Mr Simon Burns (West Chelmsford, Conservative)

I beg to move amendment No. 510, in

clause 43, page 15, line 7, after 'to', insert

'make regular reports available to the public about, and'.

Mr Win Griffiths (Bridgend, Labour)

With this it will be convenient to discuss the following:

Amendment No. 511, in

clause 45, page 15, line 36, after 'to', insert

'make regular reports available to the public about, and'.

Mr Simon Burns (West Chelmsford, Conservative)

The amendment deals with the beginning of clause 43, which refers to the general functions of CHAI, and to the information, advice and instructions laid down for it.

In relation to clause 43(1), the amendment seeks to ensure not that CHAI must keep the appropriate authority informed on the provision of health care, but that it should make regular reports available to the public on the information that it gathers and the reports that it produces. In this subsection, the appropriate body in England is the Secretary of State; in Wales it is the National Assembly for Wales. The amendment would improve the Bill because it would make the process much more transparent. I have no problems, in the context of the Government's intentions, with CHAI keeping the appropriate authorities informed.

However, I do not see why it cannot go one step beyond the appropriate bodies to the public. It is the people's health care system and national health service, and they should be entitled to know exactly what is going on. Furthermore, if one were to make the reports public, one would know what was going on at all times. There is a possibility that although CHAI might keep the appropriate authorities informed, those authorities might not pass that information on to others.

I hope that the Under-Secretary will see the amendment as a move to open out the process and to make it more transparent. I hope that that will be an attractive proposition to him.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

I support the group of amendments, as they are useful additions to the Bill. They enable the Government to give substance to one of the things that the Secretary of State said last April, when he introduced the report ''Delivering the NHS Plan'', which was that if commissions are to act as judge, the public will be the jury. It is hard for a jury to act in its proper capacity if it does not have access to information and if information is not freely provided to it. To include a clear requirement in the Bill that such information should be published in this way is a useful addition.

It would be helpful to hear the Under-Secretary's thoughts on how the two commissions will discharge that responsibility and, specifically, if he could set out how he envisages the public being kept informed about health care and social care, about the activities of the two commissions and about the findings from their inspections of health and social care.

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

Amendments Nos. 510 and 511 will place a duty on CHAI to make regular reports available to the public on the provision of health care by and for NHS bodies, and on a par with what it also provides to the appropriate authorities. The function set out in the Bill is necessary to ensure that the appropriate authorities are kept informed on the provision of health care for which they are responsible. As a way of demonstrating its increased independence, the Secretary of State will not have the regulation-making power that he has over CHI on the publication of reports.

Such a power enabled my right hon. Friend to specify the means and manner in which the old CHI disseminated its findings to the NHS and to the general public. I cannot accept this amendment, as it would, in effect, compel the new CHAI to do that. The

public rightly expect the new CHAI to be an authoritative, independent judge of quality and efficiency and to be a driving force for the continuous improvement of health care provided by all NHS bodies.

It is already obvious that the new CHAI will want to keep patients and the public informed of developments in the NHS and in independent health care provision. I am confident that CHAI will have patients and the public at the forefront of its considerations and that it will operate as openly as possible. CHAI will have ample opportunity to ensure that the public are informed about the provision of health care, and it is not necessary to state that explicitly in the Bill. I hope that the hon. Gentleman will withdraw his amendment.

Mr Simon Burns (West Chelmsford, Conservative)

I am disappointed by the Under-Secretary's response, because, notwithstanding his remarks, the amendment would be a positive step towards increasing the transparency of the process and, as the hon. Member for Sutton and Cheam (Mr. Burstow) said, towards enabling us to have a judge and jury. I should like to stress on the record that this is a wasted opportunity. I shall not press the amendment to a Division, however. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

I beg to move amendment No. 371, in

clause 43, page 15, line 7, after 'authority', insert

'and the Health Select Committee'.

Mr Win Griffiths (Bridgend, Labour)

With this it will be convenient to discuss the following:

Amendment No. 347, in

clause 73, page 28, line 19, after 'State', insert

'and the Health Select Committee'.

Amendment No. 348, in

clause 135, page 57, line 20, at beginning insert—

'(1) If at any time after the passing of this Act—

(a) the name of the Health Select Committee is changed; or

(b) the functions discharged by the Committee at the passing of this Act, or functions substantially corresponding thereto, are discharged by a different Committee of the House of Commons,

reference in this Act to the Health Select Committee shall be construed as a reference to that Committee by its new name or, as the case may be, to the Committee for the time being discharging those functions.

(2) Any question arising under subsection (1) shall be determined by the Speaker of the House of Commons.

(3) .'.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

The amendments develop the theme introduced by the hon. Member for West Chelmsford (Mr. Burns) regarding transparency and greater openness in reporting. They seek to impose a requirement on CHAI and CSCI that the information that they produce should also be provided to the Select Committee on Health. Were that Committee's title to change, there is provision in the final amendment in the group for that to be dealt with in the usual way. There are provisions in

section 13 of the National Audit Act 1983 that deal with such matters in respect of the Public Accounts Committee, and this amendment seeks to cover the Health Committee in a similar way.

The amendments simply seek to ensure that there is a clear link between the work of the two commissions and the Health Committee. That Committee has an important job to do in scrutinising the health and social care activities of the Government, the public sector and others. They would be an additional and invaluable way of ensuring that members of that Committee—and, as a consequence, all Members of the House—could make sure that both commissions discharge their duties appropriately. I hope that the Minister will accept the amendments in the spirit in which they are moved.

