Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I beg to move amendment 110, in clause 5, page 4, line 16, leave out ‘continues’ and insert

‘and the Statement of Accountability continue’.

Edward O'Hara (Knowsley South, Labour)

With this it will be convenient to discuss the following: amendment 111, in clause 5, page 4, line 19, after ‘Handbook’, insert

‘and the Statement of Accountability’.

Amendment 112, in clause 5, page 4, line 21, after ‘Handbook’, insert

‘and the Statement of Accountability’.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

The amendments are brief. They do the same thing and would insert the statement of accountability into clause 5 on the same terms as the handbook. Clause 5 is about the availability, review and revision of the handbook. Through the amendments, the statement of accountability would also have a legislative foundation for its availability, review and revision. We had many discussions about that when we debated amendment 3 and I will not rehearse those, except to ask the Minister why the handbook is in the clause when the statement of accountability is not. Logically, it should be both or neither. I hope his reply will clarify that.

Mike O'Brien (Minister of State (Health Services), Department of Health; North Warwickshire, Labour)

There is no need to place a duty on the Secretary of State to make available, review and update the statement of accountability because the Government are already committed to it. Principle 7 reads:

“The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff. The Government will ensure that there is always a clear and up-to-date statement of NHS accountability for this purpose.”

The seven principles in the constitution, including that one, cannot be changed except by regulations laid before Parliament. Therefore, no Government can renege, without parliamentary approval, on the commitment to keep the up-to-date statement of accountability. That provides ample clarification. It would be unhelpful in terms of timeline to insert into the Bill when the statement of accountability needs to be reviewed, since it describes the structure of the NHS, which might not change at all in any three-year period, or conversely might change sooner. Flexibility is needed to keep the statement up to date and so keep it useful for the audience with which it is supposed to engage.

The answer to the hon. Gentleman’s key concern is that the issue is covered by principle 7. The three-year period would just add unnecessary bureaucracy. Why, if the statement of accountability has been reviewed after two years and nine months, review it again after three years? It does not make sense. There is an obligation; it is required to be constantly updated and that is the best way to deal with it.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I am satisfied with the explanation. I beg to ask leave to withdraw.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I beg to move amendment 113, in clause 5, page 4, line 20, at end insert:

‘and may address the impact of the Handbook on National Health Services including—

(a) dentistry;

(b) audiology

(c) podiatry’.

Edward O'Hara (Knowsley South, Labour)

With this it will be convenient to discuss the following: amendment 114, in clause 5, page 4, line 20, at end insert:

‘(3A) The review may assess the cost savings made as a result of the NHS Constitution.’.

Amendment 115, in clause 5, page 4, line 20, at end insert:

‘(3A) In reviewing the Handbook and the Statement of Accountability the Secretary of State must consult the bodies listed at section 3(3).’.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

This series of amendments seeks to put in the NHS handbook strong indicative markers for performance. They might also be markers for any report on the effect of the NHS constitution under clause 6. Amendment 113 takes three areas in which the Government have consistently underperformed; I am sure that hon. Members could add others—health inequalities, malnutrition, single-sex wards and superbugs, for instance.

With regard to dentistry—a subject on which my hon. Friend the Member for Hemel Hempstead has repeatedly called the Government to account—the failure of the Government is becoming a byword. Access has declined since the Government’s new dental contract was introduced in 2006. Patient outcomes have worsened considerably and the dental professional is feeling, somewhat justifiably, disfranchised. More than 36,000 children with tooth decay are admitted to hospital each year and the figure is rising. It is now the third most common reason children are admitted to hospital, with a 13 per cent. rise in the incidence of hospital admissions relating to tooth decay in five years.

