Clause 42 - Standards set by Assembly
Health and Social Care (Community Health and Standards) Bill
8:55 am
Mr Chris Grayling (Epsom and Ewell, Conservative)
I beg to move amendment No. 476, in
clause 42, page 14, line 31, leave out 'may' and insert 'must'.
Mr Peter Atkinson (Hexham, Conservative)
With this it will be convenient to discuss the following amendments: No. 477, in
clause 42, page 14, line 33, leave out from 'may' to end of line 34 and insert
'amend the standards whenever it considers it appropriate. The National Assembly must publish amended statements'.
No. 478, in
clause 42, page 14, line 35, leave out from 'must' to end of line and insert 'publish proposals for consultation'.
Mr Chris Grayling (Epsom and Ewell, Conservative)
I have taken it upon my shoulders to move the amendment, particularly as I want to discuss amendment No. 470.
Mr Stephen Pound (Ealing North, Labour)
I invite the Under-Secretary to consider the benefits and advantages of the amendment. A fairly minor amendment in many ways, it seeks to progress matters slightly and to underline the significance of clause 42. I am happy to address any issues later.
Mr Chris Grayling (Epsom and Ewell, Conservative)
Having moved the hon. Gentleman's amendments, I will pick up his point from a different perspective. We on these Benches are anxious about separate standards for England and Wales. Amendment No. 476 inserts ''must'' as opposed to ''may'', thus compounding the problem. Rather than giving the Assembly discretion over whether Wales has standards separate from those in England, the amendment will place a requirement on the Assembly. That is wrong for two reasons. First, if one believes in devolution and local responsibility, one must allow the local decision-making body—in this case the Assembly—the freedom to decide whether it wants to opt into standards established for the entire United Kingdom, or for England and Wales, or to propose its own set of standards to meet the needs of its own country.
The second reason for our profound anxiety is that having two different sets of standards moves us away from a national health service, which is a development that we should not welcome. That will create issues in cross-border areas and unwanted discrepancies between England and Wales. I am in favour of local accountability, but the natural correlation to setting up two sets of standards—we will discuss that later in
the debate—is two different inspection regimes, and the result of that would be a lesser amount of good care for patients, duplication of resources and bureaucracy and a waste of public money.
If we bring an iron curtain down along the border between England and Wales, not only will that have an adverse effect on patients in cross-border areas, but we will lose the opportunities for sharing best practice across the border, for clinical treatment flows from one side of the border to the other, and for Wales to learn from experience in England. The end result will be a genuinely local health service. If the Government's policy is to have a Welsh health service and an English health service and to move away from the principle of a national health service, let them say so loud and clear.
Whitehall Ministers may want to get the Welsh health service off their hands. That is understandable, because the Welsh health service is not functioning well and is not responding to the aspirations of central Government.
Some of the statistics are absurd. In Wales there are 71,000 more people waiting more than six months for out-patient treatment than there are in England. There are 46 million more people in England than in Wales, so it is quite an achievement to perform as badly as that.
People in border areas are being disadvantaged by the discrepancies in the standards and frameworks on both sides of the border. A Welsh patient was told by his nearest hospital, which is in Shropshire, that he had to wait six months longer for his hip operation than English patients in the same situation, because he was Welsh. A gentleman from north Wales who had been waiting more than 16 months for vital heart surgery in a Liverpool hospital was informed by the hospital of a Government initiative under which all patients waiting more than five months would have the choice of undergoing surgery elsewhere. He was told that as he lived in Wales he would not be involved in the scheme because Welsh authorities had declined to take part.
Is it fair or appropriate to have an increasingly divergent health care system, with different standards, principles and priorities in border areas, where people may be looking to a local tertiary centre or local hospital for treatment? If we continue to go down the road of having separate systems in both countries, some people in border areas will not have the same access to health care as those who live a mile up the road. It is happening today and it will continue to happen as sure as night follows day.
Proper strategic decisions on a particular population area or a rural community are not being made. Communities that do not divide because there is a border between England and Wales are being treated differently by the health service. Decisions are being made on the basis of the villages that people live in.
It would be madness if the principle of standards meant that the two Administrations—the Secretary of State in Whitehall and the National Assembly for Wales—were telling clinicians to do one thing and not another. That would inevitably distort the services
available and the treatment that could be received by patients who live in border areas.