Mr Simon Burns (West Chelmsford, Conservative)

I declare an interest as a member of the Health Committee. The amendments of the hon. Member for Sutton and Cheam do not appeal to me. I understand the reasons form them, but they would not be practical. I do not part company with him in wanting more information and transparency. In that, we are in agreement. However well intentioned the proposal to ensure that the Health Committee gets information, his amendments are, up to a point, unnecessary and possibly misunderstand the role of the Health Committee.

The Committee usually carries out two major inquiries on health care subjects a year, in addition to a few mini-investigations on matters of health care and the provision of service. Apart from generating a great deal of effort and paper, what would be the benefit in ensuring that the Health Committee has, in effect, a statutory right to receive all the papers from CHAI?

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

I am following the hon. Gentleman's argument closely. How does he expect the amendments to work, given that they propose to insert a requirement in the Bill that would presumably have placed the same obligation on CHAI to supply all that information to the public? How does he balance that?

Mr Simon Burns (West Chelmsford, Conservative)

The public are entitled to receive that information or to have the opportunity to see it. The hon. Gentleman's amendments said that the information should be given as of right to the Health Committee. What would be the purpose of that? As I have explained, the Health Committee carries out investigations and inquiries into matters of health care and provision each year. It also calls Health Ministers to appear before it for a single sitting. However, they do not all appear at the same sitting.

Usually, the Secretary of State attends a sitting on his own, followed by the Ministers of State—[Interruption.] Of course, as the Under-Secretary has rightly just said from a sedentary position, the Health Committee had the privilege of questioning the hon. Gentleman only a few weeks ago. Sadly, it was a loss to both my education and my enjoyment that I was unable to attend because of a clash with my parliamentary duties on this Committee.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

I am grateful to the hon. Gentleman and former Minister for giving way. I want to rehearse with him one of the reasons why such a requirement might be useful. I am grateful for his exposition of the role and purpose of Select Committees, particularly that of the Health Committee. The purpose of placing that requirement in the Bill is to ensure that members of the Health Committee, who have to determine the priorities for future inquiries, will benefit from information provided by the commissions when making those determinations. That helps to widen their vision and enables them to have a better understanding when determining the priorities of future work.

Mr Simon Burns (West Chelmsford, Conservative)

I understand the hon. Gentleman's point, but I am not convinced by it. I see it as a skilful attempt to make the original point in a different way to add credence to his argument.

The other point is that the Health Committee can hold an inquiry into the operations of CHAI at any time. The Committee would receive all the information that it needed at the time to conduct such an inquiry and to monitor the activity of health care provision. Therefore the hon. Gentleman's amendments, however well intentioned, are misguided. In practice, they would add little to our knowledge and scrutiny of the operation of that area of health care, other than considerable paperwork and effort.

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

The hon. Member for West Chelmsford makes many of my points for me and makes them with some flair and panache. I discovered that he is related to a famous rock star—David Bowie. Some similarities between the two are apparent this morning.

Mr Stephen Pound (Ealing North, Labour)

I am reluctant to intrude, but I think that David Bowie himself claims to be related to the hon. Member for West Chelmsford.

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

I am grateful to my hon. Friend for putting me right on that point.

On the subject of the amendments, both Houses of Parliament have an established right to summon witnesses to appear before them to answer questions from Committees. They may summon any witness by virtue of the derogation of power. The Government fully support the principle that the commissions' work should support Parliament's scrutiny of policy in public services. That is why clauses 121 and 122 require the commissions to produce and lay before Parliament an annual report on their findings. Elsewhere in the Bill is the provision for the commissions to produce and make public reports as it undertakes studies throughout the year.

For those reasons I cannot support the amendments, and I hope that the hon. Member for Sutton and Cheam will feel able to withdraw them.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

Earlier, I inadvertently described the hon. Member for West Chelmsford—who speaks for the Opposition on the Committee—as the Minister. On this occasion, perhaps there was a sharing of the brief that is being used to rebut these amendments.

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

I ought to put on record that I am related to Eddy Grant, the famous reggae star, and perhaps that is why there was some sharing of beliefs this morning.

Mr Paul Burstow (Sutton & Cheam, Liberal Democrat)

I am grateful for the candour with which the Under-Secretary details his family tree. I do not plan to start discussing my family roots, because I would be out of order.

I have listened carefully to both hon. Gentlemen and their arguments for not accepting the amendment. It is undoubtedly an improvement to have an annual report by both commissions coming to this place; it will provide some comfort that their activities and findings can be scrutinised. CHAI would keep the appropriate authority informed on the provision of health care, but the clause does not stipulate that authorities will be deluged with tons of papers, bombarded by e-mails or in any other way completely inundated with material.

The clause enables CHAI to make a judgment about the information that it should be passing on at any given time. The improvement of the radar facilities of the Health Committee in determining the issues into which it may wish to conduct inquiries in future would be a useful addition to its many facilities. However, it is not worth pursuing the argument any further. We shall consider returning to it, having reflected on the arguments of both hon. Gentlemen. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I beg to move amendment No. 518, in

clause 43, page 15, line 7, after 'provision', insert 'and quality'.

Mr Win Griffiths (Bridgend, Labour)

With this it will be convenient to discuss the following amendments: No. 515, in

clause 45, page 15, line 36, at end insert 'and healthcare outcomes'.

No. 519, in

clause 46, page 16, line 7, after 'provision', insert 'and quality'.

