PARLIAMENTARY DEBATES HOUSE OF COMMONS OFFICIAL REPORT Standing Committee A NATIONAL HEALTH SERVICE REFORM AND HEALTH CARE PROFESSIONS BILL Fifth Sitting Tuesday 4 December 2001 (Morning) . pstallceol owneartityty: tonal |W ELLCOME LIBRARY | INP SATION SERVICE CONTENTS CLAUSE 11 agreed to. _ Adjourned till this day at half-past Four o’clock. PUBLISHED BY AUTHORITY OF THE HOUSE OF COMMONS LONDON - THE STATIONERY OFFICE LIMITED £5-00 Members who wish to have copies of the Official Report of Proceedings in Standing Committees sent to them are requested to give notice to that effect at the Vote Office. No proofs can be supplied. Corrigenda slips may be published with Bound Volume editions. 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Tuesday 4 December 2001 I welcome the Government’s commitment to (Morning) quality. We have always supported the setting up of the Commission for Health Improvement, and we [Mr. ALAN Hurst in the Chair] welcome the initiative in the Bill to make the commission more independent. What better way could there be to show such commitment than the NHS Reform & Health Care Professions Government having the courage to allow the commission to inspect the work and policies of the Clause 11 Department of Health? I accept that amendment No. 161 is not sufficient to add the Department of Health to the relevant parts of DUTY OF QUALITY the Bill or of the Health Act 1999, which sets up the 10.30 am commission. I hope, however, that the Minister will reassure me that the Department’s policies are already Dr. Evan Harris (Oxford, West and Abingdon): I subject to independent expert overview through the beg to move amendment No. 161, in page 17, line 3, at Commission for Health Improvement, or in some beginning insert— other way. “(1) In subsection 18(1) of the 1999 Act (duty of quality), after The clauses that relate to the commission make it the first word “of” there is inserted “the Department of Health,”. more effective. However, the more effective we make (2) the commission, the more important it is that it should examine the policies of the Department, whoever The Chairman: With this it will be convenient to controls it. The commission might decide that those discuss amendment No. 160, in page 17, line 5, at policies, and the priorities that they place on the end insert service, are good. The Government could publicise ‘including monitoring the provisions of health and safety and benefit from such a judgment. However, many legislation and infection control measures’. people in the health service whose work runs the risk of being deemed to be inadequate feel their political Dr. Harris: Amendment No. 161 is a probing masters should run the same risk. Given the way in amendment to discover whether the duty of quality, which the Government run the health service, they are, which is covered by the Commission for Health indeed, both political and masters. Improvement, extends to the working policies of the Department of Health. I hope that the Minister will I agree with those in the health service who feel that reassure me and other hon. Members who are the quality agenda must be dealt with. There are concerned about the matter. problems with the delivery of quality, although we accept that they are not all due to under-resourcing One of the key influences on the delivery of quality and undercapacity. The publication this morning of in the health service is Department of Health policy. the latest report by the national confidential inquiry To a certain extent, the practices of the Department into perioperative deaths puts the issue in similar and its agents are already covered by the CHI. The terms. However, much of the failure to deliver quality danger is that the commission will spend its time is due to the lack of resources. Corners are cut because inspecting the work of hospital trusts and primary care there are no funds for the staff, equipment, theatre trusts; but those trusts merely do what the lists, expert opinions and diagnostic techniques that Government have asked them to do. That may be an effective ploy for the Government, because— would deliver the highest-quality service. unintentionally or otherwise, and regardless of No local hospital or primary care trust can magic up whether the commission finds good or poor practice— extra resources; that is the responsibility of the House. its reports will let the Government and the It is also the direct managerial responsibility of the Department off the hook. However, the subjects of Secretary of State for Health, although it would those reports will be attempting merely to implement perhaps be more appropriate to say the Chancellor of policies promulgated by the Department of Health. the Exchequer. Nevertheless, such matters are dealt In earlier debates, I mentioned the Liberal with through Department of Health policies, Democrats’ concern that, however well-intentioned allocations and prioritisations. The service is short of they may be, the central diktats of the Department of cash, and quality suffers as a result. In those Health may distort clinical priorities. By that, I mean circumstances, it would be invidious for the that patients may not be dealt with according to their Department’s funding and priority policies not even to clinical needs, and that the work of doctors and nurses be inspected. It is not a question of the Department will be based upon the need to fulfil political targets set getting off scot-free; indeed, the commission’s by the Department. I do not say that the Government diagnosis might be that there is no case to answer. invented that approach, but they have perfected it. We The Health Act 1999 does not lend itself to simple need not only a truly independent commission, but a amendments that would include the Department, but definition of quality, which the Government should it lends itself to some amendments. I accept that welcome, that allows the commission to take a amendment No. 161] is not extensive enough to place a 169 Standing Committee A HOUSE OF COMMONS National