Last week, I briefly mentioned that it is perfectly conceivable—I have just illustrated that it happens—that a doctor in a clinic will have to treat his 10 o'clock and his quarter-past 10 appointments differently, even though both patients may have the same condition, because of the differences in the standards framework and the requirements placed on that doctor by the Welsh Assembly. It makes no sense. Ministers must be extremely careful about this matter.
Mr Stephen Pound (Ealing North, Labour)
I am reluctant to interrupt the hon. Gentleman in mid-flow because he seems to be constructing an exegesis that is comparable to the Schleswig-Holstein question. I appreciate that he has wider points to make; however, the purpose of the amendment is to compel the Welsh Assembly to take those factors into consideration and to drive up standards. How can he possibly have a problem with that? It would deal with the very issue of disparity in service provision about which he so eloquently speaks.
Mr Chris Grayling (Epsom and Ewell, Conservative)
What the hon. Gentleman is saying in his amendment, and I do not doubt his honourable intentions, is that inserting the word ''must'' removes discretion from the Welsh Assembly to apply common sense.
Let us suppose that in its wisdom—it would be in its wisdom—the Welsh Assembly decides that it is not in the interests of the Welsh people to have two different sets of standards. Let us suppose that it decides not to pay the money that will be required to the team that will produce a set of standards or the money that will be required to communicate those standards to medical practitioners across Wales, in border areas and in hospitals from Liverpool to Bristol. Let us suppose that it will decide not to pay the money required to set up an inspectorate to inspect those standards.
In its wisdom, the Assembly might judge it better to spend that money on patient care. The effect of the hon. Gentleman's amendment would be to say that it could not take that decision, which must be wrong.
Mr Stephen Pound (Ealing North, Labour)
Under the circumstances, why does the hon. Gentleman not simply suggest the deletion of subsection (1)?
Mr Chris Grayling (Epsom and Ewell, Conservative)
I would be delighted to see clause 42 disappear. I would argue against clause 42 in its entirety, because it is not in the interests of the people in Wales, or those in England who live close to Wales, to have separate standards. That would be a hindrance to them and a waste of public money. In the same way, I shall argue this morning that it is not in the interests of those people to have two separate, parallel inspection processes.
My concern about the amendment is that the word ''must'' creates an obligation. Clause 42(1) would then state:
''The Assembly must prepare and publish statements of standards in relation to the provision of health care by and for Welsh NHS bodies.''
That would remove from the Assembly the discretion to stick with the national standards that the Government have set out from Whitehall. It might choose to do otherwise. I think that it would be wrong to do so, but under this clause it would not have the ability to do so, and that would be a mistake.
It would be a particular mistake for cross-border areas. At least six trusts truly serve cross-border communities, including the North East Wales NHS trust and the Gwent Healthcare NHS trust. There are also the strategic health authorities on the English side of the border: Cheshire and Merseyside; Shropshire and Staffordshire; Coventry, Warwickshire, Herefordshire and Worcestershire; and Avon, Gloucestershire and Wiltshire. Each of those oversees services for significant numbers of patients from Wales. To ask each of those organisations to handle two different sets of standards would add yet more of a bureaucratic burden both to the managers running those trusts and, more particularly, to the clinicians who must deal with them. I see no benefit in doing that.
The only condition that I am aware of that came out of the debate on the Health (Wales) Bill that could be argued to be peculiar to Wales relates to those who worked in the limestone and slate industries. In a telling intervention last week, my hon. Friend the Member for Westbury (Dr. Murrison) asked the Minister how Welsh diabetes differs from English diabetes. The Minister must realise that after his Government have put the effort into creating a national service framework for diabetes, it would be nonsense if the Welsh tore that up and came up with something different just for them.
We must remember that although Wales has a proud tradition, it is also a geographical area with a population that is not much larger than Surrey and Sussex. Is it really sensible and a prudent use of public funds to have a set of standards devised for that number of people that differs from the standards that apply to their compatriots? That would cause confusion, complication and difficulties to practitioners who straddle both countries.
Therefore, the requirement under the amendment to follow that road would be short-sighted and would compound a problem that exists more broadly in clause 42, which in my view has no place in the proper provision of good health care for the future of England and Wales.
Mr Jon Owen Jones (Cardiff Central, Labour/Co-operative)
I oppose the amendment. Although it may make some sense to insert ''must'' instead of ''may'' in clause 42, clauses 41 and 42 are both worded in exactly the same way. Clause 41(1) states:
''The Secretary of State may prepare and publish statements''.
