Mr Simon Burns (West Chelmsford, Conservative)

I beg to move amendment No. 189, in

clause 41, page 14, line 17, at beginning insert—

'( ) The CHAI shall be the principal guardian of standards in the NHS.'.

Mr Peter Atkinson (Hexham, Conservative)

With this it will be convenient to discuss the following amendments: No. 108, in

clause 41, page 14, line 17, leave out 'Secretary of State' and insert 'CHAI'.

No. 109, in

clause 41, page 14, line 20, leave out 'Secretary of State' and insert 'CHAI'.

No. 110, in

clause 41, page 14, line 21, leave out 'he' and insert 'it'.

No. 111, in

clause 41, page 14, line 22, leave out 'Secretary of State' and insert 'CHAI'.

No. 112, in

clause 41, page 14, line 22, leave out 'he' and insert 'it'.

No. 113, in

clause 41, page 14, line 25, leave out from beginning to 'effects' and insert 'its opinion'.

Mr Simon Burns (West Chelmsford, Conservative)

The amendment seems to copycat the subsequent amendments. The hon. Member for

Oxford, West and Abingdon will have an opportunity to make his points when he speaks to his amendment. I assume that the main thrust of his argument will be similar to mine, because all the amendments seem to dovetail.

The clause is important, because it is all about the Secretary of State setting standards for the NHS. The Government, from the Secretary of State downwards, have said on numerous occasions that they want to take the politicians out of the health service. I suspect that they have copied that philosophy from my hon. Friend the Member for Woodspring (Dr. Fox), because the Conservative party also believes that we should take the politicians out of the health service.

It is up to the clinicians and medical practitioners in the health service to run it to the best advantage with the best provision of health care to meet the local needs of local people. That is why I am surprised that despite the rhetoric, the Secretary of State will set the standards and will be given powers to ensure that targets are met through the standards that he will set. My hon. Friends and I believe that CHAI would be the more appropriate body to do that. That would set the NHS free from politicians and from political interference and control, because, under this fundamental part of the Bill, they would have their hand on the tiller.

I hope that the Minister will appreciate the validity of that point, given his comments about CHAI in previous debates. It would kill two birds with one stone. It would help to meet the aims and aspirations of the Minister and his right hon. and hon. Friends in de-politicising the NHS, and would give it a rational, independent body that could set the pace of improvements and standards so that we can continue to make progress and improve the quality of health care that the NHS provides for the citizens of this country.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

The hon. Member for West Chelmsford is right that we are seeking the same thing. The order of the amendments on the amendment paper suggests that ours were tabled a little before the hon. Gentleman's. However, they would achieve similar things. His amendment talks about stating that CHAI should be the principal guardian of standards in the NHS, and I am more than willing—indeed, keen—to support that proposition, but that needs to be backed up with some specific measures that are found throughout amendments tabled by the Liberal Democrats and the Conservatives to subsequent clauses to make it clear how the intention behind amendment No. 189 should be implemented.

Amendments Nos. 108 to 113 are the beginnings of some of those measures and are crucial to the proposition made by the hon. Member for West Chelmsford that there needs to be an inspectorate-led guardianship of standards in the NHS, and that politicians need to be kept out of that as far as possible, except for when establishing the framework.

I am determined to make my remarks positive, so I will repeat what I have said on many occasions: this Government deserve praise for the quality framework that they have introduced. They have run the risk of

being attacked for alphabet soup for the creation of many of the organisations that they have established, such as the National Clinical Assessment Authority, the National Patient Safety Agency, CHAI, and the National Care Standards Commission. There have been specific criticisms that we might have brought some of those issues together earlier. Nevertheless, the focus that the Government have put on mechanisms and inspectorates to safeguard quality is important.

Mr Andy Burnham (Leigh, Labour)

But.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

There is no ''But''. The hon. Member for Leigh thinks that there is a ''but'' coming in this sentence and there is not. There is going to be a ''but'' at the beginning of a new paragraph, because clearly I have tabled amendments to the Government's proposals. Even in this constructive mood, I will obviously suggest that there are things that the Government could do better. It is important to put that on the record, because without the commitment that the Government have shown, both pre and post the Kennedy report on the Bristol infirmary, and without their interest in establishing quality mechanisms, we should not be having these debates.

One of the reasons for the Government's actions is that they know that they must have a tough inspectorate in health care. They cannot simply rely on patient choice to lever up quality, as might occur in the purchase of bread or some such producer-and-consumer analogy. It is much more difficult to obtain the desired effect in health care because of the inevitable differences in power between the consumer and the producer, given that it is a professionally delivered service.