No. 520, in

clause 50, page 17, line 36, after 'provision', insert 'and quality'.

No. 521, in

clause 51, page 17, line 39, after 'provision', insert 'and quality'.

No. 522, in

clause 52, page 18, line 20, after 'provision', insert 'and quality'.

No. 523, in

clause 52, page 18, line 22, after 'provision', insert 'and quality'.

No. 524, in

clause 53, page 18, line 37, after 'provision', insert 'and quality'.

Mr Chris Grayling (Epsom & Ewell, Conservative)

You will remember, Mr. Griffiths, that on one or two occasions I have spoken about the jigsaw puzzle and the pieces that we want to put in place to change the nature and tone of the inspection and regulatory system for health care in this country. I see these amendments as a significant part of that jigsaw.

The amendments are designed to change the balance of several important parts of the Bill. They add the words ''and quality'' after the word ''provision''. The word ''quality'' does not appear in

any of the clauses that deal with CHAI. In almost every case, it says ''provision.'' The problem is that provision is not quality. I could set up Dr. Harold Shipman in a surgery in a country village, and that would be a health care provision, but it may not guarantee quality of health care. That is a trite point, but it is a much more serious issue.

One of the key flaws of the target structure that the Government have established in the reference point that they will give to CHAI to assess the performance of the health service is that the focus is on the provision of health care. We do not ask whether the health service is making us better but whether it is treating us. There is a fundamental and important difference between the two. The Audit Commission's report referred to that difference this morning. We focus too much on whether we are treating people and much too little on how well we are treating them or on whether they are getting better.

The Government have set too many targets that do not examine health care outcomes. In fact, they actively distort health care outcomes by requiring clinicians to make decisions that are not necessarily in the best interests of their patients. Decisions are taken to enable the institutions of which they are part to meet the Government's targets, and the performance of those institutions will be judged against those targets. That is important because the benchmark that the Government wish to use to judge the quality and effectiveness of hospitals—the star-rating system—is not primarily about the quality of clinical work; it is about governance, management and provision.

CHAI uses 28 indicators to assess the effectiveness of a hospital in deciding whether it should be a zero-star, a one-star, a two-star or a three-star hospital. In fact, a hospital can lose a star rating due to provision and administration and not due to clinical governance. An NHS trust chief executive recently told me that he was afraid that he would lose a star this year due to financial, not clinical reasons. There was no reflection on the quality of health care carried out by that hospital. If his fears are confirmed, the rating that CHAI will place against that hospital will not be about quality of health care but about other issues.

A hospital can achieve three stars, as the 28 indicators are used to assess it against its peers to determine its star rating. The use of those indicators can mean that a hospital that does not perform well clinically can none the less get three stars if it delivers on provision and on the other factors. Therefore a hospital that does a stunning job in reducing waiting times, for example, can totally fail to treat patients effectively but still receive a high rating. The amendments seek to establish a duty, through the Bill, on CHAI to look not simply at provision but at the quality of health care being delivered.

A recent publication of a survey by the independent health care organisation, Dr. Foster, challenged the assumptions of the rating system and its effectiveness in delivering a true and proper assessment of the quality of health care achieved in hospitals. The figures demonstrated that many three-star hospitals were

doing less well clinically than hospitals with lower star ratings. Surely, we cannot tell those institutions that if they do a good job of making patients better, they will be rated by the inspection system, by their peers and by the environment in which they work less highly than those organisations that have delivered on management but not on health care. That is an anomaly that must not be perpetuated.

The amendments allow us an opportunity to write into the Bill that quality must be a fundamental part of the work of CHAI. The word ''provision'' does not allow that to happen. Provision is very much about waiting times, specific targets, capacity and recruitment of clinicians, all of which are important. The amendments do not seek to remove the word ''provision'' from the Bill; they seek to ensure, however, that when CHAI carries out its inspections it asks whether an institution is delivering quality health care; whether patients are getting better.

The part of the Bill about foundations hospitals tends to steer our discussions towards hospitals, but the issue is not purely and simply about hospitals. Ambulance trusts are judged, most significantly, on the length of time that their ambulances take to reach incidents, for which the Government have fixed a target of eight minutes. Accident and emergency departments also have targets for waiting times. The trust in Avon was recently given a hard time by CHI for its failure to tackle the waiting times in its accident and emergency departments. Much work is being done in that part of the world to resolve the issue.

However, targets do not give us a view on whether ambulance trusts save lives. Dealing with cardiac arrests is probably the most significant job that ambulance trusts do, because the length of time that it takes an ambulance to reach someone who has suffered a cardiac arrest will determine absolutely that person's chances of recovery. If he is treated quickly, he will have a fair chance of recovery. If not, he will probably die. Therefore the way that an ambulance trust performs with regard to heart attack victims is fundamental to whether those victims survive.

There is a huge disparity between ambulance trusts' recovery rates for cardiac arrest victims. In some areas, a significantly higher proportion of people are treated successfully and recover than in other areas. We should know the reason for that. We should examine what those ambulance trusts are doing and share best practice across the NHS. I am much more concerned about that than about whether a trust makes its eight-minute target across the board. What could be more important—

Mr Adrian Bailey (West Bromwich West, Labour/Co-operative)

I am following the hon. Gentleman's comments with interest. I find it odd that if it is so important that an ambulance reaches someone who is in cardiac arrest quickly, it is not imperative that there be a target time in which it should do so. Frankly, the two elements of his argument do not fit together.

