Mr Win Griffiths (Bridgend, Labour)

I remind the Committee that with this we are discussing the following amendments: No. 471, in

clause 41, page 14, line 28, leave out 'crossborder' 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 crossborder 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 David Lammy (Parliamentary Secretary, Department of Health; Tottenham, Labour)

When we adjourned yesterday we were discussing the amendment that deals with the establishment of the healthcare inspection unit for Wales. The hon. Gentleman the Member for Epsom and Ewell (Chris Grayling) was concerned that this would mean unnecessary duplication, and in strong terms questioned why we could not have the Commission for Healthcare Audit and Inspection as an inspectorate for Wales. Much of

what the hon. Gentleman said surprised me, even though he said it so strongly. The nature of the amendment also surprised me, because these health matters have been devolved to Wales for some time. In a sense, this is a settlement of an argument that Parliament heard about devolution in 1998–99.

Mr Chris Grayling (Epsom & Ewell, Conservative)

If this is a devolved matter and the issue has long been resolved, why are we debating it today and why is it in this Bill?

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

Let me make some progress and I will explain why.

Broadly, the amendments would extend the Secretary of State's standard-setting role and CHAI's various review and investigation functions to Wales and England, including the annual review, other reviews and investigations, co-ordination of those reviews and the power to require explanations.

The hon. Gentleman has forgotten that the National Assembly for Wales is responsible for health care in Wales. Clause 66 confers similar functions on the Assembly, as it is important for the Assembly's drive to improve the health of the Welsh people by ensuring that health priorities specific to Wales are addressed and monitored locally.

Mr Chris Grayling (Epsom & Ewell, Conservative)

Can the Minister give me an example of one of those health priorities that is exclusive to Wales?

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

As I was going on to explain, the National Assembly for Wales does not have primary legislative powers, only secondary ones. Nevertheless, much of what the hon. Gentleman said pertained to devolution. If I can extend the argument, he will understand why the Assembly has those powers. The Commission for Health Improvement currently undertakes these critical function reviews, but in so doing it has not been able to take fully into account defined Welsh health priorities and other issues specific to Wales.

Mr Chris Grayling (Epsom & Ewell, Conservative)

Such as?

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

The hon. Gentleman will understand that the demography of Wales and the history of the valleys, factors such as the high incidence of smoking and teenage cessation, and the Welsh industrial heritage, mean that Wales has its own characteristic demography and health economy. For those and other reasons the Welsh have chosen—as is their right—to pursue a course of action in the health economy that is specific to their needs. That is why their national service frameworks are specific to the Welsh. The coronary heart disease NSF published in July 2001, the diabetes NSF published in 2002, and the children's NSF published in 2002 are all specific to Wales.

Dr Andrew Murrison (Westbury, Conservative)

My hon. Friend the Member for Epsom and Ewell asked for specific examples of differences in Wales. The Under-Secretary responded with generalities, and pretty poor ones at that. Will he explain how Welsh diabetes differs from English diabetes?

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

I must always be careful to defer to the hon. Gentleman's clinical expertise. Having said that, I would have thought it patently obvious that the multicultural heritage of cities such as London,

Birmingham and Leicester means that the incidence and demography of diabetes is profoundly different from that in much of rural Wales.

Health care in Wales is different for several reasons, which is why the Assembly takes an interest in it. The hon. Member for Epsom and Ewell said yesterday that the Assembly was not the right place for such interest, and he challenged the scrutiny powers of the Assembly. I am sure that Members of the National Assembly for Wales would have been surprised at what was said here about their effectiveness and their powers of scrutiny. As the hon. Gentleman knows, they take scrutiny very seriously and have subject and Select Committees similar to ours.

The reporting process of the National Assembly for Wales ensures transparency and accountability, and the Assembly has set up mechanisms to ensure that the establishment of the HIUW is rigorous, and at a remove from the executive powers of the Assembly. These include the appointment of the head of the inspectorate in Wales through a process outside the Assembly; editorial control for the head of the inspectorate in Wales; simultaneous provision of reports prepared by the inspectorate to the Assembly's Health and Social Services Committee, which is similar to our Select Committee; rights of independent access for the inspectorate to the Minister for Health and Social Services; a separate complaints procedure to ensure independence; and other measures including working protocols and delegated functions.