Clause 42(1) says:
''The Assembly may prepare and publish statements''.
There is an argument that the word ''may'' should have been replaced by the word ''must''. However, if that is to happen, it should be replaced in both clauses rather than in the clause relating to the Assembly and not in the clause relating to the Secretary of State. I
have some sympathy for the application of common standards wherever possible. However, that will not be achieved by removing clause 42 in its entirety, because we would then need to reword clause 41. If we are to have common standards, it is surely not right for those standards to be imposed on Wales by the Secretary of State in Westminster without consultation.
Mr Chris Grayling (Epsom and Ewell, Conservative)
I absolutely agree with the hon. Gentleman. I hope that if we stand against clause 42, it will secure the Under-Secretary's agreement to go away and rewrite both those clauses before Report. In that way we could have what the hon. Member for Cardiff, Central (Mr. Jones) and I both wish to achieve, which is a proper set of national standards with a bit of flexibility to deal with specific local issues such as those that we have discussed in relation to the slate industry.
Mr Jon Owen Jones (Cardiff Central, Labour/Co-operative)
I am glad that the hon. Gentleman has reminded me about the use of the word ''national'', because it has been applied so far to mean England and Wales. One can argue that England and Wales are two separate nations; what cannot be argued is that the combination of England and Wales is a nation. The British state is possibly a nation, in which case we need to be arguing about common standards to be applied in Northern Ireland, Scotland, Wales and England rather than to this greater England that just happens to comprise Wales as well. That is the way that the word ''nation'' has been used in the debate so far.
It concerns me that we may have a wide range of standards, which would be deleterious to effective and efficient health care. I can think of circumstances in which some standards might diverge, but surely we should ensure that, as far as possible, common standards apply. The Bill does not do that in the best way. I do not support the amendments being proposed for the reasons that I have stated, and I do not support the deletion of clause 42, because it would make little sense, given the way in which the rest of the Bill is worded.
Mr Gary Streeter (South West Devon, Conservative)
I am listening carefully to the hon. Gentleman's point about common standards. We heard earlier that health care outcomes in Wales seem to have fallen short of those achieved in England. I am simply requesting information: does he have an explanation for that?
Mr Jon Owen Jones (Cardiff Central, Labour/Co-operative)
I do not wish to be tempted too far down the road of explaining different health outcomes. What was referred to was the different waiting times, which are not quite the same thing as health outcomes. In comparing different parts of the country, it is not valid to compare health outcomes across all of England with those across all of Wales. It is more appropriate to compare health outcomes across Wales with those in the north-east of England, because the morbidity and mortality rates are more similar for those two areas. If one does that, the results also raise several questions. However, I do not think that it would be appropriate to debate them in the context of these amendments.
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
I take this opportunity, Mr. Atkinson, to welcome you to the Chair on my first speaking appearance in the Committee. I look forward to your guidance taking us through these important Welsh clauses this morning.
I also thank colleagues on both sides for their forbearance and understanding of my limited attendance in Committee. Earlier this year, I was on three Standing Committees on three separate Bills at once, which was a bit difficult at times. Perhaps that is an answer to those who say that we have not got enough to do in the Wales Office. I will not take that point any further in case there are further announcements this afternoon. It might amuse the Committee to know that the Lincolnshire Echo arrived in my office yesterday afternoon addressed to the Arab Republic of Egypt at Gwydyr house. I do not know if that is an indication of any changes in the Wales Office.
This is a substantial and important Bill for Wales. About 50 of the Bill's clauses apply wholly or partly to Wales. The Bill will continue the joint programme that the Government are pursuing with their colleagues in the Welsh Assembly further to raise health and social care standards in Wales. For Wales, the main effects of the Bill are the inspection, monitoring and enforcement of standards of health and social care providers. At earlier sittings, my right hon. and hon. Friends outlined proposals for the Commission for Healthcare, Audit and Inspection, the new body that will assess performance and enforce standards across a range of health care providers in England and Wales.
In addition, the Bill provides for the Welsh Assembly to undertake reviews and to investigate health care provision across a series of NHS bodies in Wales. CHAI will have a wide national remit. I take the point that was made by my hon. Friend the Member for Cardiff, Central (Mr. Jones)—by ''national'' the Bill is referring to England and Wales. However, the Assembly needs the opportunity and ability to monitor and to focus closely on addressing the health priorities that it set for the people of Wales.
