Clause 11 - Duty of quality

NHS Reform & Health Care Professions – in a Public Bill Committee at 10:30 am on 4th December 2001.

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Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon 10:30 am, 4th December 2001

I beg to move amendment No. 161, in page 17, line 3, at beginning insert—

'(1) In subsection 18(1) of the 1999 Act (duty of quality), after the first word ''of'' there is inserted ''the Department of Health,''.

(2)'

Photo of Mr Alan Hurst Mr Alan Hurst Labour, Braintree

With this it will be convenient to discuss amendment No. 160, in page 17, line 5, at end insert

'including monitoring the provisions of health and safety legislation and infection control measures'.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Amendment No. 161 is a probing amendment to discover whether the duty of quality, which is covered by the Commission for Health Improvement, extends to the working policies of the Department of Health. I hope that the Minister will reassure me and other hon. Members who are concerned about the matter.

One of the key influences on the delivery of quality in the health service is Department of Health policy. To a certain extent, the practices of the Department and its agents are already covered by the CHI. The danger is that the commission will spend its time inspecting the work of hospital trusts and primary care trusts; but those trusts merely do what the Government have asked them to do. That may be an effective ploy for the Government, because—unintentionally or otherwise, and regardless of whether the commission finds good or poor practice—its reports will let the Government and the Department off the hook. However, the subjects of those reports will be attempting merely to implement policies promulgated by the Department of Health.

In earlier debates, I mentioned the Liberal Democrats' concern that, however well-intentioned they may be, the central diktats of the Department of Health may distort clinical priorities. By that, I mean that patients may not be dealt with according to their clinical needs, and that the work of doctors and nurses will be based upon the need to fulfil political targets set by the Department. I do not say that the Government invented that approach, but they have perfected it. We need not only a truly independent commission, but a definition of quality, which the Government should welcome, that allows the commission to take a

circumspect look at whether the duties imposed by the Department on trusts and staff are in the interests of patients.

I welcome the Government's commitment to quality. We have always supported the setting up of the Commission for Health Improvement, and we welcome the initiative in the Bill to make the commission more independent. What better way could there be to show such commitment than the Government having the courage to allow the commission to inspect the work and policies of the Department of Health?

I accept that amendment No. 161 is not sufficient to add the Department of Health to the relevant parts of the Bill or of the Health Act 1999, which sets up the commission. I hope, however, that the Minister will reassure me that the Department's policies are already subject to independent expert overview through the Commission for Health Improvement, or in some other way.

The clauses that relate to the commission make it more effective. However, the more effective we make the commission, the more important it is that it should examine the policies of the Department, whoever controls it. The commission might decide that those policies, and the priorities that they place on the service, are good. The Government could publicise and benefit from such a judgment. However, many people in the health service whose work runs the risk of being deemed to be inadequate feel their political masters should run the same risk. Given the way in which the Government run the health service, they are, indeed, both political and masters.

I agree with those in the health service who feel that the quality agenda must be dealt with. There are problems with the delivery of quality, although we accept that they are not all due to under-resourcing and undercapacity. The publication this morning of the latest report by the national confidential inquiry into perioperative deaths puts the issue in similar terms. However, much of the failure to deliver quality is due to the lack of resources. Corners are cut because there are no funds for the staff, equipment, theatre lists, expert opinions and diagnostic techniques that would deliver the highest-quality service.

No local hospital or primary care trust can magic up extra resources; that is the responsibility of the House. It is also the direct managerial responsibility of the Secretary of State for Health, although it would perhaps be more appropriate to say the Chancellor of the Exchequer. Nevertheless, such matters are dealt with through Department of Health policies, allocations and prioritisations. The service is short of cash, and quality suffers as a result. In those circumstances, it would be invidious for the Department's funding and priority policies not even to be inspected. It is not a question of the Department getting off scot-free; indeed, the commission's diagnosis might be that there is no case to answer.

The Health Act 1999 does not lend itself to simple amendments that would include the Department, but it lends itself to some amendments. I accept that amendment No. 161 is not extensive enough to place a

supervisory duty on the commission. However, a way could be found. If the Minister does not reassure me, we might have to return to the issue later. I hope that we can ensure that the commission examines the provision of health care and the quality of the commissioning of health care against the quality standard that, rightly, has been established. If that is not already in the remit, it is an omission.