It is also the case that the professionals are often not good at recognising quality problems, because of their essential conservatism and unwillingness to take advice from outside. That must be recognised. Nevertheless, the quality framework under this group of clauses is deficient, because there is too great a role for politicians. I have said that the Government have done well to set up a framework, but politicians should withdraw because we need to ensure that the health service is governed against objective standards of quality. Everything I say applies equally to the social care sector and CSCI.

With the best will in the world—I need not go into whether the Government have the best will in the world—it is hard for a political organisation or a politician, no matter how good his motivation, to ensure, first, that quality standards are objective and evidence-based. If they were, there would be no need for the Secretary of State to become involved. We could just ask someone with even greater expertise than him to recognise what the evidence supports to make those decisions.

Secondly, it is important not only that that process of identifying the right standards is done according to objective measures and an adequate evidence base, but that that is seen to be done, to command the confidence of users of the health service and those who work in the service. The Government are right to put in a tough quality inspection regime. It has been long awaited and I pay tribute to the fact that they

have done that over the years, but it is important to keep people on board.

For those two good reasons, I urge the Government and other hon. Members present to consider how important it is that the amendments, in some form, are made. It is critical that it is CHAI that prepares and publishes the statements of standards in respect of the provision of health care by and for English NHS bodies and cross-border strategic health authorities.

There are other amendments that I have tabled for future debates in this Committee that put into legislation the basic processes of consultation that CHAI would need to undertake. However, it is a crucial measure of the true independence of CHAI that it is able to develop its own standards, not simply measure how well hospitals are jumping through hoops that are set by other people. I have made the point that if CHAI is inspecting the hospitals, it needs to be setting the hoops. It needs to be devising the standards against which hospitals are to be measured; otherwise it would not be independent. It is, by definition, a dependent process. If someone else, in this case the Secretary of State, says to the commission that it will have to measure performance, but that the Government will tell it what to measure it against and how to judge failure, then even if, by some miracle, the Secretary of State became a non-political person—health care is, of course, highly political—and came up with sensible standards, that would still undermine the commission's independence, by forcing it to measure standards that it had no power to set itself.

I now refer to where the ''But'' comes in. The hon. Member for Leigh (Andy Burnham) said from a sedentary position that he did not think that the Secretary of State was anything other than perfect in such respects. I hope that he will be rewarded for that faith in due course, if he meant it seriously. The standards set by the Government, not under the national service framework—we must not confuse those two—are not true measures of the quality of health care, but of other things.

I shall contrast two different standards. The national service framework for coronary heart disease has several standards. They are clinically based and measure meaningful outcomes or the extent of interventions that have been shown on the evidence base to deliver meaningful outcomes. The proportion of people who are on aspirin for secondary prevention is obviously important. Stacks of evidence suggest that that relatively cheap intervention is hugely important and produces results.

The time from door to needle for thrombolysis is a standard set under the national service framework. It is not produced by the Secretary of State, but by the working group. It is a meaningful standard. It is clear that CHAI would measure the performance of health care providers against such standards when it is relevant, without the Secretary of State having a role

in the process. There is no doubt about that. However, other standards may not have been subject to the national service framework, and CHAI needs to develop them. As I have said, the amendments would make it clear that CHAI needs to consult the profession, such as the medical royal colleges although consultation may not need to be limited to them, and local patient groups, such as the Commission for Patient and Public Involvement in Health, the closest that we have to a truly accountable body that represents the consumers of health care.

It is clearly unacceptable that something that is supposed to measure quality is doing so against standards that have nothing to do with quality of health care and clinical outcome. I shall pluck one topical example out of the air; it applies to all the so-called high-level standards that are in the Government's league table assessment. I am eager for the Under-Secretary to give me an evidence base today for any of the standards of waiting lists, waiting times, trolley waits and two-week waits. I offer him that challenge; we could probably use such standards as exemplars for the rest of the afternoon.

My example shows the damage that could be done if the Secretary of State were responsible for preparing and publishing a statement. Let us consider a standard under which 70 per cent. of patients in A and E are dealt with, from the moment of being admitted to their leaving the department, in four hours. I do not mean their having been seen by a doctor. That is a different issue. If a trust meets that target while another does not, does it follow that it is delivering better health care? Not only does that not follow, but there is every reason to suggest that it not only distorts the allocation of resources for clinical decision making, but acts against the best interests of patients in respect of demonstrable outcomes. It is counter-productive.