The Healthcare Inspection Unit for Wales will undertake the reviews and inspections. It will adopt techniques that have been used successfully to review the social services in Wales and will provide a robust case for the improvement of clinical governance tailored to particular Welsh needs.
The Bill establishes the Commission for Social Care Inspection in England, and it places the responsibility for conducting such inspections in Wales on the Welsh Assembly. Consequently, it provides the same powers to the Assembly as are provided to the Secretary of State in England. Another significant change is that the Assembly will be given similar powers to those of the Secretary of State to prescribe a range of foods that are made available under the welfare food scheme. Those powers will allow the Assembly to broaden the nutritional basis of the scheme with particular regard to Welsh matters.
The Bill also recognises several other differences in the application and operation of the health service in Wales, which it would not be prudent of me to discuss at length at this stage. However, so that people may understand where I come from, and where the Government come from, I should say that I do not subscribe to tweaking every piece of legislation that comes through this place so that each has a ''made in Wales'' stamp on it. However, I do subscribe to a ''better for Wales'' stamp, whereby a piece of legislation can be improved by doing things slightly differently, as is proposed in this part of the Bill.
The amendments tabled in the name of my hon. Friend the Member for Ealing, North (Mr. Pound) take away the Assembly's discretion in preparing and publishing statements, standards and consultation documents. Under those amendments, it would be an absolute requirement for the Assembly to prepare and publish statements, standards and consultation documents.
The principle of the devolution settlement was the ability of the Assembly to conduct its business in an unrestricted way within the confines of the Government of Wales Act 1998, which was Parliament's intention when it handed over those powers and responsibilities to the Assembly. To impose an absolute requirement to prepare and publish statements, standards and consultation documents will run contrary to the fundamental principle that this place guaranteed when it passed that Act. It is for the Assembly to determine what action it should take on the provision of the health service in Wales, which is its remit through the process of secondary legislation that the Act conferred on the Assembly.
In setting standards, the Assembly consults those persons whom it considers appropriate and takes account of the standards set by bodies in England and Wales; for example, it refers to guidance provided by the National Institute for Clinical Excellence, the royal colleges and so forth. Moreover, amended powers conferred on the Assembly under the National Health Service Act 1977, to give direction to NHS trusts, special health authorities and local health boards, do not place an obligation on the Assembly, but rather permit it to issue such directions as it sees fit.
The hon. Member for Epsom and Ewell (Chris Grayling) made some important points in his useful contribution, as he did when he served on the Standing Committee on the Health (Wales) Bill. He researches well, but—this may surprise him—I disagree with several points that he made this morning. He was concerned about the question of standards, mainly the difference in standards that might apply in Wales and in England.
Standards set in Wales will be as high as those in England. They will be determined by the Assembly, but are likely to include the national clinical standards, the national service frameworks, the NICE guidelines and so on. Moreover, targets and other standards developed and issued by the Assembly will be taken into account in assessments. National standards, such
as the national service frameworks, underpin many of the standards determined by the Assembly. A clinical standards board for Wales will be set up to act as a mechanism to co-ordinate and monitor Welsh clinical standards.
Mr Chris Grayling (Epsom and Ewell, Conservative)
Will the Under-Secretary confirm that, under the Bill, the Assembly has the right to ignore NICE?
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
The Assembly will listen to points made by NICE. It was made clear last year, in discussion of the NHS Reform and Health Care Professions Bill, that NICE applies across England and Wales.
Mr Chris Grayling (Epsom and Ewell, Conservative)
If the Welsh Assembly has the right to establish its own standards, does it have the legal right to decide that it will no longer listen to NICE? I accept that it might not choose to do so.
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
That is not my understanding. We made it clear in discussions on the NHS Reform and Health Care Professions Bill last year that NICE applies across England and Wales.
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
Will my hon. Friend permit me to make this one point? I will give way in a moment.
Our problem in this discussion is the use of the word ''standards''. In my context, those are clinical standards, whereby a doctor treating a patient in England will have the same standards as a doctor treating a patient in Wales. We are confused by talk of ''standards'' when sometimes we mean ''targets''. Those are political with a big ''P'', in that the Government or the Assembly will set a target—an objective for delivery of the health service in Wales—and with a small ''p'', in that some NHS trusts will have a particular objective, target or mission statement which they want to see realised. That point must be clarified.