Health Service Reform 170 and Health Care Professions Bill [D r. Harris] environment that is safe ‘as far as is reasonably practicable’, to use ‘the best practical means’ to achieve its objectives, and to use ‘the supervisory duty on the commission. However, a way best available technology not entailing excessive cost’. The Commission for Health Improvement, as part of its could be found. If the Minister does not reassure me, inspection process”— we might have to return to the issue later. I hope that including the new inspection powers in the Bill— we can ensure that the commission examines the provision of health care and the quality of the “is in a prime position to observe whether premises, equipment, practices and procedures in each trust are sufficient to enable best commissioning of health care against the quality clinical practice.” standard that, rightly, has been established. If that is The amendment is also tabled in the name of the hon. not already in the remit, it is an omission. Member for Wyre Forest (Dr. Taylor), who may wish The commission should be able to examine the to speak about the importance of dealing with cross- quality of performance of those who direct the infection. The NAO report to which I referred commissioning and provision of health care. If recognised the widespread failure in infection control. nothing else, that describes what the Department does. It seems reasonable that the Bill should be amended to It directs providers and commissioners through ensure that that function is covered by the national service frameworks and the National Commission for Health Improvement, or that the Institute for Clinical Excellence; the body that it hides Minister should reassure us that infection control and behind when rationing decisions are made. There is a health and safety at work are already covered by it. huge incentive for hospitals, providers and The NHS staff is its major resource, on which the commissioners to comply when their political masters ' majority of its funds are spent. The way in which the tell them that they will be awarded no stars in some NHS treats its staff isa measure of the quality of the simplistic mumbo-jumbo star rating performance service. Concern has been expressed that the system, or that jobs will be on the line. They scarcely occupational health facility is poor, if it exists at all. As have time to consider whether that is in patients’ a result, trade unions and professional organisations interests, because they are faced with must-dos. run heavily subscribed helplines and stress counselling The Government could deal with the problem by lines, which should be provided within the health not producing so much centralised guidance. I think service by the employer; particularly an employer that that would be difficult for any Government. An which puts its workers under such strain. The alternative would be for the Department to allow the personnel function must not be overlooked in the same standards of inspection of its own policies as it workings of the NHS; the key to undercapacity lies not imposes on the rest of the service in both its provider only in the failure of resourcing over so many years, and commissioning status. I hope that the Minister but in the failure to retain staff, many of whom are will say that this provision is unnecessary, leaving because of the stresses and strains of the inappropriate or otherwise covered. workplace. Amendment No. 160 seeks to probe further the If occupational health policies were more effective, extent of the expansion of the definition of the duty of we might be able to improve NHS delivery and quality in the Bill. In Section 18 (4) of the Health Act maintain and increase the service’s capacity, which is the critical issue facing it. If the definition of quality 1999, “health care” is defined as: were extended to include the quality of the human “services for or in connection with the prevention, diagnosis or resource function, or the Minister were to reassure us treatment of illness”. that certain guidance clearly so extends it, the Clause 11 will add to that definition, Committee would be reassured and the amendment “and the environment in which such services are provided”. could be withdrawn. I commend the amendments to The amendment seeks to add to that definition the the Committee. implementation of 10.45 pm “health and safety legislation and infection control measures”, although I accept that its current wording does not Dr. Richard Taylor (Wyre Forest): My name is quite achieve that effect. The British Medical attached to amendment No. 160, but I support Association is particularly concerned that not enough amendment No. 161, which was tabled by the hon. priority is given to those areas by hospital managers Member for Oxford, West and Abingdon (Dr. Harris). and the health service when attempting to deliver the However, I am primarily interested in amendment No. duty of quality. 160. I thoroughly approve of the vagueness of the The cost of poor infection control to the health wording in clause 11, when it refers to service, set out by the National Audit Office less than “the environment in which services are provided.” two years ago, is high. It would be of great concern if I presume that “environment” is meant to be vague, the health service were not inspected on that quality. because it includes all hospitals, practices, clinics and The BMA briefing states: facilities where health care is provided. I approve of “despite existing legislation and guidance, health and safety is still that. The amendment attempts to make more specific not universally guaranteed throughout the NHS. The NHS has a some of the Commission for Health Improvement’s responsibility under the Health and Safety at Work etc. Act, 1974, functions. As has been said, we are interested in the and subsequent regulations on the management of health and health and safety issues, especially cross-infection. I safety to ensure the safety of all employees, contractors and members of the public as patients