Anyone who has worked in an A and E department knows that about 70 per cent. of cases are people suffering minor injuries. The people are not brought to the hospital by ambulance and are relatively well. They can be dealt with quickly and processed—to use the Government's term—and either admitted or, as most usually are, discharged within four hours. That can be done if all the concentration is on that group, but what is to happen to the other 30 per cent.? They can be left for up to 12 hours before another quality standard kicks in, and it is likely that they will be left for longer because, in the first four hours, the only thing on which the accident and emergency department is measured is whether it can deal with the least sick patients more quickly. That is a potential perversion: a distortion of clinical priority. It is not just a question of potential, however. According to the majority in a survey of 30 per cent. of accident and emergency departments, it is actually happening.

It is disgraceful enough when the Government say, ''We shall measure your performance in the interests of patients by doing something that will be detrimental to them as a group, and will damage the individual interests of the sickest.'' It is unethical for doctors to co-operate in such intervention in clinical priority setting and decision-making. However, it is worse when such measuring is delegated to what the

Government claim to be an independent commission to audit health care improvement. Clearly it is not independent. It is a charade of independence for a commission to impose the Government's standards for measurement, which have nothing to do with quality of care in terms of clinical outcomes.

It might well be that if one polled 100 per cent. of patients in an accident and emergency department, a majority would say that they would prefer 70 per cent. rather than 50 per cent. to be processed within four hours, but that is not how health care decision making works. It involves prioritising the sickest—those least likely to be able to speak for themselves—and ensuring that they are treated more quickly. Those are just a few of the problems with a single target.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

That is not right.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

The hon. Gentleman says that I am wrong. It is the view of people working in the system that there is no doubt that saying that a department will be measured by the number of patients who can be processed within the first four hours will mean that the straightforward cases will be dealt with more quickly.

A second problem is that that pressurises staff to move people out of accident and emergency departments more quickly than might be appropriate. For example, when I was working in an accident and emergency department, I was much keener for sick people to stay in it if there was not an appropriate bed for them to go to than for them to go to an inappropriate bed. I am told by consultants that, as survey evidence shows, accident and emergency departments are now under diktat to send sometimes critically ill patients to side wards or ophthalmology or obstetric wards in order that they should not be punished by the Government for missing a target. [Interruption.] I hope that the Under-Secretary will confirm that is not the case.

In health questions yesterday, the Under-Secretary argued that the testimony of the majority of accident and emergency consultants questioned in the BMA survey was not an objective measure because it measured only 30 per cent. of accident and emergency departments. However, he must understand the concept of a sample. He relies on focus groups—opinion polls are bad enough; focus groups are worse—and by scientific standards that was a sufficiently significant number of accident and emergency departments for it to represent the majority. He might not like the outcome, but he cannot deny that it is a representative sample.

That is the litmus test as to whether we have a proper system for health care audit inspection. The Under-Secretary will make what exists much worse if, despite calling it more independent, he forces CHAI to measure hospitals against quality standards established by politicians—it would apply whichever party were in power—particularly if he forces it to give legitimacy to the league table-fiddling charade in which he is engaged.

It is one thing to measure, objectively, the performance of individual clinicians, teams and

hospitals on hard clinical outcomes, adjusting for factors such as patient selection. It is another to measure performance, or to claim to do so, by imposing on an inspectorate and the service outcome measures that are not clinically based, that have no evidence behind them of any improvement in patient outcome—rather than political outcome—if they are met, and to do so in a system that is tainted by the involvement of politicians.

I understand the Under-Secretary's need to ensure that the Government get a good press on the health service. I am trying to be positive, so I shall not criticise the Secretary of State or the Under-Secretary for doing things that Secretaries of State and Under-Secretaries do in the political arena—put on the best spin, and misinterpret and selectively quote what other people say. That is all part of the political hurly-burly. However, that process should not pollute the crucial relationship between a patient and a doctor, nurse or other health care professional, or between the population served by the health service and those attempting to commission and provide health services on their behalf, particularly in the key role of measuring standards.

My final point is that this debate is important not just in a theoretical sense. We are talking about patient outcomes. Therefore, if the targets are wrong and if hospitals and other providers are forced to change their priorities according to political whim, patients suffer, as do the people who are scapegoated for attempting to do their best by the patient but not by the Government's wishes.

I urge the Government not simply to reject the amendments—there will be continued conflict about the issue throughout the course of the Bill—but to come up with something that will ensure that the Secretary of State at least has to pass an evidence test and an outcomes test before imposing such standards on the CHAI.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

To some extent, the hon. Gentleman makes my point for me. He did not mention patients in his contribution. He gave the example of the four-hour waiting period target for accident and emergency departments. I shall go on to make a distinction between standards and targets, which I do not think the hon. Gentleman has got his head around. The distinction, target and four-hour wait are about patients.