The National Assembly for Wales takes seriously its responsibilities in this area. The hon. Gentleman's new Conservative colleagues in the Welsh Assembly will surely be surprised, as I am, at how quickly their colleagues in England are pouring scorn on their ability to scrutinise health care. Perhaps the hon. Gentleman will say that his colleagues should resign their posts because there are no differences in the health economy of Wales.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I am working on the assumption that the Minister believes that the patient should come first. Returning to the earlier example of the hospital in Chester, let us take the case of a consultant who treats a patient from England at 11 o'clock and a patient from Wales at 11.30. Should that doctor use a different approach to treatment for those two patients who may have an identical condition—one to conform with the NSF in England and another to conform with the NSF in Wales?

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

The scenario that the hon. Gentleman paints is simply not correct. We are talking about an inspectorate that should pertain to the local demography of Wales. The hon. Gentleman's view is that we do not need that.

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

As I understand the Bill, that problem would not arise. The Chester hospital consultant would be subject to an inspection that reported to the Secretary of State here. He would not be subject to an inspection that reported to the National Assembly.

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

That is right. My hon. Friend asked me some important questions about cross-border inspection yesterday, and I hope to come to those shortly.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I appreciate that we will debate this issue more fully later, but may I draw the hon. Gentleman's attention to clause 66(1)(b), which says that the Assembly has the power to conduct:

''reviews of, and investigations into, the provision of health care for a Welsh NHS body''.

In other words, provision could be made by an English NHS trust for a Welsh primary care trust in the case of a border hospital. So why would the Assembly not have the power to inspect a hospital just across the border that provided a service to a substantial area in Wales, such as the hospital in Chester?

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

I wish that the hon. Gentleman would let me make some progress. The Bill clearly includes a duty of co-operation between the inspectorates in England and Wales, and both could inspect work commissioned by Wales.

As to the earlier point, there is no difference between the treatment given in England and the treatment given in Wales; nothing that I have said this morning suggests different standards of treatment. I have concentrated my remarks on differences in demography. We have already had a discussion in this place about devolution, and we have had a settlement, and that pertains to the amendment.

Dr Andrew Murrison (Westbury, Conservative)

For the Minister's benefit, he must clarify in his mind exactly what the NHS is all about—it is about treatment. If he is saying that there is no difference between treatment in England and treatment in Wales, why on earth is he making these different arrangements for England and Wales?

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

There are already different arrangements for England and Wales. The old health authorities still operate in Wales. I have explained that the NSFs in Wales are different. The hon. Gentleman makes an interesting point, but he should perhaps have made it a few years ago. Things have moved on, and there are already different arrangements in Wales. That is why the amendment does not get us far at all.

Under clause 43, CHAI will be under a duty to provide information and advice to the appropriate authority about the provision of health care in Wales, as may be requested. The Bill provides that the Assembly and CHAI must co-operate with each other where it seems appropriate to them to do so for the efficient and effective discharge of any relevant function, but it would not be proper for CHAI alone, unless under agreement with the National Assembly for Wales, to undertake those reviews. That is the duty of co-operation that I referred to.

The National Assembly for Wales has already announced its intention to establish a health inspectorate for Wales to exercise the Assembly's functions.

That will ensure that there is a strong focus on defined Welsh health priorities and that performance quality and regulation issues are fully and rigorously addressed. It will be for the Assembly and the Welsh

inspectorate to best determine the annual inspection regime. Reviews and inspections undertaken by the Welsh inspectorate will be carried out using the joint review for social services model, including the Audit Commission for Wales. Effectively, the two inspectorates will examine two separate health services. That arises as a result of the devolution settlement.

I remind the hon. Member for Epsom and Ewell that, under section 1 of the NHS Act 1977, the Secretary of State has responsibility for providing a comprehensive health service. However, by virtue of section 22 of the Government of Wales Act 1998, by council order the functions for providing a comprehensive health service for Wales pass to the Welsh Assembly. That must be the right place for that.

My hon. Friend the Member for Cardiff, Central (Mr. Jon Owen Jones) raised an important point about cross-border inspections in towns such as Shrewsbury, Chester and others. Welsh people use hospitals and medical services on the English side and vice versa. The duty of co-operation means that the English and Welsh inspectorates may establish protocols and carry out studies of issues that are pertinent to those hospitals. However, the relevant inspectorate must conduct the study and work in co-operation with colleagues across the border.

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

It is difficult to remember exactly what was said yesterday, but I recall that I was concerned about the need to have comparable standards so that we could examine how each branch of the health service was performing in important areas. It would benefit hospital services in both England and in Wales if comparable standards were set and published so that we could judge performance. I understood that that would happen. I was seeking reassurance from the Under-Secretary that we would try to ensure that such comparisons were made.