My hon. Friend and our party have pledged to restore access to an NHS dentist for the million patients who have lost it under the Government’s current failed system, by slashing bureaucracy and cutting waste and creating new incentives for dentists to spend more time on preventive dental care, improving oral health and reducing long-term costs. It is important to use money that is currently spent on carrying out unnecessary treatments to reintroduce dental screening for children in schools, so that children aged five can have their oral health addressed. That is also part of a scheme that would give  dentists the freedom to charge patients who repeatedly miss appointments—a counterpoint to what we were discussing a moment ago—and ensure that taxpayer-trained dentists work for the NHS for at least five years. If this were a benchmark for the performance of the handbook and the constitution, we might get a real sense of what improvements they can bring.

To take another example, in January 1,849 people were still waiting more than 18 weeks for digital hearing aids, 585 of whom had waited more than a year. That has been a long-running scandal which has particularly affected older people. The ability of the constitution and the handbook to deliver on that would also be a mark of their value; failure to deliver would be a mark of their failure.

To emphasise the need for the three amendments we also need to look at podiatry services, where older people have long been neglected. Age Concern has been campaigning for years on podiatry services and its “Feet For Purpose” document, published in August 2007, shed light on the horrific circumstances of many people. It found that one in three of the 2 million people in England over the age of 65 cannot cut their nails. Lack of even the most basic foot care can lead to complications resulting in dangerous falls, severe restrictions on mobility and social isolation. Proper foot care is key to the dignity and freedom of so many older people and, yet again, the dignity challenge is silent. The press has reported that at least 12 PCTs have cut podiatry services, and the Government’s national service framework for older people in 2001 highlighted the need for podiatry as part of old age specialist care. Functioning podiatry services would make a real difference to older people and the NHS, and would be a good benchmark for measuring the effectiveness of the constitution and the handbook.

I also pay tribute to Diabetes UK, which made a particular point of emphasising the need for better and more accountable podiatry services. One of the many unseen challenges and afflictions that affect the many people who suffer from diabetes is the difficulty, not only in making sure that they can cut their nails, but in keeping healthy feet when facing so many other challenges.

Amendment 114 would enable the Committee to explore two intriguing statements in the Department of Health cover note to the impact assessments on the Bill. Paragraph 3 states:

“The benefits of each of these proposals are expected to outweigh the associated costs.”

Paragraph 7 of the NHS constitution states:

“These may have both costs and benefits; there is currently insufficient data to make a realistic estimate.”

I hope the Minister can explain that contradiction and tell the Committee how much the constitution has cost to date; otherwise he might want to add that to his letter pile.

Finally, as with so much in the Bill, the review seems to be left at the potential whim of the Secretary of State. Amendment 115 would ensure that all the bodies and persons who feed into the tenure review of the constitution also support the review of the functioning of the handbook. It is right that such a review should be open, informed and honest, and I hope that the Minister will accept that and our other amendments.

Sandra Gidley (Romsey, Liberal Democrat)

While I cannot argue with the hon. Gentleman, I find amendment 113 a little confusing. It is fairly weak because the wording states that it “may address the impact”, so it hardly seems worth putting in the Bill. It seems to be a “do it if you want to” approach. He mentioned areas of neglect and quite rightly highlighted three that are of concern. However, by putting those into the Bill, he may be neglecting other important areas. For example, we could easily add “access to talking therapies” or “availability of NICE medicines”—it would be interesting to force a review of that because implementation is patchy. Others may prefer “access to IVF services” to be listed. Those three examples immediately sprang to mind, but if we brainstorm—I am not sure that we are allowed to use that phrase anymore—we could come up with a long list of underfunded services. I am concerned about supporting the amendment, although I recognise the intention behind it.

Similarly, I am concerned about amendment 114, which again contains the weasel word “may”. I have sat in many Committees in which the Conservatives tried to strike out each “may” and replace it with “must”, so I am surprised to find the word here. I would not necessarily support a “must” in this case. The constitution is not about finance, and the unnecessary bureaucracy involved in assessing the financial implications of the constitution runs counter to everything we hear about the Conservatives wanting to reduce regulatory burdens, but I may have missed something. I find it difficult to support the amendment.