Hon. Members may all be able to think of a doctor who talks at the patient but does not really take on board how they feel, and we know about the vested interests that may exist in organisations such as the NHS. I ask the hon. Gentleman to take off his doctor's hat and think about the patient. He may not have been listening to his constituents, but the Government heard and understood them. I know that his constituents in Oxfordshire do not want to wait in an A and E department for six, seven, eight, nine, 10 or 12 hours, which was the case until a few years ago. For some people, four hours is too long.

It is right that in setting targets the Government understand the standard. The standard in this case is that people want to be seen quickly and efficiently. We

can have a discussion about the target of four hours, but the hon. Gentleman needs to understand it and not just startle us with a series of ideas, facts and contributions that really do not take on board its importance. [Interruption.] I hear hon. Members from a sedentary position say, ''Waffle.'' Well, that it may be, but it is about patients and the fact that patients do not want to sit in A and E departments.

I am surprised that the hon. Gentleman, who is a senior politician—[Hon. Members: '' No, he's not.''] The Committee corrects me. I am not as surprised as I was then. It would be wrong for the body responsible for setting standards to be responsible for assessing them. That is why we set up CHAI as an independent body.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

Will the Under-Secretary give way?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

No, I want to make progress.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

Will the hon. Gentleman give way before he moves on?

Mr Peter Atkinson (Hexham, Conservative)

Order. The Under-Secretary has indicated that he is not prepared to give way.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

We set up CHAI as an independent body to assess whether the standards set by the Government have been reached. Furthermore, it would be entirely wrong for the Government to hand over to an independent body the responsibility for raising standards in health care, which would be the effect of the amendment. It is for the Government of the day to determine the framework of standards within which the NHS should operate. That is why we have a national health service.

My hon. Friends understand that shrugging off that duty as proposed in the amendment would be a dereliction of the Government's responsibility. We have consistently shown our commitment to improving the health service, driving up quality through a number of initiatives, the most important of which are the establishment of national service frameworks and NICE. The NSFs are one element of an overall programme of modernisation. They are designed to help to improve health and social well-being by providing services to more people more quickly, and to a higher standard, by improving the patient experience, which the hon. Gentleman never mentions, and by reducing variations in care and increasing compliance with evidence-based practices. It is for the Government to bear those things in mind.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

Will the Under-Secretary give way?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

I shall make a little more progress. We set up NICE to set common standards across the NHS by providing a national source of clinical guidance. That position has been underlined by the requirement that, in general, NHS funding is provided to underpin the most positive recommendations in NICE appraisal guidance.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

The Under-Secretary claimed that it was the Government's responsibility to set standards and

that it would be wrong to shrug it off on to another organisation. On what basis did the Government choose to give NICE the job of reforming clinical guidelines and evaluating the proper use of NHS resources? On what basis did the Government set up the working groups? They are still working hard on national service frameworks, but the Under-Secretary says that it is a job for the Department of Health. What clinical support has there been for targets such as waiting list numbers, four-hour waits or two-week waits? If he can give us the evidence, we can have a debate.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

I refer the hon. Gentleman to the Kennedy report, which covers many of the points that he raises. The Government set the NSF standards, which will be incorporated into the Secretary of State's standards; that is clear. NICE standards will be incorporated within the Secretary of State's statements of standards. The hon. Gentleman is right to say that evidence is important, which is why we will fully consult on standards before they are included in the Secretary of State's statements of standards.

As I said before, the hon. Gentleman is confusing standards with targets. The distinction must be made; standards are not the same as targets. They may form the basis of targets, but the statement of standards will not set targets. The target, for example, is for patients to be seen in our accident and emergency departments within four hours. The standard is for patients to be seen speedily. I ask the hon. Gentleman to get his head round that distinction.

Mr Simon Burns (West Chelmsford, Conservative)

I have listened carefully to the Under-Secretary, but I maintain my original view that this part of the Bill is crucial. I would like to see a Division on the amendment.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

I am grateful for the opportunity to respond to the Under-Secretary, since for the first time in the Committee he refused take interventions, even though we have moved along reasonably swiftly today. I am not sure why he refused, perhaps he can explain. I raised a series of concerns that he has simply not dealt with, as the record will show. The record will also show that I was talking from a patient perspective. The Under-Secretary may disagree, but he will not be able to substantiate his argument on the basis of the number of times that patients were mentioned in the record of our debate.

I turn now to the matter of the difference between standards and targets. The Under-Secretary claimed that the standard was for patients to be treated speedily and the target was for them to be treated within four hours. We used one example in the interests of brevity, but there are eight others that we could have used. I am prepared to accept that distinction, but is that the right standard? Should it not be that people are seen quickly in order of clinical priority? That is the kind of standard the Under-Secretary seeks to impose on CHAI. Health professionals and informed patients are concerned not only about the total speed of the operation, but about people being treated in the correct order. If that is an example of the standards that the Secretary of

State will impose on CHAI, it spells problems for patient outcomes.