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

I hope that standards used in Wales and by CHAI in the English regions will be equally high and that inspections undertaken in Wales will take place against a framework determined by the Assembly and including both national English and Welsh standards and standards developed by the Assembly. National standards such as the national service frameworks underpin many of the standards determined by the Assembly just as the national service frameworks determine standards on the English side.

My hon. Friend raised an important point. I should like Hansard to put on record that standards are high on both sides of the border. That is important. The duty of co-operation means that it is pertinent and important that the chairpersons of the English and Welsh inspectorates work closely in the early days to ensure that those protocols, cross-border issues and standards are ironed out.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I must say, Mr. Griffiths, that that is completely bonkers. The Under-Secretary's words describe a thoroughly bad deal for health care in this country; the United Kingdom, of which we were all still a part when last I looked.

The Bill provides for the establishment of health care standards in Wales that differ from those in England. We are not talking about an island somewhere out in the Atlantic; we are talking about a country that is part of our nation and shares facilities. When asked to address the issue of commonality of standards, the Under-Secretary said that he hoped that they would all marry up. He was asked to rationalise that, and he talked about the distinctive nature of the demographic situation of health care in Wales. My hon. Friend the Member for Westbury (Dr. Murrison) rightly pulled the Under-Secretary up; he could not name a single example of a health care condition that was exclusive to Wales. That is because there is none. Actually, there is one exception. During the debate on the Health (Wales) Act 2003, it was pointed out that there were specific instances of health problems in Wales related to the limestone mining industry in the north of that country.

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

I refer the hon. Gentleman to the publication ''Health in Wales—Chief Medical Officer's Report 2001/2002''. Page 82 states that against every measure—including circulatory disease, cancer and respiratory disease—health in Wales is worse than it is in England.

Mr Chris Grayling (Epsom & Ewell, Conservative)

That is ironic, since we know that the national health service spends more on each person in Wales than it does in England. Unless I am mistaken—my hon. Friend the Member for Westbury captured the moment perfectly—there is, of course, no difference between medical conditions in Wales and in England. The illnesses are the same, and they require the same treatments and the same medical expertise. We ought to judge the quality of treatment in the same way.

The Under-Secretary said a couple of days ago that the establishment of the NSF for particular diseases, such as diabetes, was one of his proudest moments since becoming Under-Secretary. What is different in Wales that means that his NSF is not good enough for the people of Wales and that they need something different? Why is it not applicable to them? Why is it necessary to duplicate it? Why is it necessary to spend public funds, which would otherwise have been available to treat patients, to create a second NSF for Wales?

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

Do the hon. Gentleman's Conservative colleagues in the Welsh Assembly share his opinions?

Mr Chris Grayling (Epsom & Ewell, Conservative)

My concern is about what is right for the patients. We are the Parliament of the United Kingdom.

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

Does that mean that the Welsh Conservatives are patently wrong?

Mr Chris Grayling (Epsom & Ewell, Conservative)

The Under-Secretary may have missed the point, which is understandable; as he said yesterday, the role is new to him. I should like to remind him that he is an Under-Secretary in the United Kingdom Parliament, not an English Parliament. I was under the impression, Mr. Griffiths, that it was our duty in this place to make decisions in the interests of the people of the United Kingdom.

I do not understand how it can possibly be in the interests of the people of Wales to create a second NSF, with people putting together information, secretariats assembling documentation and expenditure being provided for the communication of that NSF to medical practitioners across Wales. That money could otherwise have been spent on operations and on reducing the ridiculously long waiting lists that most patients in Wales currently experience. This is an absolute nonsense.

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

I do not wish to intrude on this interesting discussion, but suppose that the Welsh Assembly—including Welsh Labour—took the same view as the Audit Commission in its report this morning and decided that, as far as possible, it did not want those targets and their associated standards imposed on the Welsh people. Does the hon. Gentleman accept that, if that were the case, the way in which the Bill is written provides an escape—at least in Wales—from the imposition of what is a very poor policy, according to the Audit Commission? That is one benefit of devolution.

Mr Chris Grayling (Epsom & Ewell, Conservative)

The hon. Gentlemen is more of a pessimist than me. I very much hope that the weight of argument that will come from the Conservative Benches and the Liberal Democrat Benches in the next few days about the roles and responsibilities of CHAI will encourage Ministers to step away from imposing such a huge burden of target pursuit on the health service and from forcing the inspectorate to use those targets as their prime reference point.