Amendment 115 is perfectly sensible. It may be superfluous, but I have no difficulty supporting it.

Andrew Turner (Isle of Wight, Conservative)

I am concerned about dentistry, because it is very poor on the island, despite attempts by Ministers to do something about it. The problem is that the recording system is based entirely on the number of appearances before a dentist. We no longer have a system that looks at each person; instead it looks at the number of visits. That tells us how many appearances, not how many people, there are before the dentist. That is the wrong system and it gives the wrong impression. It appears that more people have inspections, but in fact they are the same people—the same people are going to the dentist more and the same people are going to the dentist less. We must fix that problem by recording the number of visits that each person has, not just the smaller number of people who have regular visits.

Mike O'Brien (Minister of State (Health Services), Department of Health; North Warwickshire, Labour)

Amendments 113 and 114 would allow the Secretary of State to address the impact of the handbook on national health services, including dentistry, audiology and podiatry, during the first three-yearly review of the handbook, and to assess the cost savings made as a result of the constitution during each three-yearly review.

The hon. Member for Eddisbury set out on a general rant about the NHS. Let me remind him that the NHS now has the shortest waiting lists since its records began. Across England, the NHS has met its target to treat patients within a maximum of 18 weeks from referral by their GP to consultant, including audiology  patients referred to ENT departments. The hon. Gentleman mentioned audiology: the NHS is also ensuring that patients do not wait a long time to access a non-consultant-led audiology service, and the median waiting time from referral to direct access to audiology treatment is now just 4.6 weeks. He mentioned podiatry: foot care services for older people have been reviewed as part of the prevention package announced in May 2008. The package is due to be launched later this year, with the publication of guidance for commissioners and providers of foot care services for older people, and self-care guidance for the public.

The hon. Members for Isle of Wight and for Eddisbury mentioned dentistry services. There are a number of issues in relation to those services and the hon. Member for Isle of Wight raised a particular point. I am not sure that the handbook is the way to address it, and I hope he forgives me for not going down the route he invites me to take. In general terms, we have invested a record £2 billion in dentistry and set up a national access programme. We have also commissioned an independent review of NHS dentistry led by Professor Jimmy Steele. The review will report later in the summer and give an independent view of how we should further develop dentistry in the coming years.

Amendment 115 would oblige the Secretary of State to consult on reviews in relation to the handbook and the statement of accountability. The Conservatives ask how the constitution will be a cost-saving exercise, but it is not intended to be a cost-saving exercise. All too often, the Conservatives are obsessed with how to make cuts in the NHS. They have recently made statements that indicate how they want to make cuts across the board—

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

Anything but.

Edward O'Hara (Knowsley South, Labour)

Order. The Minister has got away with enough so far.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I can but try, Mr. O’Hara. You quite rightly bring me back to order.

The aim of the reviews is not to cut costs; it is to empower patients and staff through greater understanding of their rights and responsibilities. We do not want to single out particular areas or services in the reviews—they must be looked at as a whole. As the hon. Member for Romsey pointed out, if we start picking services, we could leave others off the list. She rightly identified some services that the Conservatives have left off their list.

Sandra Gidley (Romsey, Liberal Democrat)

The Minister reads his briefing notes very well, but I must admit that his mention of podiatry rather incensed me, because podiatry services are non-existent in some parts of the country. I am sure that he wants to get out and about to meet people, so I invite him to Hampshire to witness podiatry services—I would not quite use the phrase “in action”. He will see that there is a problem. It is not the thrust of the Bill, but after we have finished our deliberations on it, it might be nice for him to get out a little more.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I welcome the hon. Lady’s offer to take me out, but I will decline for the moment. I remind her that the aim is to launch a podiatry services package  later this year, with the publication of guidance for commissioners and providers of foot care services. When that happens, perhaps she will see that the Government are focused on the issue as she would like.