The Secretary of State cannot say that evidence-based clinical outcomes are simply whatever he thinks the public or patients want. What is the point of having health services research that looks at the issue, if a Minister, the Secretary of State, a focus group or a special adviser comes up with the latest gimmicky idea about what will be popular, rather than thinking about what is necessary to extract the maximum health benefit for the population served by a health care provider? I do not deny that I feel strongly about this issue, but I feel no more strongly than many other people who have worked in the health service. They feel that milestones and targets that glibly refer to treating people speedily, which, like motherhood and apple pie, sounds so good, actually prevent people from being treated in order of clinical priority. Clinical priority should be the standard.

I wish that the Under-Secretary would take the opportunity to engage in debate on the issues. I notice from his response to my question that he was not able to come up with clinical evidence for any of the nine standards that I mentioned. I have asked his colleagues that question in various Adjournment debates, and they have never answered it. No clinical groups supported the decision to have a target or standard based on the number of people on a waiting list. Indeed, it has been broadly recognised, even by some of the Under-Secretary's colleagues, that that effectively made matters worse for patients, because they simply waited longer to get on the waiting list.

Has the Under-Secretary any reply to what I thought were balanced, serious observations about the problems of setting standards? [Interruption.] The Under-Secretary says, ''Of course.'' I started my contribution by stating that I recognised that the Government have made progress on quality issues. I am sorry that he did not feel able to respond in kind. That is his decision. However, he cannot say that I was entirely negative.

I am disappointed that the Under-Secretary did not feel able to take an intervention, to respond to my comments or to support the call for a Division to show how strongly the Opposition, and especially the Liberal Democrats, feel about the issue.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

We cannot get into the business of drafting standards in the Committee. That must be clear to the hon. Gentleman. I believe that he is being myopic. There exists in the NHS a series of different standards and, as a result, targets. The hon. Gentleman made that clear. He talks about the door-to-needle time vis-à-vis the wait target in accident and emergency, but there are clear differences between standards and targets. There is not an either/or for the Government; there is a need for standards across the NHS, and our objective is to set them. The hon. Gentleman, in his wide-ranging contribution, and with the clinical expertise that I know he brings to these matters, makes the Government's points for us.

Question put, That the amendment be made:—

The Committee divided: Ayes 8, Noes 12.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

I beg to move amendment No. 391, in

clause 41, page 14, line 17, leave out 'and publish'.

Mr Peter Atkinson (Hexham, Conservative)

With this it will be convenient to discuss the following:

Amendment No. 392, in

clause 41, page 14, line 19, at end insert—

'(1A) The Secretary of State must publish all such statements, and must publish a statement of the evidence base upon which these standards are set.'.

Amendment No. 393, in

clause 41, page 14, line 20, leave out from 'and' to end of line 21 and insert

'may amend the standards whenever he considers it appropriate.

(2A) The Secretary of State must publish amended statements, and must publish a statement of the evidence base of the statements.'.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

I am glad that I got what I said previously on the record. It is part of the justification for this group of amendments, which, I should have thought, are pretty non-controversial. If the Secretary of State is to issue standards, and give assurances that those standards are rational, that there is an evidence base behind them and that the reasons for the Government's issuing them are transparent, the minimum that is required is that he publishes the standards together with the justification.

The Government rightly insist that the delivery of health care, not just by doctors and nurses but by other health care professionals, should be rational. If public money, or indeed patients' money, is to be spent appropriately and delivery is to be rational and based on evidence, doctors and other health care professionals must demonstrate how they are doing that. The same must apply to the macro-questions that, sadly, dictate clinical priority and the allocation of resources. The Secretary of State must show the rational, clinical and evidential basis for those decisions. That is not an onerous or bureaucratic requirement to place on the Government. If this unsatisfactory clause is not amended in any other way, that requirement needs to be included to ensure that transparency.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

While seeming to be helpful and inclusive, the amendments will only cause further bureaucracy, delay and division. The Secretary of State will not burden the NHS with health care standards that are not supported by evidence or by

consensus of professional opinion. To require the statutory publication of the evidence base for every standard adds unnecessary further layers to the publication of standards. The Government have already proved their belief in using the best available evidence to provide guidance for the health service by establishing NICE, which produces guidance based on the best available evidence and on expert professional advice.

Clause 41 requires the Secretary of State to consult those considered appropriate before health care standards are set. There is no need to require statutory consultation for every new publication or for each slight amendment to an existing standard. That would simply cause additional bureaucracy and delay.