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

I share the hon. Gentleman's hopes, if not necessarily his optimism. He will agree that if we were able to change the Bill in the way for which we both voted last time—which would mean that CHAI would set the standards after consultation with the Department of Health and the Welsh Assembly—at least different political opinions on setting standards could be channelled through one organisation. We could then have a more transparent process, which would solve some of the problems that he has identified.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I very much agree with that. The hon. Gentleman will recall my expression of disappointment that the Bill appears to leave greater political control in one part of our country than in others. My view, and that of my colleagues, is that politicians do not have the expertise to inspect and establish health care standards.

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

There is a precedent in Wales for separate inspectorates; they already have separate inspectorates for social services and for education. Does the hon. Gentleman's remark also pertain to those?

Mr Chris Grayling (Epsom & Ewell, Conservative)

I fear that I would be treading on your patience, Mr. Griffiths, were I to steer the discussion towards social services and education. I am interested solely in the best interests of the patient, and particularly in the best interests of those in the border areas—either just in Wales or just in

England—where services do not stop at the boundaries, but cross over. In those areas, patients from England may go to a hospital in Wales because it is nearest, and vice versa. Patients may even go to a GP across the border. There is a danger that those patients in particular will lose out. That will happen partly because of the waste that I have described from creating parallel structures, parallel administrations and parallel NSFs. Patients will lose out because of the nonsense of doctors having to pursue one NSF with one patient and a different NSF with another. If those structures are to be different, doctors will have a duty to do precisely that.

If the Under-Secretary thinks that that is a mythical possibility, let me give him a real example of something that occurs in the NHS today. Different purchasing patterns in different primary care trust areas mean that doctors have to ask patients where they live before their treatment can be decided on. I know this because I have talked to doctors in London who have said that they have to ask those questions. Returning to the Prime Minister's area of interest, I have talked to diabetes specialists in London—[Interruption.] I apologise to the Under-Secretary; I do not want to ruin his prospects any more than they already have been by the rumours about his future career prospects. Diabetes consultants in London tell me that different primary care trust spending patterns mean that they can prescribe to one patient something that they cannot prescribe to another. The NSF for England may make a specific recommendation about a drug, a form of treatment or a device that should be part of the treatment for that condition, but the NSF in Wales might not do that and may recommend something different.

In that case, a doctor may have to give one treatment to one patient and something else to another, even if they come from adjoining villages and have consecutive appointments in the calendar. Is that honestly in their best interests, let alone those of the doctor who must remember where each patient lives and work out what to do? That would be an absurdity.

My concern is not whether politicians in Wales or England have decision-making powers, but that an absolute nonsense will be created for patients. Duplication and confusion will provide only a disservice, and that is surely not the best way to work.

My last point concerns the one-way nature of the exercise. I refer the hon. Member for Cardiff, Central to my point about clause 66. The Under-Secretary will correct me if I am wrong, but the Bill provides the Welsh Assembly with the power to mandate inspections of English bodies that provide health care services in Wales. Therefore, a hospital in Chester may face two inspections rather than one. Can the Minister assure me categorically that that will not be the case? I doubt that he can, and additional bureaucracy will be imposed as a result.

The same is not true in reverse. The Bill does not give CHAI the right to ask whether a decent job is being done for English patients whose local hospital

is in Monmouth, Newport or mid-Wales. That is also an absurdity. If there are to be two-way inspections—I do not believe that there should—it is nonsense that they go one way and not the other. Is it necessary to have a situation whereby a hospital might be inspected twice? Any hospital manager will confirm that a CHAI inspection is onerous and challenging and requires a considerable investment of management time that could be better used in running the hospital. For that to happen twice, rather than once, is unnecessary.

That part of the Bill is bizarre and unnecessary, and devolution would not be damaged if it were set to one side. Certainly, the management of the health service in Wales and deployment of resources rest with the Welsh Assembly. My colleagues in Wales will be delighted to endorse that contention. However, is it necessary for the United Kingdom Parliament to set up two inspectorates when one can, and should, do the job? The Under-Secretary's arguments have been unconvincing, and I ask my hon. Friends to back me by challenging the Government's ludicrous assumptions and by voting for these amendments.

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

Understandably, those Members of Parliament who do not represent Wales have a patchy knowledge of how Welsh affairs are arranged. It is true that the health service in Wales is organised separately from that in England. To answer the question raised by the Member for Oxford, West and Abingdon (Dr. Harris), targets set in Wales are different from those in England. I have no difficulty with that.