The commission should be able to examine the quality of performance of those who direct the commissioning and provision of health care. If nothing else, that describes what the Department does. It directs providers and commissioners through national service frameworks and the National Institute for Clinical Excellence; the body that it hides behind when rationing decisions are made. There is a huge incentive for hospitals, providers and commissioners to comply when their political masters tell them that they will be awarded no stars in some simplistic mumbo-jumbo star rating performance system, or that jobs will be on the line. They scarcely have time to consider whether that is in patients' interests, because they are faced with must-dos.

The Government could deal with the problem by not producing so much centralised guidance. I think that that would be difficult for any Government. An alternative would be for the Department to allow the same standards of inspection of its own policies as it imposes on the rest of the service in both its provider and commissioning status. I hope that the Minister will say that this provision is unnecessary, inappropriate or otherwise covered.

Amendment No. 160 seeks to probe further the extent of the expansion of the definition of the duty of quality in the Bill. In Section 18 (4) of the Health Act 1999, ''health care'' is defined as:

''services for or in connection with the prevention, diagnosis or treatment of illness''.

Clause 11 will add to that definition,

''and the environment in which such services are provided''.

The amendment seeks to add to that definition the implementation of

''health and safety legislation and infection control measures'', although I accept that its current wording does not quite achieve that effect. The British Medical Association is particularly concerned that not enough priority is given to those areas by hospital managers and the health service when attempting to deliver the duty of quality.

The cost of poor infection control to the health service, set out by the National Audit Office less than two years ago, is high. It would be of great concern if the health service were not inspected on that quality. The BMA briefing states:

''despite existing legislation and guidance, health and safety is still not universally guaranteed throughout the NHS. The NHS has a responsibility under the Health and Safety at Work etc. Act, 1974, and subsequent regulations on the management of health and safety to ensure the safety of all employees, contractors and members of the public as patients and visitors. Each NHS Trust and Primary Care Trust has a statutory duty to provide an

environment that is safe 'as far as is reasonably practicable', to use 'the best practical means' to achieve its objectives, and to use 'the best available technology not entailing excessive cost'.

The Commission for Health Improvement, as part of its inspection process''—

including the new inspection powers in the Bill—

''is in a prime position to observe whether premises, equipment, practices and procedures in each trust are sufficient to enable best clinical practice.''

The amendment is also tabled in the name of the hon. Member for Wyre Forest (Dr. Taylor), who may wish to speak about the importance of dealing with cross-infection. The NAO report to which I referred recognised the widespread failure in infection control. It seems reasonable that the Bill should be amended to ensure that that function is covered by the Commission for Health Improvement, or that the Minister should reassure us that infection control and health and safety at work are already covered by it.

The NHS staff is its major resource, on which the majority of its funds are spent. The way in which the NHS treats its staff is a measure of the quality of the service. Concern has been expressed that the occupational health facility is poor, if it exists at all. As a result, trade unions and professional organisations run heavily subscribed helplines and stress counselling lines, which should be provided within the health service by the employer; particularly an employer which puts its workers under such strain. The personnel function must not be overlooked in the workings of the NHS; the key to undercapacity lies not only in the failure of resourcing over so many years, but in the failure to retain staff, many of whom are leaving because of the stresses and strains of the workplace.

If occupational health policies were more effective, we might be able to improve NHS delivery and maintain and increase the service's capacity, which is the critical issue facing it. If the definition of quality were extended to include the quality of the human resource function, or the Minister were to reassure us that certain guidance clearly so extends it, the Committee would be reassured and the amendment could be withdrawn. I commend the amendments to the Committee.

Photo of Richard Taylor Richard Taylor Independent, Wyre Forest 10:45 pm, 4th December 2001

My name is attached to amendment No. 160, but I support amendment No. 161, which was tabled by the hon. Member for Oxford, West and Abingdon (Dr. Harris). However, I am primarily interested in amendment No. 160. I thoroughly approve of the vagueness of the wording in clause 11, when it refers to

''the environment in which services are provided.''