and visitors. Each NHS Trust remind the Committee of the recent seminar held by and Primary Care Trust has a statutory duty to provide an the Patients Association, which pointed out the 171 Standing Committee A 4 DECEMBER 2001 National Health Service Reform 172 and Health Care Professions Bill tremendous risk of the transmission of very serious fortunately not as serious, that regularly occur in the infections through the re-use of surgical equipment. health service—one needs the best monitoring and Policies in units that have allowed that to happen are checking of standards. somewhat lax. It is crucial that the CHI is able to It is equally crucial that we use all means available to inspect for that sort of thing. The amendment is ensure that our hospitals are as clean as possible. The designed to add teeth to the clause, so that cross- number of patients who become infected as a result of infection is inspected meticulously during CHI the conditions in hospital is a serious problem. The inspections. National Audit Office recently identified the fact that, as a result of failures of cleanliness in the NHS, around Mr. Simon Burns (West Chelmsford): As the hon. one in 11 hospital patients at any time has an infection Member for Wyre Forest said, the clause is vague in its caught in hospital. That is apparently equivalent to at definition of the environment in which such services least 100,000 infections a year. The old, the young and those who undergo invasive procedures are the most are provided. The hon. Gentleman welcomed that vulnerable. vagueness because he thought that it would make the clause all-embracing in its interpretation. I have a lot Most people would find it incredible that, when they of sympathy with his point. However, as hon. go into hospital to be treated for and hopefully cured of the medical condition from which they suffer, they Members who have received the BMA briefing on the might pick up an infection that compounds the amendment will know, at this stage in the problem and proves fatal in some cases. In my youth, consideration of the Bill such vagueness must be we were brought up to think that hospitals were not explained further to reassure Members that the only warm but spotlessly clean. It is sad that those provision will enhance the inspection process and the standards have not been maintained in recent years. standards to be imposed on our hospitals and patient The problem is serious. The amendment would care, rather than being so vague that nobody knows strengthen the powers of inspection and the duties what it means and it achieves nothing. I suspect that placed on bodies within the NHS to seek to improve the latter analysis is inaccurate and that the Minister and enhance standards and quality of care. In some will reassure us that such vagueness will enhance the areas, those standards have deteriorated so much that process. As the BMA rightly said, the amendment is they are a serious scandal. probing. We want to find out how the Minister and the Department envisage matters. Dr. Harris: With the narrowness of the As the hon. Members for Oxford, West and Government’s extension of the definition of health Abingdon and for Wyre Forest pointed out, it is care, focusing on the environment in which services are important that we monitor what goes on in our provided might mean that a hospital is found liable for hospitals more closely and more effectively, and that failures if that environment is grubby. I recently asked a parliamentary question that revealed that the cost of We improve the quality of health care. We all rightly repair and maintenance backlogs throughout health recognise that the quality of health care is not simply authorities and hospitals in England and Wales was confined to the quality of patient care that individuals £52 billion. Even the best manager will not be able to receive, however important that is. It also includes a conjure up that sort of funding to ensure that the whole host of other issues, such as cleanliness and the environment in which services are provided look administration and bureaucracy involved in running adequate, let alone function adequately. hospitals. Hon. Members have mentioned the responsibilities Mr. Burns: The hon. Gentleman makes an of the NHS under the Health and Safety at Work, etc. interesting and important point. Without getting Act 1974. I was especially interested in the fact that the sidetracked, I must say that it will be interesting to hear BMA said in its briefing, from which the hon. Member the Minister’s reply, given the views and concerns that for Oxford, West and Abingdon has quoted, that the have been expressed. I hope that the Minister will be NHS had a responsibility to ensure the safety of all able to reassure us that amendment No. 160 is employees, contractors and members of the public as unnecessary because enough provisions exist in patients and visitors. The BMA has also said that each existing legislation and in the Bill to overcome the NHS trust and primary care trust had a statutory duty concerns and fears that hon. Members have expressed. If that were so, I would be delighted. to provide an environment that was safe so far as was reasonably practicable, and to use the best practical Similarly, I hope that the Minister will give a better means to achieve its objectives. explanation of what he and the parliamentary draftsmen mean by “environment” in the context of Such issues are especially important in an area such the clause. I hope that, however vague the wording as mine. There was a desperately unfortunate tragedy may seem to us non-lawyers, it is suitably widespread at Broomfield hospital in my constituency in the and all-embracing to fulfil the functions that we hope summer, when a blockage in an oxygen tube resulted in for from the clause. the death of an 11-year-old boy who went into hospital simply because he had injured his finger in the spokes Dr. Andrew Murrison (Westbury): National health of his bicycle. Due to his age, the clinical decision was service