My concern is that, without some mechanism to ensure comparability, two inspection regimes will be wasteful and will not provide the best service to people on both sides of the border. There should be such mechanisms to ensure co-ordination and comparability, but they do not appear to be in the Bill. I suspect that well-informed peers in another place will want to scrutinise that.

Before CHAI is established, the body known as CHI—chaired by Dame Deirdre Hind, the former chief medical officer for Wales—is currently conducting a joint inspection in England and Wales. Contrary to what my hon. Friend the Under-Secretary said, I do not believe that that body has expressed any difficulty in inspecting services in Wales.

The Welsh Assembly has decided, however, that it wants a separate inspection. That is all very well, but the Bill should contain some guarantee that we can compare, contrast and co-ordinate the two inspection systems, even though I do not think that two separate systems are necessary.

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

I respect my hon. Friend and hope that he is satisfied with clause 132. If he is not, I shall be happy to reconsider.

Question put, That the amendment be made.

The Committee divided: Ayes 6, Noes 17.

Mr Win Griffiths (Bridgend, Labour)

The hon. Member for Ealing, North (Mr. Pound) has just voted in Welsh. Although the debate concerns England and Wales—and even though I recognised the other language—I remind Members that, while we are in London, we will vote in English.

Mrs Cheryl Gillan (Chesham & Amersham, Conservative)

On a point of order, Mr. Griffiths. Just as the Division was called, the hon. Member for Cardiff, Central inexplicably left the Committee Room, so that he was not able to vote on a Welsh matter. Is it in order for a Member to leave the Committee after a Division has been called in order to avoid voting on a measure that affects the country of which he is a representative?

Mr Win Griffiths (Bridgend, Labour)

That is not a point of order. The hon. Gentleman might have had to deal with some urgent personal matter.

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

I beg to move amendment No. 394, in

clause 41, page 14, line 22, after 'consult', insert

'the royal medical colleges and the CPPIH and'.

Mr Win Griffiths (Bridgend, Labour)

With this it will be convenient to discuss the following:

Amendment No. 395, in

clause 41, page 14, line 22, after 'appropriate', insert

'and must publish a draft statement for consultation'.

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

Given the Government's answers, yesterday's debate was unsatisfactory. Many of the issues touched on by this group of amendments have been raised before, and I do not expect a long debate.

We have been seeking to ensure that the targets and standards—or milestones or whatever the latest spin word is—that the Secretary of State will force CHAI to use, unless the Bill is amended, are clinically relevant. Our concerns are based on a view that I outlined yesterday about a target-based culture, or even a culture based on standards and not targets. If those standards or targets are neither evidence-based nor relevant to real and important clinical outcomes, as opposed to political outcomes, it will lead to a bad situation.

Some care must be taken in clinical terms before standards and targets are imposed on the national health service, whether it be directly, as now, by the Secretary of State in his name, shame and blame culture, or—even worse, in a sense—through CHAI, because that seeks to legitimise an illegitimate process.

It is reassuring that there is support for our position, not only from groups such as the King's Fund—which operates very much from a patient-focused point of view—but from organisations such as the British Medical Association, the royal medical colleges and, especially, the Audit Commission, whose report, issued this morning, states:

''Targets that frontline clinicians and managers perceive to be unrealistic, inappropriate or not the real priorities can become obstacles to change.''

That is putting it mildly. The report goes on to state:

''Rather than becoming an integrated part of day-to-day management, such targets risk being seen as an irritating distraction . . . For example, some doctors have questioned whether clinical priorities are being distorted by the focus on waiting times (by making patients who are clinically more in need wait for their treatment because a relatively non-urgent patient is approaching the NHS Plan target maximum wait).''

The Under-Secretary has dismissed and failed to address that opinion. Indeed, he said that this Committee was not the place in which to discuss a clause entitled ''Standards set by the Secretary of State''. He must address—

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

I did not say that.

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

The Under-Secretary says that he did not say that.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

If my hon. Friend reads yesterday's Hansard, he will be interested to note that, during an exchange with me about questions as to the effectiveness of the Bill to deliver scrutiny of the Government's decisions and their impact upon health care, the Under-Secretary said:

''The hon. Gentleman should direct that question to those who will head the new organisations if the Bill is passed and they are established.''—[Official Report, Standing Committee E, 4 June 2003; c. 497.]

In other words, questions will be answered after the event.