I presume that ''environment'' is meant to be vague, because it includes all hospitals, practices, clinics and facilities where health care is provided. I approve of that. The amendment attempts to make more specific some of the Commission for Health Improvement's functions. As has been said, we are interested in the health and safety issues, especially cross-infection. I remind the Committee of the recent seminar held by the Patients Association, which pointed out the

tremendous risk of the transmission of very serious infections through the re-use of surgical equipment. Policies in units that have allowed that to happen are somewhat lax. It is crucial that the CHI is able to inspect for that sort of thing. The amendment is designed to add teeth to the clause, so that cross-infection is inspected meticulously during CHI inspections.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

As the hon. Member for Wyre Forest said, the clause is vague in its definition of the environment in which such services are provided. The hon. Gentleman welcomed that vagueness because he thought that it would make the clause all-embracing in its interpretation. I have a lot of sympathy with his point. However, as hon. Members who have received the BMA briefing on the amendment will know, at this stage in the consideration of the Bill such vagueness must be explained further to reassure Members that the provision will enhance the inspection process and the standards to be imposed on our hospitals and patient care, rather than being so vague that nobody knows what it means and it achieves nothing. I suspect that the latter analysis is inaccurate and that the Minister will reassure us that such vagueness will enhance the process. As the BMA rightly said, the amendment is probing. We want to find out how the Minister and the Department envisage matters.

As the hon. Members for Oxford, West and Abingdon and for Wyre Forest pointed out, it is important that we monitor what goes on in our hospitals more closely and more effectively, and that we improve the quality of health care. We all rightly recognise that the quality of health care is not simply confined to the quality of patient care that individuals receive, however important that is. It also includes a whole host of other issues, such as cleanliness and the administration and bureaucracy involved in running hospitals.

Hon. Members have mentioned the responsibilities of the NHS under the Health and Safety at Work, etc. Act 1974. I was especially interested in the fact that the BMA said in its briefing, from which the hon. Member for Oxford, West and Abingdon has quoted, that the NHS had a responsibility to ensure the safety of all employees, contractors and members of the public as patients and visitors. The BMA has also said that each NHS trust and primary care trust had a statutory duty to provide an environment that was safe so far as was reasonably practicable, and to use the best practical means to achieve its objectives.

Such issues are especially important in an area such as mine. There was a desperately unfortunate tragedy at Broomfield hospital in my constituency in the summer, when a blockage in an oxygen tube resulted in the death of an 11-year-old boy who went into hospital simply because he had injured his finger in the spokes of his bicycle. Due to his age, the clinical decision was that he needed a general anaesthetic before the damaged finger could be repaired, and that had tragic consequences. In the light of that tragedy—and others,

fortunately not as serious, that regularly occur in the health service—one needs the best monitoring and checking of standards.

It is equally crucial that we use all means available to ensure that our hospitals are as clean as possible. The number of patients who become infected as a result of the conditions in hospital is a serious problem. The National Audit Office recently identified the fact that, as a result of failures of cleanliness in the NHS, around one in 11 hospital patients at any time has an infection caught in hospital. That is apparently equivalent to at least 100,000 infections a year. The old, the young and those who undergo invasive procedures are the most vulnerable.

Most people would find it incredible that, when they go into hospital to be treated for and hopefully cured of the medical condition from which they suffer, they might pick up an infection that compounds the problem and proves fatal in some cases. In my youth, we were brought up to think that hospitals were not only warm but spotlessly clean. It is sad that those standards have not been maintained in recent years. The problem is serious. The amendment would strengthen the powers of inspection and the duties placed on bodies within the NHS to seek to improve and enhance standards and quality of care. In some areas, those standards have deteriorated so much that they are a serious scandal.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

With the narrowness of the Government's extension of the definition of health care, focusing on the environment in which services are provided might mean that a hospital is found liable for failures if that environment is grubby. I recently asked a parliamentary question that revealed that the cost of repair and maintenance backlogs throughout health authorities and hospitals in England and Wales was £52 billion. Even the best manager will not be able to conjure up that sort of funding to ensure that the environment in which services are provided look adequate, let alone function adequately.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The hon. Gentleman makes an interesting and important point. Without getting sidetracked, I must say that it will be interesting to hear the Minister's reply, given the views and concerns that have been expressed. I hope that the Minister will be able to reassure us that amendment No. 160 is unnecessary because enough provisions exist in existing legislation and in the Bill to overcome the concerns and fears that hon. Members have expressed. If that were so, I would be delighted.