hospitals are potentially very hazardous places; that he needed a general anaesthetic before the indeed, that is true of all hospitals and medical damaged finger could be repaired, and that had tragic facilities. My hon. Friend the Member for West consequences. In the light of that tragedy—and others, Chelmsford (Mr. Burns) referred to the cosy image of 173 Standing Committee A HOUSE OF COMMONS National Health Service Reform 174 and Health Care Professions Bill [Dr. Andrew Murrison] recently, sadly, of elderly patients not receiving the correct food, or enough of it, in hospitals. Secondly, health services, but by and large the environment is not privacy and dignity are always matters of concern. sparklingly clean, and violence is often visited on Any hon. Members who have been in hospital recently health practitioners. There are also biohazards, and we may have been asked whether they would like to be have recently heard a lot about prions in relation to called by their Christian name or a title. Ihla ve spoken surgical instruments. Radiation hazards are also a to elderly ladies who have been greatly bothered when problem for patients and practitioners, and we have junior nurses called them by their Christian names. heard about the problem of violence in accident and That is a small matter, but it is a matter of dignity, emergency departments. In short, hospitals are which comes under the heading of quality. hazardous places. We know that the Health and Safety Executive is The Minister of State, Department of Health (Mr. under-resourced and overstretched, and although it John Hutton): This has been a good debate, and I take attempts to exert its inspection function, it is not it to have been a constructive attempt to get to the equipped for a specialised task that needs independent bottom of the provisions. It may help if I explain the and expert overseeing. The Patients Association report intention of clause 11, as I think that there was some that was published last month, and to which the hon. confusion about it on the part of the hon. Member for Member for Wyre Forest referred, is the most telling Oxford, West and Abingdon. document that I have seen in relation to those matters. In simple terms, clause 11 is intended to widen the We should give some attention to the report, which is definition of health care in section 18 of the Health Act a compilation of reports from a variety of authorities, 1999 to include, in broad terms, the patient including the Infection Control Nurses Association, environment. The clause supports the expanding role the Institute of Sterile Services Management and the that we envisage for the Commission for Health National Association of Theatre Nurses. The report Improvement. If the Bill becomes law, the commission takes the form of a survey of 300 members of those will be able to examine the wider patient environment. associations. Several hon. Members spoke about what is meant, The survey stated: for our purposes, by the word “environment”. It is “Almost a third of respondents . . . said that they did not think important that discussion of the quality of care given that the CE mark guaranteed instrument sterility.” by hospitals—NHS providers and others—should not That is a serious finding. The report also stated that be confined to issues of clinical care. As the hon. “one-fifth of respondents do not currently have an infection Member for Wyre Forest pointed out, with practical control policy in place relating to decontamination issues.” emphasis, quality goes much wider and deeper than That is extremely worrying. that. We simply want to allow the commission to “Only just over half of respondents (56 per cent.) said that their conduct a wider range of inspections based on the hospital had a single-use policy committee in place, despite this expanded definition of the duty of quality. being a suggestion from the Department of Health.” We envisage “environment” covering, for the The survey is worrying, and the Bill presents a good purpose of the clause—I am not giving an exhaustive opportunity for the Government to embed health and list, but suggesting our thinking—the cleanliness of safety and infection control, which are both aspects of hospital wards, which would clearly not be covered by quality, in the national health service in a way that is the current definition of health care; the cleanliness of not happening at present. waiting areas and other parts of the hospital; and the 11 am quality of the food given to patients. The hon. Member for Wyre Forest noted the importance of food, in his To return to my original premise, we need to start remarks about nutrition. Many aspects of the thinking of hospitals as hazardous places. The Health and Safety Executive is used to dealing largely with environment in which NHS care is given are relevant. The clause would establish a broader view of quality. factories. The industry that we are considering is, one might say, a factory with a multitude of fairly The hon. Member for Oxford, West and Abingdon unregulated processes. It is not a production line and wanted to know whether the Commission for Health cannot be well regulated. Many unexpected events are Improvement would be able to consider the quality of built in to the activities of clinicians in hospitals; that commissioning. It can already do that. The makes things hazardous. That is why we need to attend commission can certainly examine the quality of particularly to health and safety and, of course, commissioning by NHS _ bodies in_ reviewing infection control. arrangements for improving and monitoring the I support the amendment, and particularly the quality of NHS care under section 20(1)(b) of the attempt to embed health and safety and infection Health Act 1999. control in the national health service at this seminal Hon. Members made important points about cross- time of change. infection and the importance of maintaining a safe, sterile environment in hospitals. Dr. Taylor: I am grateful for a second bite of the cherry, Mr. Hurst. I