Mr Chris Grayling (Epsom & Ewell, Conservative)

That is a fair point, so I will explain why it is not necessarily a matter of getting every ambulance to every incident within eight minutes. Let

us suppose that there are two incidents in the Committee Room. One occurs where the hon. Member for the City of Chester (Ms Christine Russell) is sitting.

Mr Stephen Pound (Ealing North, Labour)

One of them is certainly not me.

Mr Chris Grayling (Epsom & Ewell, Conservative)

Since the hon. Gentleman wants to contribute, let us say that one of the incidents is where he is sitting, and the other is where the Chairman is sitting. Two ambulances are available. Let us suppose, God forbid, that the hon. Member for Ealing, North is a cardiac arrest victim. One of those ambulances can get to him more quickly than the other. However, if that ambulance goes, the other cannot get to Mr. Griffiths within eight minutes. If the ambulances are reversed, it may take longer to reach the cardiac arrest victim, but the trust will have met its target of having both ambulances reach their destinations within eight minutes. If one target were missed, however, an ambulance could reach the hon. Member for Ealing, North within two minutes.

The point is that, in pursuing a flat, numerical target, it may be that the wrong clinical decision is taken. It may be that if things were done differently, a life could be saved. I am not saying that it is wrong to have a target or an aspiration for the time within which ambulances should reach incidents. Equally, however, we should not constrain trusts by saying that that is their only driving force. Trusts should not be judged exclusively against that measure. If a trust demonstrates that by doing things differently it saves more lives, we should at least look at that and judge its performance against that criterion as well as the simple ability to reach an incident in the designated time.

Mr Stephen McCabe (Birmingham, Hall Green, Labour)

I am falling in love with the ingenuity of the hon. Gentleman's imagination. Can he give any examples of the wonderful description he has just given? Is there any documented evidence of the ambulance scenario he has just depicted, or is it purely a figment of his imagination?

Mr Chris Grayling (Epsom & Ewell, Conservative)

I would never secure a documented example of that because no trust would ever give it to me. However, there are specific documented examples of trusts that perform much more effectively than others in dealing with cardiac arrest victims. They are not judged. The headline figures that the Government use relate to the provision of ambulance services—the provision of a service within eight minutes. Trusts are not judged on whether they save lives. My argument is not that the one is wrong but that both are necessary.

Going through the Bill, we see again and again the word ''provision'' but not the word ''quality''. Both are important. The omission of the word ''quality'' from the Bill is extremely important and should be rectified.

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

I support what the hon. Gentleman has just said, in two areas. He made a point similar to what I have been saying for five years about the danger of targets so distorting clinical priorities that patients suffer more. He used the example of the ambulance trust in that respect. What the hon. Gentleman did not point out—though he could have—is that the eight-minute target applies only to certain categories of calls.

There is no objective definition of those categories, and each trust can decide into which category a call comes.

There is Audit Commission evidence, and some whistle-blowing from trusts, to show that ambulance trusts put calls into categories depending on whether they think they will make it in eight minutes, or whatever the next category is. Since there is no objective measure—perhaps there cannot be one, because each call is different—it is open to distortion based on how it is measured.

The major problem is not that targets are met through the fiddling of their measurement—that is a problem in itself, but less of a problem than that of meeting targets while damaging patients. Even though both are wrong, it is better to save the patient and fiddle the figure than to meet the figure and let the patient suffer.

The way in which patients can suffer due to the meeting of these targets—or standards, because the Under-Secretary loves making that distinction—can be best seen using the example of the maximum waiting time for operations. I will give the hon. Member for Birmingham, Hall Green (Mr. McCabe) a specific example of how this damages people in the real world. I raised this in the last Health questions but one.

The target is to ensure that everyone has their operation within whatever the latest maximum waiting time is, say 12 months. CHAI will have to report on the provision, and it may well describe a trust as having met its target. Not only does that not report on whether the maximum benefit to patients is being achieved, but there is strong evidence that inevitably the imposition of that target—particularly where it is difficult to achieve because of capacity constraints—will damage patients. It will not just have a locus on quality, but will damage patients, because the patients who are usually left waiting at 12 months are, by definition, not urgent. Yet the patient who is in most urgent need in a trust is the one who is approaching his operation deadline.

What doctors and clinical teams tend to do is stratify patients according to the urgency of their operation. In the area of cardiology, for example, there are patients who are not emergencies but need urgent treatment. They may have unstable angina, critical left main stem disease or critical valve disease. They are not classed as emergency cases and may have had symptoms for a while, but every week that they wait poses a significant risk of a bad outcome, which in this case is dropping dead. I hope that that language is not too technical.

The problem is that in order to meet the target, waiting times for the other higher urgency patients have lengthened. People tell me that there are patients in my local trust areas who used to be seen within three days in order to reduce the risk of their dying while waiting who now have to wait for three weeks. Patients who used to be treated within three weeks, and who are often at home with unstable cardiac pain, are now treated within three months, which is well within the target, but poses significant risks for the patient. However, joy of joys, patients who used to wait for 14

months are now being treated after a 12-month wait, and for that group of patients there is a less significant risk.

No one wants patients to wait longer than they need to. Each patient, looking at the situation himself, and given that there are more in the low-risk category, will want to be treated quickly. However, the least urgent patients should not be the only priority in the system because of the maximum waiting time target. That would come at the expense of the overall quality of care for the most critical patients.

