the Government invented that approach, but they have perfected it. We need not only a truly independent commission, but a definition of quality, which the Government should welcome, that allows the commission to take a
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circumspect look at whether the duties imposed by the Department on trusts and staff are in the interests of patients.
I welcome the Government's commitment to quality. We have always supported the setting up of the Commission for Health Improvement, and we welcome the initiative in the Bill to make the commission more independent. What better way could there be to show such commitment than the Government having the courage to allow the commission to inspect the work and policies of the Department of Health?
I accept that amendment No. 161 is not sufficient to add the Department of Health to the relevant parts of the Bill or of the Health Act 1999, which sets up the commission. I hope, however, that the Minister will reassure me that the Department's policies are already subject to independent expert overview through the Commission for Health Improvement, or in some other way.
The clauses that relate to the commission make it more effective. However, the more effective we make the commission, the more important it is that it should examine the policies of the Department, whoever controls it. The commission might decide that those policies, and the priorities that they place on the service, are good. The Government could publicise and benefit from such a judgment. However, many people in the health service whose work runs the risk of being deemed to be inadequate feel their political masters should run the same risk. Given the way in which the Government run the health service, they are, indeed, both political and masters.
I agree with those in the health service who feel that the quality agenda must be dealt with. There are problems with the delivery of quality, although we accept that they are not all due to under-resourcing and undercapacity. The publication this morning of the latest report by the national confidential inquiry into perioperative deaths puts the issue in similar terms. However, much of the failure to deliver quality is due to the lack of resources. Corners are cut because there are no funds for the staff, equipment, theatre lists, expert opinions and diagnostic techniques that would deliver the highest-quality service.
No local hospital or primary care trust can magic up extra resources; that is the responsibility of the House. It is also the direct managerial responsibility of the Secretary of State for Health, although it would perhaps be more appropriate to say the Chancellor of the Exchequer. Nevertheless, such matters are dealt with through Department of Health policies, allocations and prioritisations. The service is short of cash, and quality suffers as a result. In those circumstances, it would be invidious for the Department's funding and priority policies not even to be inspected. It is not a question of the Department getting off scot-free; indeed, the commission's diagnosis might be that there is no case to answer.
The Health Act 1999 does not lend itself to simple amendments that would include the Department, but it lends itself to some amendments. I accept that amendment No. 161 is not extensive enough to place a
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supervisory duty on the commission. However, a way could be found. If the Minister does not reassure me, we might have to return to the issue later. I hope that we can ensure that the commission examines the provision of health care and the quality of the commissioning of health care against the quality standard that, rightly, has been established. If that is not already in the remit, it is an omission.
The commission should be able to examine the quality of performance of those who direct the commissioning and provision of health care. If nothing else, that describes what the Department does. It directs providers and commissioners through national service frameworks and the National Institute for Clinical Excellence; the body that it hides behind when rationing decisions are made. There is a huge incentive for hospitals, providers and commissioners to comply when their political masters tell them that they will be awarded no stars in some simplistic mumbo-jumbo star rating performance system, or that jobs will be on the line. They scarcely have time to consider whether that is in patients' interests, because they are faced with must-dos.
The Government could deal with the problem by not producing so much centralised guidance. I think that that would be difficult for any Government. An alternative would be for the Department to allow the same standards of inspection of its own policies as it imposes on the rest of the service in both its provider and commissioning status. I hope that the Minister will say that this provision is unnecessary, inappropriate or otherwise covered.
Amendment No. 160 seeks to probe further the extent of the expansion of the definition of the duty of quality in the Bill. In Section 18 (4) of the Health Act 1999, ''health care'' is defined as:
''services for or in connection with the prevention, diagnosis or treatment of illness''.
Clause 11 will add to that definition,
''and the environment in which such services are provided''.
The amendment seeks to add to that definition the implementation of
''health and safety legislation and infection control measures'',
although I accept that its current wording does not quite achieve that effect. The British Medical Association is particularly concerned that not enough priority is given to those areas by hospital managers and the health service when attempting to deliver the duty of quality.
The cost of poor infection control to the health service, set out by the National Audit Office less than two years ago, is high. It would be of great concern if the health service were not inspected on that quality. The BMA briefing states:
''despite existing legislation and guidance, health and safety is still not universally guaranteed throughout the NHS. The NHS has a responsibility under the Health and Safety at Work etc. Act, 1974, and subsequent regulations on the management of health and safety to ensure the safety of all employees, contractors and members of the public as patients and visitors. Each NHS Trust and Primary Care Trust has a statutory duty to provide an
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including the new inspection powers in the Bill
''is in a prime position to observe whether premises, equipment, practices and procedures in each trust are sufficient to enable best clinical practice.''
The amendment is also tabled in the name of the hon. Member for Wyre Forest (Dr. Taylor), who may wish to speak about the importance of dealing with cross-infection. The NAO report to which I referred recognised the widespread failure in infection control. It seems reasonable that the Bill should be amended to ensure that that function is covered by the Commission for Health Improvement, or that the Minister should reassure us that infection control and health and safety at work are already covered by it.
The NHS staff is its major resource, on which the majority of its funds are spent. The way in which the NHS treats its staff is a measure of the quality of the service. Concern has been expressed that the occupational health facility is poor, if it exists at all. As a result, trade unions and professional organisations run heavily subscribed helplines and stress counselling lines, which should be provided within the health service by the employer; particularly an employer which puts its workers under such strain. The personnel function must not be overlooked in the workings of the NHS; the key to undercapacity lies not only in the failure of resourcing over so many years, but in the failure to retain staff, many of whom are leaving because of the stresses and strains of the workplace.
If occupational health policies were more effective, we might be able to improve NHS delivery and maintain and increase the service's capacity, which is the critical issue facing it. If the definition of quality were extended to include the quality of the human resource function, or the Minister were to reassure us that certain guidance clearly so extends it, the Committee would be reassured and the amendment could be withdrawn. I commend the amendments to the Committee.