shall be brief. Dr. Harris: Will the Minister repeat his reference to The Royal College of Nursing has raised several the Health Act 1999? issues about quality that have not been mentioned yet, the first of which is nutrition. There have been reports Mr. Hutton: I referred to section 20(1)(b). WS Standing Committee A 4 DECEMBER 2001 National Health Service Reform 176 and Health Care Professions Bill The issue of cross-infection is important. I am sure Department of Health in the process of forming that hon. Members will be conscious of the action that policy. We must be clear; that is our job. It should not we have taken to bring about improvements in that be given to someone else. It is the role of Parliament respect. That includes issuing, in November 1999, and the job of Members in this place to hold Ministers national standards for hospital-acquired infection. to account for their decisions. Those standards are being reviewed by the The hon. Gentleman raises a fair point about there Department, with the help of interested professional being one standard for Ministers and one for the NHS, groups. I know that the chief medical officer is working but he is confusing two separate issues. Ministers must on those issues. The Department of |H ealth be properly accountable to this place for the quality commissioned evidence-based _ guidelines _ for not only of their decisions, but of the care available to preventing hospital infection and those were published our constituents. In turn, we have a responsibility to in January as a supplement to the Journal of Hospital put in place a range of measures designed specifically Infection. The guidelines cover general principles for to improve quality of care. That is why we now have preventing infection in hospital, and for the prevention arrangements to set national standards through the of infections associated with specific clinical national service framework. It is why we have the procedures. Commission for Health Improvement—it has been Hon. Members may know that all acute NHS trusts given an expanded role in the Bill to go into every must, as of April this year, participate in the national corner of the NHS and consider the quality of care and surveillance of hospital-acquired infection. Data from the patient environment—and the National Institute that exercise will be available from April next year. for Clinical Excellence, which provides clear guidance That is the first stage in developing a comprehensive to the service about the availability of new drugs and NHS surveillance service. One of the problems has treatments. been the lack of consistent definitions and data about methicillin-resistant staphylococcus aureus and other Such arrangements are precisely the right ones for acquired infections. We are obviously anxious to Ministers to put in place. Ultimately, the ensure that the necessary information is obtained to accountability for decisions is inappropriate for the allow us to make progress. commission. It should rest with Members of Parliament in this place. Dr. Harris: When the Minister referred to section 20(1)(b), I thought that he meant section 21(b). Section Dr. Harris: I am grateful to the Minister for the 20(1)(b) refers to considered and thoughtful way in which he is “the function of conducting reviews of, and making reports on, responding, and I accept his point, to an extent. arrangements by Primary Care Trusts or NHS trusts for the However, I shall give an example of my concern about purpose of monitoring and improving the quality of health care for which they have responsibility”. Department of Health guidance. If the CHI has the No specific mention is made of commissioning or, power to consider commissioning policies that might indeed, the Department of Health policies on which be based on a direction from the Department that says, those commissioning policies must be based. “Thou shalt commission to ensure maximum waiting times that shall not be exceeded,” can it take a view on Mr. Hutton: The commission is able, under section whether that is a sensible, quality-based, patient- 20(1)(b) to examine the quality of the commissioning centred approach? process. We are in no doubt about that, and neither is the commission. It is perfectly proper for the Mr. Hutton: In a sense, some of the hon. commission to focus on that, if it chooses. Gentleman’s concerns may be the subject of a fuller We need to focus our concern on the amendment, debate on clause 14, which entrusts to the commission and I hope that what I have said about health and the responsibility for publishing an annual report on safety legislation and infection control measures— the state of the NHS. with which the hon. Gentleman’s amendment No. 160 The hon. Gentleman made a point about the role of deals—makes matters clear. We consider that section the commission, which clearly will comment on the 18 of the Health Act 1999, once amended under the quality of patient care, in the widest sense of that Bill, would enable those issues to be taken fully into definition. Through these measures, the commission is account. NHS bodies are already required to comply being given greater independence from _ the with health and safety legislation, and the service is Department, an important step that contradicts the obliged to follow extensive departmental guidance on hon. Gentleman’s obsessive theory about micro- infection control measures; a matter that the Commission for Health Improvement can pursue. In management of the NHS. The debate has been full, and we have been over the course on this issue many view of all that, the amendment would have no practical consequence, as it would provide for exactly times. what is happening. We should return to clause 11 or we will find The hon. Member for Oxford, West and Abingdon ourselves in some trouble. It provides an important raised an important issue that is not covered by the extension of the duty of quality, which I accept has the amendment, although he suggested that he might want deliberate intention of expanding