Mr Stephen McCabe (Birmingham, Hall Green, Labour)

I can see the general point that the hon. Gentleman is making. Manipulating targets in a way that disadvantages patients is not desirable. I am not sure where the massive difference is. Is it not the case that consultants have, for years, manipulated targets and priorities for varying interests, which have often nothing to do with the patients at all? The hon. Gentleman is objecting to a situation relating to Government targets for speeding up forms of treatment or waiting times. The same criticism about the way in which patients have been manipulated in the interests of consultants' priorities has been being made for years.

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

It is not wrong of the hon. Gentleman to seek to defend a bad idea—the imposition of targets, particularly those that concentrate only on the least urgent patients, therefore damaging overall health care—by alleging concerns about another poor practice. If I accepted that there are some consultants who seek deliberately to lengthen waiting times for non-urgent patients who are thought to have some money so as to encourage them to go privately, which I think is what the hon. Gentleman is saying, I would condemn it. However, for the Government, as the hon. Gentleman implied, to do no more or no less than that is not a defence against the charge that I am making.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I am disappointed by the intervention that has just been made by the hon. Member for Birmingham, Hall Green, because it undermines the professional reputation of consultants in a totally unjust way. Has the hon. Gentleman spoken, as I have, to consultants in diabetic clinics who find that if they have an out-patient needing urgent admission to an in-patient bed, they have to telephone the accident and emergency department to ensure that no one has been waiting for more than four hours before they can get access to a bed?

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

I am not going to go down that path because it is another example of the sort of distortions that exist. However, the point that the hon. Member for Birmingham, Hall Green made may be valid in some cases. He will know from my amendments on private practice of the instances in which NHS beds are needed by a more clinically urgent patient. I am in congruence with his general thrust, but I am also grateful that he has at least conceded, I think, that the point I making is valid and that these targets can be damaging.

The problem is that a trust is measured on whether it meets the maximum waiting time target. It is not measured, in this performance rating system, on the outcomes, taking into account the level of patient sickness. It is not just that trusts fail to measure true clinical patient outcomes, but the imposition of something else makes it worse. I agree with the hon. Member for Epsom and Ewell on this point. Indeed, I would go even further. It is not a surprise that trusts that are not measured as performing as well as other trusts in the Government's performance tables might do better than trusts that are performing well in those tables. Sometimes it is because they do not do as well, because they are not prepared to distort clinical priorities, that they are actually performing better in terms of hard clinical outcomes.

I want to reinforce what the hon. Member for Epsom and Ewell said about the problem of Dr. Foster and the performance star-rating system. It is the problem of the man with two watches. The man with two watches will never know what exactly the right time is.

Mr Simon Burns (West Chelmsford, Conservative)

Why not?

Mr Win Griffiths (Bridgend, Labour)

Order. That is not a point for debate.

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

I wish to explain, because it is extremely relevant. Two watches will often show slightly different times.

Mr Simon Burns (West Chelmsford, Conservative)

Only to a Liberal.

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

Of the two clocks in the Room, one reads 10.46 am and the other reads 10.47 am. Who knows which one is right? The Chairman regards the time on the annunciator as being right. Generally speaking, except perhaps in the ordered world of the hon. Gentleman, watches often show slightly different times.

The Secretary of State is like a man with three watches. He has Dr. Foster, which the Department of Health co-operates with by providing data; he has the Commission for Health Improvement reports; and he has star-rating systems. They often say different things. The most appropriate rating system at the moment is a CHI report, because it is not forced to measure performance on star ratings, and it is able to look at the overall picture of a trust.

The next most appropriate and most effective measure of performance is Dr. Foster, which looks at some characteristics of the patient base that a unit, team, or even a commission eventually, is dealing with. It also looks at proper clinical outcomes, such as the number of deaths within 30 days of surgery, which is a meaningful clinical outcome. Dr. Foster fails because the Government have not yet sold it all the confidential patient data, and therefore it cannot yet grasp the level of health of the patients on an individual basis. Consequently, that can distort the outcomes.

The better units, which treat the more difficult cases, will have worse outcomes. Nevertheless, they are better, and it is because they are better that they have worse outcomes. Dr. Foster cannot yet grasp that. The

star-rating system does not even come near to considering whether a unit is taking more difficult patients because it is a better unit.

In this group of clauses, the Government propose to force CHAI, whose predecessor is the best measure of hospital performance, to adopt the star-rating system. That is why the amendment is so important. Multi-star trusts have had stars knocked off on several occasions following a CHI report. That shows that the Government accept that, compared with in-depth CHI reports, the star-rating system is a joke when it comes to measuring quality and proper clinical outcomes.

The combination of the imposition of the star-rating system on CHAI and the failure to put the onus on CHAI to look at quality, rather than just provision as the Government define it, is what is so worrying about the Bill and why this group of amendments is important and worthy of support.

Sir George Young (North West Hampshire, Conservative)

I very much hope that when the Minister replies to the debate he will reflect seriously on the two speeches that he has just heard. They have included some very powerful points.

We have recently agreed clause 40, which sets out what the NHS bodies are meant to be doing. The word ''quality'' is used. Clause 40(1) states:

''It is the duty of each NHS body to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care provided by and for that body.''

Clause 43 deals with the functions of CHAI, which is the authority that will monitor the NHS bodies. Clause 43(1), to which the amendment refers, does not mention quality; it simply mentions provision.