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

Yes, that is the problem. I am grateful to my hon. Friend, because when the Government is faced with such questions on the Bill, they refuse to answer. They say that this is not the right place or that we must wait until the Bill is law. It will be too late, therefore, to scrutinise before questions of the victims of poor legislation are addressed.

If this section of the Bill is to have any credibility—indeed, if the Under-Secretary is to have any credibility in his defence of it—he must address the question raised by the King's Fund, the British Medical Association, the royal colleges and now by the Audit Commission. The Audit Commission is the Government's independent watchdog—perhaps it is more independent than the Government wanted—concerned with the proper use of resources, let alone the proper treatment of patients.

That is the basis for this group of amendments, which is yet another attempt to limit the damage that the imposition of the political targets, and the political standards upon which they are based, will have on patient care.

To recap briefly, the standards and targets that we are discussing are not the national service framework targets. Those are promulgated by a group—many of whose members have relevant clinical experience—after it has studied the strength of the evidence for specific standards and policies. In that respect, I doubt whether there would be any difference between NSFs in England and Wales, for example, given that the evidence base will be similar.

We are not talking about those standards and targets, but about the political targets that this Government have imposed for, for example, waiting times and the time spent in accident and emergency departments. The target in accident and emergency departments is not even the time taken for a patient to be seen by a doctor, which has some clinical relevance, but the time taken for the patient to leave the department, even if that is the best place for the patient. That point was raised by the British Medical Association.

Dr Andrew Murrison (Westbury, Conservative)

Is the hon. Gentleman suggesting that national service frameworks are being politically sanitised? They are surely not documents produced just by professionals; they come from the Department of Health. He may wish to reflect upon the status of those documents and consider whether they have been subject to political tweaking. I am sure that they have.

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

The hon. Gentleman makes an interesting point that should concern us. At least the process in developing national service frameworks is better and more transparent. We shall never know what happens to some of the drafts unless the people who write them point out that they have been sent back with changes from the Under-Secretary's desk, the Secretary of State's desk or—this is something that concerns us—the Prime Minister's desk.

I am relatively happy that it is appropriate to have a process that is clinically focused and that considers the evidence. Indeed, looking at the results, people will ask, as I have, whether clinicians working in the health service and in some of the groups that I mentioned have concerns about NSF targets. Generally, they do not. The NSF approach is one that my hon. Friends and I support. There is a question about which target comes first and its effect on areas for which priorities have not yet been set because of the tyranny of the appraisal. Nevertheless, one must start somewhere, and we are on record as supporting the process.

Our concerns are focused on the political targets. We have attempted to ensure that CHAI sets the NSF and other standards and that it publishes the evidence. We have also asked that if the Secretary of State sets the standards, he publish the evidence, and its strength. So far, both suggestions have been rejected.

We now come to our third attempt to improve this part of the Bill in the interests of patient care. We want to ensure that the Secretary of State is not given discretion to consult only such persons as he considers appropriate, because we know that that will exclude those who disagree with the Secretary of State. If the Secretary of State had consulted anyone on the standards and targets and had listened to the findings of the consultation, those standards and

targets would not have seen the light of day, given the huge number of organisations—including all those with a clinical focus—that oppose their imposition.

We would like the Bill to force the Secretary of State to consult at least—the list is not exclusive—those organisations that represent clinicians and the organisation that represents the patients' voice in the health service. That is why we propose in amendment No. 394 that the Secretary of State consult the royal medical colleges and the Commission for Patient and Public Involvement in Health, and then such persons as he considers appropriate.

In amendment No. 395, which has been grouped with amendment No. 394, we ask the Secretary of State to publish in draft the standards for consultation so that, in a transparent process, anyone can feed in their views on the questions. That ensures that no one is excluded, but that there is a minimum requirement to consult representatives of both sides of the clinical divide, because it is right that doctors and patients make decisions together.

Dr Andrew Murrison (Westbury, Conservative)

I am interested by the hon. Gentleman's reference to ''royal medical colleges''; they should be referred to as ''medical royal colleges''. I am interested to know why he has put it that way round, but that is beside the point. Why has the hon. Gentleman specified medical royal colleges? In so doing, he will exclude from the consultation other non-doctor organisations. Indeed, that might skew the standards that will eventually result, particularly those for nursing-run procedures, physiotherapy and occupational therapy; even alternative therapies will be disadvantaged by the hon. Gentleman's proposal.

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

Good point.