the remit of the to return to it later; perhaps on Report. He said that commission to the consideration of patient quality. the Commission for Health Improvement should have That has to be good for our constituents. We all know a duty to inspect the quality of decisions made in the that we are as likely to hear complaints about hospital 7 Standing Committee A HOUSE OF COMMONS National Health Service Reform 178 and Health Care Professions Bill [Mr. Hutton] Mr. Hutton: The hon. Gentleman will not be surprised that I disagree with every word of what he food, cleanliness, general tidiness and civility—the said. He is wrong. It does not serve the quality of our hon. Member for Wyre Forest mentioned the last of debate for the hon. Gentleman to pretend that his those—as we are complaints about the quality of care. Government were not interested in doing the same. We If we start from the proposition that the commission should not forget that the Conservative party set the is the right repository of the relevant functions, the original maximum waiting time of 18 months for right set of structures are in place to drive up the treatment in the national health service in England. He quality of care in the NHS, given that the commission cannot now pretend that his Government were not is at arm’s length from the Government, has the fullest fundamentally concerned with that matter. remit that we can construct for it and is consistent with Mr. Burns: We were talking about times, not about established lines of accountability, under which numbers. Ministers and their decisions are accountable to the House. Mr. Hutton: The hon. Gentleman must follow the logic of that conclusion. I know the view of the hon. Dr. Harris: I congratulate the Government on Member for Oxford, West and Abingdon, which could making the Commission for Health Improvement also be the view of the hon. Gentleman; we may yet more independent, and for recognising that that was find out. Perhaps the hon. Member for Oxford, West the correct conclusion for the Kennedy report to and Abingdon believes that even setting a maximum recommend. However, I want to return to my specific waiting time could distort clinical priority— point. Under the Bill or the existing powers, will the [Interruption.| That is his view. I wonder if that might commission have the ability to judge whether the be the view of the hon. Member for West Chelmsford, commissioning of services to provide maximum whose party set the original waiting times target. waiting times as an end-point is good for quality of care? Will it be able to comment on such policies? That Mr. Burns: The initiative of the last Parliament, is an example; I would not want to appear obsessed. which was based on numbers, distorted clinical priorities. However, I have sympathy with the Mr. Hutton: We have to consider the subject in a Minister when he says that all of us—apart from the slightly broader context. Inspection of the national Liberal Democrats, it would seem—want people to health service is not a role only for the Commission for wait less. I believe that having maximum times and Health Improvement. For example, value-for-money then reducing them will improve and enhance health issues are the remit of the Audit Commission, and I care for our constituents. know only too well that that commission’s writ runs freely across the value-for-money agenda of the NHS. The Chairman: Order. I am sure that hon. Members Indeed, the commission has done so recently in will be mindful not to stray too far from the relation to the issues raised by the hon. Gentleman, amendment. such as clinical priorities and setting reasonable targets to reduce waiting. Mr. Hutton: I must apologise, Mr. Hurst; I lured the hon. Gentleman into that. I generally give way when it I, my colleagues in the Government and, I hope, my suits me, and he does the same. I have given way when hon. Friends believe that our constituents’ most important concern about the NHS is the length of time it did not suit me, and I have had to bear the consequences. However, we all make mistakes. that they have to wait. We are travelling in absolutely the right general direction to so organise the services The amendments are unnecessary because they provided and funded by the NHS that we can reduce would have no practical consequence. I have explained that time. I believe that it is possible to do that without that the issues are already subject to inspection and distorting clinical priorities. We make it clear in review. The amendments have served the purpose of guidance to the service that care should ultimately be winkling out a wider sense of what we mean by “the determined according to clinical priority; indeed, that environment”. I have tried to give practical examples is the first sentence of the guidance. It is not the job of of what that might mean, but it would have been a Ministers, nor should it ever be, to decide which mistake to attempt to produce an exhaustive list. patients are treated first, or last. That is the job of The hon. Member for Wyre Forest was right that we clinicians, as we have always tried to spell out. need some laxity in the definition. That suits our purpose. However, we want also to broaden the 11.15 pm concept of health care under section 18 of the 1999 Act—that is obvious from the Bill—so that the Mr. Burns: The Minister is being a little naive in Commission for Health Improvement, in its inspection coming out with that pious point. He knows as well as and monitoring role, can look at the issues, which are anyone that under the discredited waiting list initiative important to patients. I have tried to respond of the previous Parliament, clinicians and hospital positively to the hon. Gentleman’s points, but I am managers were under such pressure to meet the unable to accept his amendments. politically motivated number deadlines that clinical decisions were grossly distorted. That was done to Dr. Harris: I am grateful that the Minister gave ensure that Ministers, including the Prime Minister, some