If there is to be some consistency between the responsibilities of CHAI and the jobs that CHAI is meant to be supervising, the word ''quality'' should appear in clause 43. I agree with the point that has just been made: if all that CHAI does is look at the provision of health care, that will be a partial discharge of its responsibilities. One wants to know more than what services were provided; one wants to know whether they worked and were successful. There is something unilateral about simply measuring the provision—these are the services that were provided. I hope that CHAI will go beyond that and look at the outcomes.

Amendment No. 515 relates to clause 45, which deals with NHS foundation trusts. Clause 45(1) states:

''The CHAI is to keep the regulator informed about the provision of health care''.

The one thing that the regulator already knows is what the foundation trusts are providing, because under clause 4 they have to tell him. However, he may not know if the outcomes were any good. Amendment No. 515 inserts after ''provision'' the key words ''and healthcare outcomes'', which will give the regulator some useful information that he does not stand to have at the moment.

Within this group of amendments are amendments relating to clause 46, which deals with annual reviews of NHS foundation trusts. These annual reviews

should not be just about the provision of health care; they should be about quality. I agree with my hon. Friend the Member for Epsom and Ewell that the amendment relating to clause 46 is powerful.

Clause 51 deals with annual reviews. Clause 51(1) refers to ''performance rating''. If we are to go into the business of rating performance, quality is an essential input. We should not measure only the provision of services, but also the quality. CHAI will have to deal with failings, and we will discuss that when we come to clause 54. If we are to make a judgment about whether a body is failing, we must look beyond the services provided and see how effective they are.

Let us say that we had the equivalent of CHAI to audit and inspect Members of Parliament. It would not look simply at the provision of services by Members of Parliament and at how many advice bureaux they held; it would go beyond that and look at the quality of the advice. I see surprise and astonishment on the faces of Committee members. However, if we are to have a body that does its job well, it must look beyond the numerical measurement of services and try to come to some judgment about the quality. I hope that the Minister will either accept these amendments or come up with some amendments of his own.

Mr Gary Streeter (South West Devon, Conservative)

Mr. right hon. Friend is making a very important speech. Is it not now commonplace for the Department for Education and Skills to measure added value and outcomes in schools? If that can be done in schools, is it beyond the wit of man to come up with a similar proposal for health care?

Sir George Young (North West Hampshire, Conservative)

I award the highest possible quality mark to my hon. Friend for his intervention. It is indeed the case that in other Departments quality and value added are measured. Look at Ofsted, for example. I hope that when the Under-Secretary replies he will take on board the thrust of the argument and points made in interventions, and say either that CHAI will do that or that he will amend the Bill to ensure that its responsibilities go beyond the simple measurement of provision and require it to come to some judgement about the quality of services provided.

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

The amendments seek to ensure that CHAI comments on the quality of health care provided by and through NHS bodies, and on other health care outcomes, when discharging its functions to provide information and advice, carry out reviews and publish national performance data.

It is the Government's intention that CHAI be established as an authoritative, independent judge of quality and efficiency and that it will be a driving force for continuous improvement across all NHS bodies. The right hon. Member for North-West Hampshire (Sir George Young) mentioned the use of the provision in clause 43. I want to reassure him that clause 43 is a general expression, covering different aspects of the service, including quality.

Mr Chris Grayling (Epsom & Ewell, Conservative)

No, it would not.

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

Let me go on.

In a sense, that clause and this amendment should be read in the light of clause 49(2)(b), which places CHAI under a clear duty of quality. Clause 40 puts a duty of quality on the NHS, and CHAI will be expected to inspect against that. Therefore, much that has been said on the issue of quality is provided for in the context of that clear duty under clause 49(2)(b).

I want to reassure the Committee that that is the Government's intention. We feel that as we have empowered CHAI with such functions, it will want to concern itself with the quality of health care provision and assessment of health care outcomes.

Sir George Young (North West Hampshire, Conservative)

The Under-Secretary makes a good point, but why does clause 49 not apply to the earlier clauses? Why does it apply only to clauses 50 to 54 and not to clauses 43 to 48?

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

The right hon. Gentleman makes a good point. I will need to take advice and come back to him. It is my understanding, on the face of it, that there is a general duty that obliges CHAI to provide a duty of quality across the board, and that that duty of quality is implicit throughout the Bill.

Mr Chris Grayling (Epsom & Ewell, Conservative)

This is an important point. Is the Under-Secretary's understanding of it the same as mine? It is my understanding that any statutory body established in primary legislation does not have a duty to do something unless that duty is enshrined in the legislation.

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

What I said was that the duty of quality is pervasive. It is set out in clause 49(2)(b), and that duty of quality is implicit. The right hon. Member for North-West Hampshire pointed out, rightly, that the proposal is specific to clauses 50 to 54. My advice is that the duty is implicit and pertains to the functions of CHAI. However, I will seek further advice on that technical point and come back to the Committee in due course.

Ms Patsy Calton (Cheadle, Liberal Democrat)

When the Under-Secretary comes back with advice on clauses 50 to 54, will he also reflect on clause 49? That clause refers to quality, but does not require that quality be reported on. If the Under-Secretary looks at the amendments, he will see that they are asking for quality to be reported on and not just examined, as clause 49 requires.

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

The hon. Lady's point flows from the points that were made by the right hon. Member for North-West Hampshire. I want to undertake to examine this matter again, and this is the purpose of the Committee. It is my intention that there should be a general duty of quality. I want to ensure that that quality is pervasive and that CHAI must have that in mind.