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

The hon. Gentleman can be reassured—not by the Under-Secretary congratulating him from a sedentary position; that should worry him—because no one is excluded from the consultation. If the amendment is agreed to, the Secretary of State will have discretion, after consulting the medical royal colleges and the Commission for Patients and Public Involvement in Health, to consult groups that he considers appropriate, and I would expect him to do so. As well as that, amendment No. 395, which the hon. Gentleman should not overlook, states that the standards will be published in draft for consultation. That will allow all those with an interest to be consulted and to feed in their views.

It is difficult to be too selective, but the alternative is not to make any amendment. Then the Government would probably seek to avoid consulting the key groups or representatives of those groups that have a clinical purpose. In saying that, I do not deny that other health care professionals have a view. If the hon. Gentleman wants to amend the clause to add specific groups or if the Under-Secretary wants to add groups to the initial consultation compulsory list, that is fine. However, my proposal does not exclude people from the consultation.

The hon. Gentleman asked why my amendment says ''royal medical colleges'' instead of ''medical royal

colleges.'' I shall return to my original scribbled draft of the amendment and perhaps give him some assurance on whether it was my error or a transcription error.

Dr Andrew Murrison (Westbury, Conservative)

I have been listening with a great deal of interest to what the hon. Gentleman said about the wide consultation in amendment No. 395. That would, of course, eclipse amendment No. 394, which specifies medical royal colleges, or royal medical colleges. However, that would be eclipsed by the general, more eclectic consultation that he envisages in amendment No. 395. Does the hon. Gentleman agree?

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

No, because it is a two-stage process. Amendment Nos. 394 and 395 should be read together—I am not arguing that they should not—but amendment No. 394 asks that the draft statement of standards be produced after consultation with three groups of people or institutions. Those groups should include the medical royal colleges and the CPPIH, both of which, in answering the consultation, would discuss the matter with constituent bodies. The CPPIH would discuss it with the patient forums for which they have responsibility, and the medical royal colleges would discuss it with the colleges. The third group to be consulted would be made up of those considered appropriate by the Secretary of State.

That would be the basis for the publication of the draft standards. There would then be a second process of public consultation in which groups that had been omitted by the Secretary of State would be given the opportunity to make their contribution before the final standards were published. It would be the Secretary of State who omitted those groups, not the amendment, because there is a catch-all to allow the Secretary of State to consult those groups that he deems appropriate. That offers the best of all worlds because it maximises the consultation on a critical issue.

The amendments would have stood even if our amendment on CHAI, instead of the Secretary of State, had stood. The promulgation of standards, which tends to dominate many of the questions about resource allocation and clinical decision-making, is so important that it must be got right. I hope that the hon. Member for Westbury accepts my assurances that the amendment does not exclude anyone; rather it increases dramatically transparency and consultation and the advice that the Secretary of State receives.

Of course, we cannot force the Secretary of State to take advice; indeed, this Secretary of State seems to disregard medical advice on targets and standards other than those in NSFs. In this way, however, we can at least guarantee that the Secretary of State is forced to receive it, even if he chooses to ignore it. I commend these amendments to the Committee.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I echo the hon. Gentleman's sentiments and share the direction in which he wishes to go. I wish that these amendments were not necessary, because if we could remove the words ''Secretary of State'' from subsection 1, the issue would not arise in the first place. Our original amendment said that CHAI should be the ''principle guardian of standards'' in the NHS. If the

Government had accepted that wording, none of this discussion would have been necessary.

I wholeheartedly support amendment No. 395, which would be a valuable addition to the Bill and would, quite rightly, open up a proper debate among professionals about the standards that the Government are putting forward. That cannot be done solely by a committee. We all know that committees can be populated by placepeople; I am not suggesting that they always are, but they can be. At least we shall be creating a process in which the full gamut of medical opinion can be brought to bear on an issue.

I share the concerns of my hon. Friend the Member for Westbury about amendment No. 394, which is too prescriptive and risks excluding several important parts of the medical profession from the process. I am much less uneasy about amendment No. 395.

Underlying all this, there remains the concern that the Government continue to manage a politicised NHS. Standards are set in Whitehall to stipulations set out by Ministers, and we know that that it is not working; the Audit Commission told us that this morning. No other country has such a high degree of political control of its health care systems. In every other European country there is much greater professional involvement, much greater decentralisation and much less political involvement and control. That system works significantly better. We must make Ministers understand that a core part of the path to improved health care in this country is for politicians to take a step back—

Mr Win Griffiths (Bridgend, Labour)

Order. I had hoped that the hon. Gentleman would begin to speak to one of the amendments, but he is going into a very wide field of general issues. Important though he may feel those issues to be, I ask him to speak to the specifics of the two amendments.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I apologise. I thought that I had set out the reason that I felt that amendment No. 395 was right; it goes some way to counterbalancing the unwanted trend of centralisation. For the Secretary of State to be able to prepare and publish standards without even having to consult on them or without being open to a challenge in court is another piece of the jigsaw puzzle of over-centralisation and its consequences that we have described as we have gone through this Bill.