response to amendment No. 160, which relates to were not embarrassed by a failure to meet promised the quality of the environment. I am disappointed that targets. he did not address human resources policies, which I 179 Standing Committee A 4 DECEMBER 2001 National Health Service Reform 180 and Health Care Professions Bill included in my introduction. The quality of such The terms of the Kennedy report were clear; for policies impacts indirectly—and directly—on patient example, waiting list policies in the early 1990s were care. I am not clear whether the Commission for partly responsible for the problems at Bristol; they Health Improvement has a remit to consider the were ultimately problems of quality. The failure to quality of human resources policies and occupational follow the spirit of the Kennedy report is that the health within the NHS. Will the Minister respond? Commission for Health Improvement will have no remit even to look at the Department of Health’s Mr. Hutton: I am sorry. I assumed that the hon. policy, rather than at its decisions per se. Gentleman knew that the Commission for Health Mr. Hutton: The hon. Gentleman prayed the Improvement already has that responsibility and can Kennedy report in aid, but Professor Kennedy did not look at those issues. make those particular recommendations. Dr. Harris: I am grateful. Perhaps I shall be able to Dr. Harris: I read the Kennedy report with great see whether it does so in due course. I have spoken interest. It cited the waiting list policies—the professor informally to the hon. Member for Wyre Forest and described them as policies “of 10 years ago”, but they we would be happy to withdraw amendment No. 160. are still with us—as a cause of quality failures. The The hon. Member for Wyre Forest expressed some waiting times target is just one example of sympathy towards amendment No. 161, which is Government policy; I do not want the debate to be tabled in my name. I am not convinced that the solely about that. However, when waiting times are Government have addressed the issue. I am conscious decreasing, more and more patients will be considered that we should not stray too far from the amendment. urgent in terms of waiting list management and will be The fundamental test posed by the amendment is able to jump the queue at the expense of clinically whether the Commission for Health Improvement— urgent patients. Kennedy was clear about the need for which is the quality body, as opposed to the value-for- expert quality checks. Hon. Members may think that money body, which is the Audit Commission—has the they are experts, but they are not always in command ability to look at the impact on the quality of health of the detail. Expert quality checks on the possible care of policies that commissioners and providers are detrimental impact of Government policy on the directed to follow by the Department of Health. quality of provision, whether it is intentional or The decisions of Ministers should be accountable to unintentional, are necessary. this place in so far as they impact or might impact on the quality of health care. The expert body charged Mr. Hutton: I agree with the hon. Gentleman’s with investigations and reviews on quality should be comments on Professor Kennedy’s report. Professor Kennedy welcomed the Government’s measures for entitled to give a view. In holding Ministers to account, improving quality. However, the report, which the the House should be entitled to reports and reviews hon. Gentleman cited in aid of his arguments, did not from expert groups looking at those issues. recommend giving to the Commission for Health The Minister says that we have charged that a Improvement the power that the hon. Gentleman says Department of Health policy of maximum waiting it should have. times distorts clinical priorities. That dismisses the distortion of clinical priorities that are not concerned Dr. Harris: Professor Kennedy did not recommend with quality. The policy has a huge impact on quality against giving the Commission for Health if the most clinically urgent patients have to wait for Improvement the power that I recommend, either. more managerially, politically, directionally or policy- [Hon. Mempers: Oh!] It is true that the professor did driven urgent patients, who may be less clinically not specifically recommend that the commission urgent, who are subject to maximum waiting times. should be given such a power. However, I am sure that That is why our party has changed its view on we could enter into an interesting correspondence with maximum waiting times; we regret that the Labour the professor and his colleagues about whether they and Conservative parties have not done so. think that the Government should have carte blanche If the Minister will not give us a clear indication that to implement policies that may run counter to the the Commission for Health Improvement can look at patient’s best interests, simply because the policies those broad policy directions and the directions to conform to those of the politician. That would apply commissioners and providers from the Department of whichever party was in government, and it is an Health, we will certainly have to revisit this issue. I important power. accept that the phrasing of the amendment does not I do not intend to divide the Committee on the raise that issue, but amendments can be tabled that amendment, but I hope that, after consulting outside would clearly place that power with the Commission bodies, we will be able to return to the matter later. I for Health Improvement. Today we have heard the beg to ask leave to withdraw the amendment. Government say, “No, the Commission for Health Amendment, by leave, withdrawn. Improvement does not have the power to criticise what Question proposed, That the clause stand part of we do where it impacts on the quality of care and the the Bill. functions of primary care trusts and NHS trusts, which are going to be inspected by the commission; nor do Mr. Burns: I do not want to detain the Committee the Government