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

Will Government amendment No. 284, which inserts ''subsection (1) and'' before sections 50 to 54, provide answers to some of the issues raised by the right hon. Member for North-West Hampshire, because clause 49(1) appears to be a general duty on CHAI?

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

That may well form part of the further deliberations that the Government wish to have. I repeat my wish to come back to Committee on that important point.

Mr Chris Grayling (Epsom & Ewell, Conservative)

We have had an important debate. I think and hope that the Under-Secretary has understood the strength of feeling in the Committee about the issue. I am slightly disappointed that he is not sufficiently up to speed on the issues to be able to respond immediately. That said, I am grateful for his assurances that he will look at the issue again, and on that basis I am happy to beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 43 ordered to stand part of the Bill.

Amendment proposed: No. 274,

That Clause 43 be transferred to the end of line 14 on page 20.—[Mr. Lammy]

Mr Win Griffiths (Bridgend, Labour)

With this it will be convenient to discuss the following:

Government amendments Nos. 275 to 278.

Amendment No. 514, in

clause 46, page 16, line 9, leave out from 'trust' to end of line 9.

Amendment No. 513, in

clause 46, page 16, line 11, leave out from 'it' to 'and' in line 12.

Amendment No. 517, in

clause 47, page 16, line 30, leave out paragraph (b).

Amendment No. 516, in

clause 47, page 16, line 24, leave out paragraph (a).

Amendment No. 512, in

clause 47, page 16, line 41, leave out 'if regulations so provide'.

Amendment No. 480, in

clause 47, page 17, line 4, at end add—

'(9) In exercising its functions under this section in relation to any health care the CHAI must take into account the standards set out in statements published under section 41.'.

Government amendments Nos. 282 and 283.

Amendment No. 481, in

clause 49, page 17, line 23, leave out 'other than' and insert 'including'.

Amendment No. 397, in

clause 49, page 17, line 24, after 'sections', insert '45 and'.

Government amendment No. 173.

Government amendment No. 287.

Government amendments Nos. 289 to 291.

Government amendments Nos. 294 to 297.

Government amendment No. 30.

Government amendment No. 298.

Government amendment No. 300.

Government amendment No. 303.

Government amendment No. 452.

Government amendments Nos. 306 and 307.

Mr Chris Grayling (Epsom & Ewell, Conservative)

I am interested that the Under-Secretary does not want to explain his own

amendments because, as far as we can see, they represent a significant change to the Bill.

The amendments appear to change the whole nature of the division of responsibility that CHAI will have over foundation and non-foundation trusts. The deletion of clause 46 would remove one of the most significant clauses in the Bill. I should like the Under-Secretary to give a much clearer explanation of what is happening. Given the context, the star-rating system, which would be perpetuated by clause 46(1), is a cornerstone of the process by which foundation trusts are established. There have been some significant question marks against that cornerstone. Initially, the Government's stated intention was that only three-star hospitals would be eligible to become foundation trusts in the first wave. Indeed, all the initial applicants and those on the shortlist are three-star trusts.

After that statement was made, it became clear that the situation was not that clear. The reason is very simple; the Government's aspiration, unless something has changed, remains that all hospitals should be able to become foundation trusts within a few years. We have expressed strong disagreement with that approach. We believe that all trusts should become foundation trusts immediately. If that does not happen, we will see what has been described by my hon. Friend the Member for Woodspring (Dr. Fox) as a dog-eat-dog culture in the national health service.

Nonetheless, the Government have told us that it is their aspiration to achieve foundation trust status right across the national health service within a few years. For that to happen, the linkage between the star-rating system and foundation trust applications becomes much less clear. Initially, the Government's stated intention was that as each hospital rose up the star-rating league and achieved three-star status, it would be eligible to become a foundation trust. That cannot be the case.

The star-rating system is proportional to the total number of hospitals. The three-star status is intended to represent only a certain percentage of hospitals. The system does not provide for every hospital to become a three-star hospital. It would be impossible for that to happen and for every hospital to achieve foundation status. If all the hospitals that are currently at the top of the league retain their position, it will be possible for a hospital that currently has no stars to achieve foundation status only if foundation status can be achieved by hospitals with two, one or even no stars.

Before the Minister tears up CHAI's role in assessing the star ratings of foundation trusts, it is extremely important that he now explains exactly how the star-rating system will work. He should explain what the difference will be, if any, between the way an assessment takes place on a three-star hospital with or without foundation status and how, if at all, foundation hospitals will be judged differently.

It surely cannot be the case that a non-foundation trust hospital can be judged in precisely the same way as a foundation trust hospital, because it is operating with different systems of governance and has additional freedoms. The whole point about

foundation hospitals is that they are supposed to be different. If they are different, how can we have a common rating system, and how will we compare the rating systems of foundation and non-foundation hospitals? By throwing out clause 46, the Government appear to be saying that we will no longer have separate performance ratings for foundation trusts and that we will no longer judge them differently. Frankly, I am a bit confused about what will happen.

It is particularly extraordinary that the Under-Secretary simply stood up to move these amendments formally. He did not consider a major change of this respect to be worthy of explanation to the Committee. That does him discredit. I am astonished that that is the case. I very much hope that when I have finished speaking and he has been able to gather his thoughts—

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

May I put on record that I received bad advice from my Parliamentary Private Secretary? There was no other intention. Mistakes happen in all walks of life.

Mr Chris Grayling (Epsom & Ewell, Conservative)

That is an enlightening statement. I would not wish to cast the same aspersions on the hon. Member for Weaver Vale (Mr. Mike Hall), whom I know.