We use the word ''standards'' when all sorts of other things, such as targets, clinical standards and so on, are meant. There is a difference. The standards I refer to are those of delivery and the quality of health care. Targets are different—they are set by politicians, systems, Government Departments and agencies and others in order to achieve objectives.
Mr Jon Owen Jones (Cardiff Central, Labour/Co-operative)
Before the publication of the Bill, was consideration given in the Welsh Assembly and in the Government to a form of wording which involved the co-ordination of standards so that, as far as possible, common standards could be met? If not, could it now be considered during the Bill's progress in this House and in another place?
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
Yes, of course there were discussions on the issue of standards at ministerial and official levels between the Department of Health and the Assembly. We shall try to ensure that the national standards that I mentioned are broadly similar across England and Wales in respect of CHAI. Those discussions are ongoing, and we shall, as I have said, seek to ensure that the standards in Wales are as high as those in England. That will involve much co-operation and collaboration between HIUW, CHAI and the various Departments.
The hon. Member for Epsom and Ewell was also concerned about duplication. In previous sittings he has made several points about where he considers there may be waste, in that CHAI and HIUW would be in competition and that inspections would be duplicated. There will be no such duplication. CHAI's role in Wales is important, but it is restricted to undertaking—I apologise to my hon. Friend the Member for Cardiff, Central—national reviews in England and Wales of the particular health care provided by the English and Welsh NHS trusts, and so on.
The review of cross-border issues and special health authorities will be carried out by CHAI. Under section 41 of the Government of Wales Act, the Assembly, through HIUW, may enter into arrangements with CHAI, whereby CHAI may undertake investigations into serious service failures or malpractice on behalf of the health inspectorate in Wales and, if appropriate, accredit HIUW's inspection methodology.
The health care inspectorate in Wales will undertake reviews and investigations of Welsh NHS bodies using the joint review of the social service model that involves the participation of the Audit Commission. We have used that successfully in Wales. It will also assess the management arrangements that are in place to deliver NHS services, and the quality of NHS services across all the agencies and service providers. It might be helpful if I wrote to colleagues at the end of the sitting to give them a breakdown of how we see CHAI operating and how we see the health inspectorate unit in Wales operating, and to explain how their objectives are quite different.
Mr Chris Grayling (Epsom and Ewell, Conservative)
The Under-Secretary has described the defining line between the two organisations. However, the point that I am seeking to make is that two organisations with two secretariats and so forth will inevitably create additional costs. Why is it necessary to have two organisations? Why will one inspectorate—CHAI—not be able to do the job properly for the people of England and Wales?
Mr Peter Atkinson (Hexham, Conservative)
Order. We are already straying away from the territory of clause 42 into that of clause 66. We will come to those matters later.
Mr Don Touhig (Parliamentary Under-Secretary, Welsh Office; Islwyn, Labour/Co-operative)
I take the point, Mr. Atkinson. I will reserve some of my comments until we reach that part of the debate.
The hon. Member for Epsom and Ewell mentioned some of the problems that we have had with delivering the health service in Wales. There are differences in the rates of treatment, particularly for orthopaedics in Wales. That is being addressed through further funding and reforms. To make a partisan point, I must say to the hon. Gentleman that 18 years of under-investment in the health service has left its mark in Wales. Certainly, we have serious difficulties in delivering health care in Wales.
Demographically, 17 per cent. of the population in Wales is aged over 65, compared with 15 per cent. in England. There are also regional differences within Wales. Only 14 per cent. of the population are over 65 in the constituency of my hon. Friend the Member for Cardiff, Central (Mr. Jones), compared with 25 per
cent. in Conwy in north Wales. We are seeking to address those differences with this legislation.
I am sure that we will have further debates on standards and so on when we move to clause 66, so I shall conclude at this point. As I said, I am not clear who moved these amendments, although they were tabled by my hon. Friend the Member for Ealing, North. I am told that, in a vote last week, he answered in Welsh. Some people say that Welsh is the language of heaven, but it is certainly not the language of this place. If my hon. Friend has the interests of Wales at heart, I invite him to withdraw the amendment so that we can make some progress.
Mr Peter Atkinson (Hexham, Conservative)
Order. The amendment was moved by the hon. Member for Epsom and Ewell, although he did not appear to be in favour of it.
Mr Chris Grayling (Epsom and Ewell, Conservative)
You will therefore not be surprised to hear, Mr. Atkinson, that I beg to ask leave to withdraw the amendments.
Amendment, by leave, withdrawn.
Clause 42 ordered to stand part of the Bill.