To specify two groups, as the amendment does—the medical royal colleges and the Commission for Patient and Public Involvement in Health—gives those bodies, worthy though they are, a statutory status denied to all others, from the Royal College of Nursing and the Commission for Health Audit and Inspection to individual patients and international experts, all of which may have an equally valid interest in a specific standard.

The process of setting the health care standards will be inclusive and will take full account of the views of the key stakeholders.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

The Under-Secretary may have elided this group of amendments and another group. I look to advice. I am quite capable at this hour, after a transatlantic flight yesterday, of being wrong, but I believe that the issues that he referred to are probably dealt with more appropriately on amendments Nos. 394 and 395. I seek to be helpful, to give the Under-Secretary an opportunity to check whether that is the case.

Perhaps I may say at the same time that I did not quite catch the Under-Secretary's second sentence, which was a little sotto voce and lost in the acoustics. He said that the Government would not publish standards that were not supported by—and I missed the next word. If he has an opportunity to re-read that bit, I shall be grateful.

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

The point in this series of amendments is the same. The hon. Gentleman challenges the basis on which the Secretary of State publishes his standards and places additional requirements on him. Therefore, much of what I have to say answers the points that he made in his previous contribution and in the one that he has just made. I hope that that is helpful.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

The Under-Secretary said that the Secretary of State would never publish standards that were not based on evidence. I am therefore puzzled about why, given his clear commitment to the Committee today, he would not wish to see, attached to the standards, references to the evidence that underpins them. Surely that is a sensible practice. It may not require amendments to achieve it. Can the hon. Gentleman not give that assurance?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

I think that I have made the point.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

I think that my hon. Friend the Member for Sutton and Cheam would say that the Under-Secretary has not made the point that would answer his question, but a point has been made.

The Under-Secretary said in his response that the change would be bureaucratic. How bureaucratic would it be? It is now the case that clinical guidelines are never issued by any organisation worldwide—certainly in this country and the United States—without a statement detailing the underlying evidence and the strength of that evidence. If the Under-Secretary can give me an example of standards set for clinical actions where that is not the case I shall be grateful. That is not done for the heck of it, but because it inspires confidence in the standards.

Such a statement not only shows that there has been a process to establish the evidence, but that the strength of that evidence is tested. It is usually ranked 1, 2 or 3, where 1 is the strongest evidence usually based—although not exclusively—on randomised controlled trials. More contentious evidence, backed by a majority view, is graded next, and contentious views that are still felt to be part of the evidence are graded below that. It is a helpful process and not an unreasonable thing to request.

Further to the question posed by my hon. Friend the Member for Sutton and Cheam, if the Under-Secretary is correct in saying that the Secretary of State would never set standards, or the targets that flow from them, that were not based on evidence—otherwise, he would be conceding that the targets were not based on evidence—why does he not publish the evidence base for any of the nine targets that govern the first round of league tables? What is the evidence base for the maximum waiting time, the number of people on waiting lists, the two-week wait ''for cancer''—which is a two-week wait for diagnosis, not treatment—the 12-hour target for trolley waiting, the four-hour target, the clean hospitals target, which my hon. Friend demonstrated has little to do with issues related to cross-infection, and the rest of them? Will the Under-Secretary give a commitment to place in the Library the evidence base for any one of those nine standards, targets, milestones or whatever he wants to call them?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

The hon. Gentleman knows that the Committee is not the forum for citing this or that standard. The important thing is that the standards will be agreed as a result of full consultation with all stakeholders. The Bill says that the Secretary of State must consult on the standards. We are committed to ensuring that the standards consulted upon are based on the best available evidence. I am sure that during consultation we shall hear loud and clear if individuals or groups, including CHAI, think that the Secretary of State is setting inappropriate standards, and we will review and amend those standards wherever appropriate.

Dr Andrew Murrison (Westbury, Conservative)

The Under-Secretary is being a little unhelpful. I believe that the hon. Member for Oxford, West and Abingdon is merely asking the Government to publish the evidence on which they are basing their targets and standards.

There are two issues. First are standards that relate to housekeeping issues such as ward cleanliness, waiting times and so on, which are concerned with a large element of patient choice—what our constituents want to see in the NHS. The other issue is the scientific evidence for particular interventions. The hon. Gentleman mentioned the hierarchy of such evidence. That is a good discipline because it focuses the minds of all—not least politicians—on what works.