Amendment 114 would be out of kilter with the purpose of the reviews of the handbook. It is not designed to go further than assessing the helpfulness of the document itself. A review is not a broad review of every service, and the measure is about looking at the document and determining whether it fulfils the role that was intended for it.

On amendment 115, the Secretary of State may make minor changes to the handbook at any time to bring it into line with current departmental policy or changes in the law, to ensure that the handbook is always up to date. It would not be appropriate to impose a requirement on the Secretary of State to consult on such changes. The handbook is not intended to be a legal document as such; it is merely guidance for the general public. Any changes to the law or to departmental policy that are more significant would, in themselves and by their very nature, trigger consultation requirements, either by virtue of statute, or to comply with the Government’s code of practice on consultation, or because we would be expected to consult. We have therefore decided not to include that as part of the requirement.

When reviewing the handbook, we will certainly continue informally to involve patients, the public and other groups and parties who have contributed to its development. However, we do not want to impose a formal duty to consult every time that there is a minor change. It is important that the handbook is regularly updated. On the statement of accountability, as I have previously mentioned, it is a public-facing and factual document that explains roles, responsibilities and accountability in the NHS. To require the Secretary of State to consult on it would be inappropriate, and the changes would merely bring it in line with the current structure of the NHS. Such changes, not the document itself, should be the subject of consultation. I hope that those explanations will lead to the withdrawal of the amendment.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I listened to the Minister with some care. He was unusually opportunistic in suggesting that I am obsessed with cost savings. I will not go down the wholly inappropriate and erroneous route that that he went down. The Government have been keen to reverse the declining productivity in the NHS, and we thought that it would be helpful to discuss that.

I would also like to draw attention—I could do this during the stand part debate, but I might as well cover it now—to something that is not the subject of an amendment. Paragraph 86 on page 18 of the explanatory notes centres on clause 5 and mentions how the Department intends to use the reports on the effect of the NHS constitution to assess what further measures are required. I am a little concerned by the use of the word “Department”, because normally it is either the Government or the Secretary of State who are involved. I will not press the issue—I dare say that there is an explanation—but I wanted to ensure that it was highlighted.

I am particularly grateful to my hon. Friend the Member for Isle of Wight for highlighting the situation of members of an island community who do not want  to have to travel by ferry to access services. It is important that that is seen as a community interest that needs to be supported by public services. He also made the important point about access to NHS dentistry services. We want to ensure access to services, rather than simply concentrate on the quantity of particular people’s visits and the absence of access by others.

I am also pleased that the Minister made a semi-announcement that Diabetes UK’s campaign on podiatry services will bear some fruit and that an announcement will be made later this year. That will be extremely welcome news to Diabetes UK and the many others who have vigorously and rightly campaigned for such a focused and strategic uplift of such services.

I remain concerned that we have not received the strong answer for which I had hoped in response to the amendments. Indeed, I had hoped that the Minister would adopt the amendments.

Mike O'Brien (Minister of State (Health Services), Department of Health; North Warwickshire, Labour)

Perhaps I could strengthen my answer by mentioning a point that I did not refer to earlier. The total cost from the inception to the completion of the constitution was just under £1 million.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative)

I am grateful for that, because it means that I will not have to ask that question again. The figure is useful and is now on the record. I also want to address the implied criticism from the hon. Member for Romsey when she said that she did not fancy the word “may”. It would not be appropriate for the Government, as the Bill’s promoters, or for my hon. Friend the Member for Hemel Hempstead and I, as the amendment’s proposers, to bind the hands of any kind of review. Inevitably, that is in the conditional, or the subjunctive to be more precise, and it is important to note that it is about guidance, rather than legal force. I made the clear distinction of saying that there were three items, but that is inclusive—it was not intended to be exclusive. I thought that those were three good examples that would help to highlight the matter. In considering that we should flag up our intent, perhaps for no other reason than emphasis, and despite recognising that the Minister has given some partial answers, I would like to press the amendment to a vote.