Yes, my Lords. I hope that I can reassure noble Lords on their very valid concerns on this topic. Perhaps I can say a few general words first of all about quality. The Government's ambition in modernising the NHS is to create a health service that delivers outcomes as good as any in the world. We all know that at its best the NHS is world-class, but we also know that there are important areas where the quality and outcomes of care could and should be improved. If we are to safeguard the quality of services and drive improvement, we must take positive action. We are addressing the structural weaknesses in the system and seeking to embed the principle of quality throughout. This is why the Bill creates a legal duty for the Secretary of State and for the NHS Commissioning Board and clinical commissioning groups to be guided by the need to improve quality in all that they do.
In doing this we are building on the work of the previous Government under the noble Lord, Lord Darzi, and in particular we are using the definition of quality that he introduced-care that is effective, safe and delivers a good experience for patients. By positioning the quality duty in the context of a duty in Clause 3-to bear in mind the need to reduce inequalities within the population in designing services, particularly the most vulnerable members of society-we intend that these reforms will deliver the vision of high-quality care for all, as he so ably articulated.
Amendments 9, 10 and 14 place a duty on the Secretary of State to provide or secure the provision of services that in their turn should secure continuous quality improvement. We have already debated at great length Clause 1 and the duty to provide, and I shall not rehearse that discussion again, but I should like to be clear that it is the role of commissioners to drive quality improvements and the role of the Secretary of State to seek to improve quality by exercising his functions. He will do this, for example, through the mandate that he sets for the board, or the outcomes framework which he will issue and to which the board must have regard when it exercises its duty in relation to quality.
The amendments also place a duty on the Secretary of State to secure continuous improvement in the quality of services. Similar amendments were debated at some length in another place. It was clear throughout those debates that there is extensive and wide-ranging support for the principle that the health service should strive to provide the best possible service to patients. I thank the noble Baroness, Lady Thornton, for indicating her support for that principle. I am sure that we share it. As drafted, the Secretary of State, and in practice the Department of Health, is required to seek to achieve continuous improvement even if external factors mean that in particular cases such improvement may not be delivered. In our view, the clause as drafted should do what is necessary to deliver improvement in the quality of services while not imposing unreasonable or unrealistic burdens on the Secretary of State and the NHS. We believe that this duty, taken alongside those placing the same duty on the board and clinical commissioning groups, and the expectations that the Secretary of State will set through the outcomes framework, already ensures that the principle of securing continuous improvement in service quality is embedded throughout the health service and the wider care system. I hope that I have reassured the noble Baroness, Lady Thornton, of the Government's commitment to the continuous improvement of quality within the health service, and that she will not press her amendments.
I turn to Amendments 10A, 10B and 11A, tabled by the noble Baroness, Lady Finlay. They seek to strengthen the duty by inserting "and" in place of "or" where the clause lists the areas that the duty to secure quality improvement applies to. The noble Baroness expressed concern previously about the wording. I assure her that "or" is the appropriate word and that we are not allowing the Secretary of State to neglect certain aspects of healthcare when exercising their duty. There is no risk that the courts could misinterpret the unamended clause as meaning that the Secretary of State has to exercise his functions with a view to securing continuous improvement in the quality of services in only some rather than all areas that the Bill specifies.
The duty refers to quality in respect of services provided to individuals. In many cases, particular services provided to an individual will relate to one or more of the matters referred to in new subsection (1)(a) and (b), but not to all of them. For example, the service may be to prevent or diagnose illness but not to treat. Another service might be to treat but not to diagnose. The use of "or" makes it clear that the duty applies to the quality of all services, whatever the purpose for which they are provided. Although I am certain that it is not the noble Baroness's intention, the use of "and" would inaccurately suggest that the duty could apply only to the provision of services that prevent or treat illness.
Amendment 10A seeks to extend the duty to improve the quality of services from those provided to individuals to those provided at a population level. Of course it is just as important for public health services to improve as it is for any other sort of health service, but new Section 1A already recognises that with its explicit reference to public health services in subsection (1)(b), which refers to the,
"protection or improvement of public health".
The wording is echoed in Clauses 8 and 9, which set out the new public health duties of the Secretary of State and of local authorities.
Clauses 8 and 9 provide examples of steps that may be taken under those duties and that might therefore be subject to the duty of quality in new Section 1A. They include providing information and advice, for example, as well as preventing or treating illness. This means that new Section 1A already applies to a wide range of public health services. Any public health activity that involves the provision of a service to individuals-albeit that the general purpose is to improve or protect health at a population level-such as vaccination or smoking cessation, would be covered by the duty in the clause as drafted. Of course, improving the health of populations cannot be achieved without improving the health of individuals. I make it clear that some steps may be taken to improve or protect public health under Clauses 8 and 9. These extend beyond services provided to individuals.
I turn to questions that were raised. The noble Baronesses, Lady Thornton and Lady Finlay, spoke about the importance of commissioning for an area-based population. We completely agree with the general sentiment. That is why CCGs, contrary to the perception of some noble Lords, will commission for all unregistered patients within their geographic area, as well as for those on their registered lists and others to be defined in regulations. I refer noble Lords to Clause 10(3), which is on page 6. It is also why we are establishing health and well-being boards to agree a holistic strategy for their area. That is Clause 190.
We amended the Bill in another place to clarify that clinical commissioning groups have responsibility not only for patients registered with the GP practices that comprise their membership, but for those usually resident in the clinical commissioning group's area who are not registered with any GP practice. We must also ensure, when we exercise the power to set out other persons for whom a CCG has responsibility, to provide through regulations that a CCG has responsibility for ensuring that everyone in its area can access urgent and emergency care. I turn to my noble friend Lady Tonge, who asked me about that issue.