If politicians are to impose targets, they must be prepared to publish the evidence on which they are basing the imposition of those targets. That is a reasonable thing to ask. It would certainly discipline politicians to focus on patients. The Under-Secretary was very concerned that we were not mentioning patients enough; I am suggesting that we should focus on their needs rather than those of politicians. I must say that I am very much in favour—rather unusually—of the Liberal Democrat position. It seems entirely reasonable to publish the evidence base for targets imposed on the NHS. I have to say well done to the hon. Member for Oxford, West and Abingdon.

Dr Evan Harris (Oxford West & Abingdon, Liberal Democrat)

I rise briefly to thank the hon. Gentleman for those comments, to which I entirely subscribe.

I have one final thing to say to the Under-Secretary. When I asked him whether he would publish evidence for any of the nine standards for hospital performance—they are clearly not national service framework standards, which are published with evidence—he said that this place was not the place to discuss standards set by the Secretary of State. I look around at other hon. Members, and find myself in a Committee of the House of Commons debating a clause entitled, ''Standards set by Secretary of State''. If this is not the place to discuss things—I know that it is often the place where we do not get answers—everything that the Government say about the Secretary of State being accountable to Parliament and their therefore not needing to have their policies scrutinised by CHAI and CSCI rings hollow. The Under-Secretary is always saying that there is no need for the Department and the Secretary of State to be inspected or judged by those bodies because that is what this place is for. I have asked for the evidence for standards to be placed in the Library, and I have been told not only no, but that I should not be raising the question in the first place because this is not the forum for it. I therefore intend to press the amendment to a vote.

Question put, That the amendment be made:—

The Committee divided: Ayes 8, Noes 11.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I beg to move amendment No. 469, in

clause 41, page 14, line 18, leave out 'cross-border' and insert 'Welsh'.

Mr Peter Atkinson (Hexham, Conservative)

With this it will be convenient to discuss the following amendments: No. 471, in

clause 41, page 14, line 28, leave out 'cross-border' and insert 'Welsh'.

No. 472, in

clause 41, page 14, line 29, at end add—

'(5) The standards set out in statements under this section are to be taken into account by every cross-border SHA.

(6) The standards set out in statements under this section are to be taken into account for Northern Ireland when required.'.

No. 24, in

clause 51, page 18, line 1, after 'English', insert 'and Welsh'.

No. 25, in

clause 51, page 18, line 17, after 'English', insert 'or Welsh'.

No. 26, in

clause 53, page 18, line 38, after 'English', insert 'or Welsh'.

No. 27, in

clause 53, page 18, line 42, after 'English', insert 'or Welsh'.

No. 29, in

clause 53, page 19, line 2, leave out 'Secretary of State' and insert 'appropriate authority'.

No. 28, in

clause 53, page 19, line 4, after 'English', insert 'or Welsh'.

No. 32, in

clause 55, page 20, line 19, after 'English', insert 'or Welsh'.

No. 33, in

clause 56, page 20, line 28, leave out from 'trust' to end of line 29.

No. 38, in

clause 65, page 24, line 22, leave out 'Secretary of State' and insert 'appropriate authority'.

Mr Chris Grayling (Epsom & Ewell, Conservative)

We arrive at the first of what I suspect will be a number of debates about inspection in England and Wales. We will come to the Welsh clauses later. The amendments have two objectives. The first is to ensure that control over standards resides with the inspectorate, rather than in the hands of politicians. We mentioned that principle in earlier debates on this part of the Bill, and it is also expressed in the measures that will set up new structures in Wales. Secondly, and more particularly, the amendments would remove the anomaly and nonsense of allowing the establishment of a parallel but separate and distinctive process in Wales.

The Bill continues the process of dividing up our health service, so that we will no longer truly have a national health service. The Bill divides the inspection process in England and Wales. It leaves the Assembly in the driving seat, deciding how the inspection process will work in Wales. In England, the decision-making will, to a significant degree, move into the hands of the inspectorate. I accept that, despite our earlier debates.

That is complete nonsense for four reasons. First, it puts far too much of the inspection process in Wales into the hands of its politicians. I accept what the Under-Secretary said: he is creating a structure that is in part independent of politicians. We have had our disputes about the degree of independence, but it is quite clear that the Bill gives the health service in Wales an inspectorate that is much less independent of political interference than that in England.

The second point is about the duplication of effort. It would be straightforward to have an inspectorate for the national health service. What on earth is the point of having parallel health processes? Why, if we are creating a centre of inspection expertise, will the situation in Wales be different to that in England?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

Devolution.

Mr Chris Grayling (Epsom & Ewell, Conservative)

The Under-Secretary says devolution, but if the Government go ahead with regional assemblies, will we have different inspection regimes in, say, the north-east, the north-west, Yorkshire and East Anglia? Where will the process stop? The Under-Secretary himself made great play this morning of his pride in the diabetes national service framework, which he says is a national standard. But is it? Clause 42, which we shall debate later, provides for the Welsh to have their own standards. We will have different standards for different parts of the country. Where will that stop? Why do we need so much duplication in the inspection process?