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

In the light of that revelation, and to speed things up, would the hon. Gentleman consider inviting the Under-Secretary to speak next to explain the amendments, particularly in the absence of any explanatory notes? I realise that the hon. Gentleman and the hon. Member for West Chelmsford have already raised that matter. We could make quicker progress that way, rather than doing things in reverse order.

Mr Chris Grayling (Epsom & Ewell, Conservative)

That is a sensible point. I will happily give way to the Under-Secretary, and I might then seek to catch your eye, Mr. Griffiths. Before I sit down, I should like to ask the Under-Secretary three questions that he can address when he speaks. First, what are the reasons behind the change of heart? Secondly, how will CHAI's reviews reflect the terms of the foundation trusts' authorisation? Thirdly, how will CHAI work with the regulator to ensure that its review reflects the demands set out in the regulator's authorisation?

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

The Government amendments seek to ensure that the same regime effectively applies to NHS foundation trusts as to other bodies. The Bill, as currently drafted, seeks to make a distinction between the inspection regime that applies to NHS foundation trusts, by linking inspections and reviews to the terms of authorisation and contracts with primary care trusts, and the inspection and review that applies to other NHS bodies. In practice, there is likely to be very little distinction between the reviews and inspection of NHS foundation trusts and those of other NHS bodies. Everything will be reviewed against the duty of quality, as in clause 40. For the sake of clarity, we are tabling these amendments to make it explicitly clear that a common inspection regime applies to both NHS foundation trusts and other NHS bodies.

Some minor differences result from the roles of the independent regulator and the Secretary of State in

relation to foundation trusts and other bodies. In some cases, clarification is achieved by making the clause apply to all NHS bodies by removing the exclusions that apply to foundation trusts.

Mr Simon Burns (West Chelmsford, Conservative)

The Under-Secretary has made an important speech, and I have listened carefully to it. What are the differences that he mentioned?

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

If I may continue, the hon. Gentleman will get the clarity that he is seeking. In some cases, clarification is achieved by making the clause apply to all NHS bodies by removing the exclusions that apply to foundation trusts. Fourteen amendments fall into that category—Nos. 30, 173, 283, 287, 289, 290, 291, 294–97, 306, 307 and 452—and all have that effect.

Amendment No. 276 is a drafting amendment recommended by parliamentary counsel to ensure consistency with other parts of the Bill. Counsel has also suggested that CHAI's function of encouraging and improving the provision of health care is technically a general function. Amendment No. 282, therefore, seeks to make that clear.

Amendment No. 277 places a duty of co-operation upon the independent regulator and the CHAI when carrying out their respective functions under part 1, chapter 3 of the Bill. It will ensure that CHAI and the independent regulator work together efficiently in the discharge of their respective functions.

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

I have been following the Bill, and, indeed, this group of amendments, closely. The Under-Secretary is not speaking particularly quickly. However, in the absence of a written explanation, it is quite hard to prepare one's response to the point that he is making and the explanation that he is giving. Why was it not possible for an explanation to be given of the group as a whole, and of the distinctions made between the various amendments, in order to help Opposition Members? In a positive spirit, would it be possible for that to be provided by this afternoon's sitting? I understand that we are to finish in 10 minutes. I suspect that the Under-Secretary will not have finished within the next 10 minutes. Could that explanation be arranged, so that we can have a more constructive debate?

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

I undertake to have something prepared by this afternoon, which I hope will provide the clarity that hon. Members seek.

I was saying that the provision would ensure that CHAI and the independent regulator worked together efficiently in the discharge of their respective functions. It would also avoid duplication and ensure that opportunities to rationalise information requirements from NHS trusts are taken. CHAI will still be able to provide advice and information to foundation trusts if they request it under clause 49(1), which encourages improvement. Other amendments have clarified the position of CHAI in respect of NHS foundation trusts. In doing so, clause 48, which places a duty on CHAI to report significant failures to the independent regulator with regard to the provision of health care by or for an NHS foundation trust, will be removed.

Mr Simon Burns (West Chelmsford, Conservative)

We are extremely grateful for the Under-Secretary's assurance about a briefing. However, does he agree that, given the problems that were raised by the hon. Member for Oxford, West and Abingdon, it might be sensible to adjourn the Committee now, so that we can resume this afternoon, when we will have had the briefing and will be able to understand better the context of what he is talking about?

Mr Stephen Pound (Ealing North, Labour)

On a point of order, Mr.Griffiths. Is it in order for my hon. Friend the Member for Rossendale and Darwen (Janet Anderson) to flourish a bottle of champagne in the Committee Room, or is it permissible only on those occasions when we wish to celebrate the recent wedding of my hon. Friend the Member for Poplar and Canning Town (Jim Fitzpatrick)?

Mr Win Griffiths (Bridgend, Labour)

I thank the hon. Gentleman for raising that point of order. It is not strictly in order, but—[Laughter]. I ask the Under-Secretary to give us a sentence to complete his speech, and we can then move to the Adjournment.

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

I hope that I have been able to reassure the Committee that we will be able to provide further advice on the issue. However, as I stated originally, the group of amendments will simply bring matters in line and make clear that foundation trusts should be subject to the CHAI regime, as are other NHS bodies.

Debate adjourned.—[Jim Fitzpatrick.]

Adjourned accordingly at eighteen minutes past Eleven o'clock till this day at half-past Two o'clock.