Although I do not know what the aspirations of the hon. Member for Oxford, West and Abingdon are in regard to these amendments, I could not in good faith ask my hon. Friends to support amendment No. 394, which is the lead amendment of this group. I am not persuaded that, in its present form, it is the right way to make an addition of this kind to the Bill.

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

I did not want to interrupt the hon. Gentleman earlier but, in discussing amendment No. 394, he said that it would exclude groups; I hope I am not misquoting him. I hope to impress on the hon. Gentleman that the amendment does not exclude any groups. By including the words ''as appropriate'', and

taken with amendment No. 395—which would allow a draft to be published even for those groups that have been excluded by the Secretary of State—the amendment guarantees inclusion for two groups, without excluding any groups.

I accept that the amendment treats groups unequally, but that is in the nature of the need to construct legislation that includes any sort of list. I hope that the hon. Gentleman will not say that it excludes people. I hope that he will reconsider that term.

Mr Chris Grayling (Epsom & Ewell, Conservative)

Amendment No. 394 makes a subjective selection of organisations that are to have a statutory right of consultation. Several other organisations could be considered to have an interest in playing a role in such consultations. Should patient groups that represent those who suffer from diabetes also have a statutory right to be consulted on the formation of a NFS for diabetes? I do not think so. Equally, I do not see why such a group should have more or less of a right of representation than the CPPIH, for example. I would not wish to exclude either the royal colleges or the CPPIH, but I am not persuaded that they are the only two organisations that should have a statutory right of consultation in the Bill. The hon. Gentleman makes a good point when he says that amendment No. 395 permits everyone to be involved. That is the route that I wish to take. Amendment No. 395 does the job, whereas amendment No. 394 is unduly prescriptive.

The attempts made by Opposition Members to deal bit by bit with this jigsaw puzzle of centralised control—these two amendments, particularly amendment No. 395, are one small part of that—reflect a shared aspiration and view on these Benches that the direction of many parts of this Bill is not right.

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

The hon. Member for Oxford, West and Abington is confusing standards with targets. I explained yesterday the need to recognise this distinction, and I do not wish to rehearse those arguments today, even though the hon. Gentleman feels the need to do so. He listed the King's Fund, the BMA and the Audit Commission, as well as the report that the Commission published today. Those groups are not included in the amendment. That supports the point that I made yesterday, and which I wish to make again today, that it is difficult to determine where such a list should begin and where it should end. For example, the hon. Gentleman has chosen, through amendment No. 394, to list the CPPIH in the Bill. The amendment would add bureaucracy, delay and division to the health service, and I hope that the hon. Gentleman will withdraw it.

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

I interrupt the Under-Secretary because I am waiting for him to respond to amendment No. 395, which is also in this group of amendments. I note the point that was made by the hon. Members for Westbury and for Epsom and Ewell, and by the Under-Secretary, that any list of statutory consultees would give those groups a greater right of consultation than others.

I invite the Under-Secretary to comment on amendment No. 395. After all, we are here to debate

the amendments and to hear the Government's response. I ask the Government to publish in draft, for public consultation, the standards that it is forcing on the NHS. I should be grateful to the Under-Secretary for a response. I can then judge which amendments, if any, I should press to a Division.

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

As I said, those arguments were rehearsed yesterday. We have heard them replicated in slightly different language, but they are the same arguments. The Secretary of State has a duty to consult, and that is sufficient. For the reasons of bureaucracy, delay and division that I mentioned, I would resist amendment No. 395 as well.

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

I am keen to press amendment No. 395 to a Division. However, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: No. 395, in

clause 41, page 14, line 22, after 'appropriate', insert

'and must publish a draft statement for consultation'.—[Dr. Evan Harris.]

Question put, That the amendment be made:—

The Committee divided: Ayes 8, Noes 13.

Mr Win Griffiths (Bridgend, Labour)

I request hon. Members to bear in mind that sometimes during Divisions it is difficult to hear what is being said because of a slight undercurrent of noise in the Room.

Clause 41 ordered to stand part of the Bill.