Mr David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

I hesitate to intervene, but I want to be clear: Wales is a country, and it has a National Assembly. That is important, and we support devolution. The hon. Gentleman raises the issue of regional assemblies, but does he accept that there is a big distinction to be made, if we are not to offend the people of Wales?

Mr Chris Grayling (Epsom & Ewell, Conservative)

I simply disagree. We should not have separate inspection processes for the NHS in England and Wales. That is nonsense. It will create a duplication of effort and cause enormous confusion in cross-border areas. At the start of the debate, we discussed the Countess of Chester NHS trust in the constituency of the hon. Member for City of Chester (Ms Russell). That is an example of a trust that could have two sets of inspections: inspections from Wales, because it provides services to the Welsh population, and inspections from England, because it provides services to the English. The hospital's management team are there to facilitate the treatment of patients, and it would be absurd for them to deal with not one set of inspectors checking what they are doing, but two.

It is quite right and proper that, where practical and possible, responsibilities are devolved to local communities, but it does not necessarily follow that that should be done in a way that creates unnecessary duplication, wasted resources and confusion. Perhaps the Government are saying that we no longer have a national health service; we have an English health service, a Welsh health service, a Scottish health

service and a Northern Ireland health service. In that case, let us drop the ''national'' altogether. Let us have no further pretence about the fact that we have a national health service, because we do not.

Perhaps the Government really see total responsibility for health care residing in Wales, Northern Ireland and Scotland. Perhaps they envisage no national frameworks whatever, an ability for each home nation to set its own health care standards, and cross-border inspections taking place all the time from one side to the other. That would be to the detriment of good governance and it would waste management time. If that is really the Government's goal, let the Under-Secretary say so, but it is a monumental waste of expertise and of what CHAI could, and should, be.

I hope that the opportunity will arise to extend CHAI's power still further, so that the phrase ''more independence'', as used by the Under-Secretary this morning, no longer applies and the word ''independent'' reflects the organisation's status. If CHAI achieves what it should, builds expertise, knowledge and understanding, and comes to shape the way in which our health care is delivered, it would be nonsense not to use that expertise throughout the country. It would be fundamentally wrong to create a parallel process and to duplicate effort, people, costs and bureaucracy by having a separate structure in Wales.

I hope that Ministers will think through the implications of what they are doing. There is no need for duplication or for politicians in Wales to have an inspectorate that is totally different from that set out in the Bill. There is no need to create confusion in border areas or to waste CHAI's expertise. CHAI is intended to be a centre of excellence, and it can serve the whole of England and Wales. I fail to understand why the Government seem to believe that it is not necessary simply to set out the framework, from the start, in the Bill.

Mr Jon Owen Jones (Cardiff Central, Labour/Co-operative)

I am afraid that I will disappoint the Under-Secretary because I have some sympathy with the arguments. It is clear that the United Kingdom already has four effective regions with different health policies and standards. However, when the health inspection process was first mooted—I raised the matter on the Floor of the House—I understood that it would be a joint process, at least in England and Wales, and I do not see why that should not extend to Scotland, as well. It should be a joint process because the organisation will demand a great deal of expertise and bureaucracy, and it would not be sensible to duplicate in different areas. It should be a joint process also because all those who want improvements in health care throughout the UK want the greatest possible degree of comparability. We could then learn from one another's best practices and, perhaps, from one another's worst practices. I had understood that CHAI would be a joint body.

The clause gives the Welsh Assembly and the Secretary of State the power to set their own standards, but I am not sure why that means that the inspections should be carried out separately. It

would be ridiculous to have two different sets of inspections for hospitals catering for large numbers of patients on both sides of the border. It would also be difficult to justify applying two different sets of standards. In answer to a question on the Floor of the House yesterday, the Minister of State, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), stated that the number of Welsh patients seeking treatment in English hospitals had increased from 26,000 in 2001 to 37,000 in 2003. As an increasing number of Welsh patients are being treated in English hospitals, there is an increasing need to apply similar standards. Even if slightly different standards are to apply, the same inspection

regime should at least operate on both sides of the border.

I would therefore be grateful if the Under-Secretary could clarify how the system will work. I hope that he can reassure me that the inspection system will give patients from Wales the same degree of protection as patients in England.

Debate adjourned.—[Jim Fitzpatrick.]

Adjourned accordingly at eighteen minutes to Five o'clock till Thursday 5 June at five minutes to Nine o'clock.