want it to.” That is a failure in terms for long, but I have an important point to raise with the of quality. Minister. The clause is about enhancing the quality of 181 Standing Committee A HOUSE OF COMMONS National Health Service Reform 182 and Health Care Professions Bill [Mr. Burns] important issue of access to and around NHS sites for people with a disability. He gave the example of people care and the definition of the duty of care. I was who are blind. I strongly agree with his sentiments. reassured by the Minister, who seemed to suggest that Given the extension of the definition of health care the vagueness of the term “environment” was for the to the patient environment, the issues that the hon. common good. I should be interested to hear the Gentleman raised will fall well and truly within what Minister’s comments on the points raised by the Royal we are trying to achieve. Issues such as providing National Institute for the Blind about the care and signage sites and ensuring that blind and other treatment of blind and partially sighted people in the disabled people have proper information to help them NHS. As the Minister will be aware, there is great to get around sites fall four-square within the concern among the blind and partially sighted that the definition of the patient environment that we seek to health service fails to understand their predicament add to clause 18. The hon. Gentleman made a fair and introduce the appropriate measures to help them. point, and the commission will want to consider it. Surveys have revealed the extent of the failure of Question put and agreed to. most trusts and health authorities to provide Clause 11 ordered to stand part of the Bill. information accessible to blind and partially sighted people and other people with disabilities. The RNIB’s Clause 12 recent survey shows that only 4 per cent. of test results are made available in large print. Only 2 per cent. of test results are provided in Braille or by tape. FURTHER FUNCTIONS OF THE COMMISSION FOR HEALTH Information about treatments and medical conditions IMPROVEMENT is made available in alternative formats by fewer than Mr. Burns: I beg to move amendment No. 155, in half of NHS trusts. Some 86 per cent. of blind and page 17, line 29, at end insert— partially sighted patients in eye clinics receive ‘(3A) In subsection (2), at the end of paragraph (b) there is appointment letters in normal-sized print—a format inserted “including co-ordinating visits to Primary Care Trusts or that most find difficult, or even impossible, to read. It to NHS Trusts with other bodies carrying out monitoring or would not take much to tackle those sensitive issues, inspections of those premises”. and I hope that the clause will lead to an improvement The Chairman: With this we may discuss if and when the Bill becomes law. amendment No. 162, in page 17, line 30, after “(2),’, insert 11.30 am ‘paragraphs (a) and (b) are omitted, and’. The absence from many eye hospitals of trained workers to provide those facing a diagnosis of sight Mr. Burns: The amendment is in my name and those loss with emotional support and information is also of of my hon. Friends the Members for Woodspring huge concern to the RNIB and its members. We are all (Dr. Fox) and for North-East Hertfordshire (Mr. fortunate enough to understand that sight is the sense Heald). Im ake no bones about the fact that the British that the vast majority of people most fear losing. When Medical Association recommended it to us. In many individuals confront that unfortunate possibility, they ways, it is a probing amendment. As the Minister is experience considerable fear, stress and distress. It is aware, the British Medical Association supported the important that staff who provide health care have the establishment of CHI in 1999, and has not wavered in means to help people through an especially difficult its support. As was said when we debated the previous and emotional time. Practice should reflect that in clause, the main function was to consider the question other sectors of the health care system, which deal with of duty of care and enhance the quality of care, anda highly distressing and emotional conditions by function of CHI is to monitor the quality of care providing back-up support when patients are provided in the health service to ensure that it meets the highest standards. diagnosed and throughout their treatment. I hope that the Minister can reassure us on the All too often, those who suffer from conditions such danger that may result from the fact that several as blindness and partial sightedness are forgotten. different bodies have responsibility for visiting, Sighted people tend to take it for granted that inspecting and monitoring the services and quality of everyone is like them and to push the concerns of care provided by NHS trusts and GPs’ surgeries. others to the back of the queue, as shown by the Those bodies include CHI itself, the medical royal experiences in the surveys that I cited. I hope that the colleges and the Audit Commission. If the relevant clause and the activities of the Commission for Health clauses remain in the Bill and the Bill becomes law, Improvement will help not only blind and partially patients forums may also carry out inquiries into areas sighted patients but patients in other forgotten areas of of health care at all levels. Most visits that those bodies the health service, where fit and able-bodied make will be appropriate to the fulfilment of their individuals in the medical profession and outside it functions, but there is a danger that without co- tend to forget the needs of others. ordination, visits from and inspections by the various organisations and bodies will cause disruption to Mr. Hutton: I do not intend to go into further detail trusts and GPs’ surgeries. The amendment would about clause 11. I hope that I spelled out the issues a ensure that co-ordination. I am sure that the few minutes ago. The hon. Gentleman raised the Government do not intend such disruption to be the