Similarly, I hope that the Minister will give a better explanation of what he and the parliamentary draftsmen mean by ''environment'' in the context of the clause. I hope that, however vague the wording may seem to us non-lawyers, it is suitably widespread and all-embracing to fulfil the functions that we hope for from the clause.

Photo of Andrew Murrison Andrew Murrison Conservative, Westbury

National health service hospitals are potentially very hazardous places; indeed, that is true of all hospitals and medical facilities. My hon. Friend the Member for West Chelmsford (Mr. Burns) referred to the cosy image of

health services, but by and large the environment is not sparklingly clean, and violence is often visited on health practitioners. There are also biohazards, and we have recently heard a lot about prions in relation to surgical instruments. Radiation hazards are also a problem for patients and practitioners, and we have heard about the problem of violence in accident and emergency departments. In short, hospitals are hazardous places.

We know that the Health and Safety Executive is under-resourced and overstretched, and although it attempts to exert its inspection function, it is not equipped for a specialised task that needs independent and expert overseeing. The Patients Association report that was published last month, and to which the hon. Member for Wyre Forest referred, is the most telling document that I have seen in relation to those matters. We should give some attention to the report, which is a compilation of reports from a variety of authorities, including the Infection Control Nurses Association, the Institute of Sterile Services Management and the National Association of Theatre Nurses. The report takes the form of a survey of 300 members of those associations.

The survey stated:

''Almost a third of respondents . . . said that they did not think that the CE mark guaranteed instrument sterility.''

That is a serious finding. The report also stated that

''one-fifth of respondents do not currently have an infection control policy in place relating to decontamination issues.''

That is extremely worrying.

''Only just over half of respondents (56 per cent.) said that their hospital had a single-use policy committee in place, despite this being a suggestion from the Department of Health.''

The survey is worrying, and the Bill presents a good opportunity for the Government to embed health and safety and infection control, which are both aspects of quality, in the national health service in a way that is not happening at present.

To return to my original premise, we need to start thinking of hospitals as hazardous places. The Health and Safety Executive is used to dealing largely with factories. The industry that we are considering is, one might say, a factory with a multitude of fairly unregulated processes. It is not a production line and cannot be well regulated. Many unexpected events are built in to the activities of clinicians in hospitals; that makes things hazardous. That is why we need to attend particularly to health and safety and, of course, infection control.

I support the amendment, and particularly the attempt to embed health and safety and infection control in the national health service at this seminal time of change.

Photo of Richard Taylor Richard Taylor Independent, Wyre Forest 11:00 am, 4th December 2001

I am grateful for a second bite of the cherry, Mr. Hurst. I shall be brief.

The Royal College of Nursing has raised several issues about quality that have not been mentioned yet, the first of which is nutrition. There have been reports

recently, sadly, of elderly patients not receiving the correct food, or enough of it, in hospitals. Secondly, privacy and dignity are always matters of concern. Any hon. Members who have been in hospital recently may have been asked whether they would like to be called by their Christian name or a title. I have spoken to elderly ladies who have been greatly bothered when junior nurses called them by their Christian names. That is a small matter, but it is a matter of dignity, which comes under the heading of quality.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

This has been a good debate, and I take it to have been a constructive attempt to get to the bottom of the provisions. It may help if I explain the intention of clause 11, as I think that there was some confusion about it on the part of the hon. Member for Oxford, West and Abingdon.

In simple terms, clause 11 is intended to widen the definition of health care in section 18 of the Health Act 1999 to include, in broad terms, the patient environment. The clause supports the expanding role that we envisage for the Commission for Health Improvement. If the Bill becomes law, the commission will be able to examine the wider patient environment.

Several hon. Members spoke about what is meant, for our purposes, by the word ''environment''. It is important that discussion of the quality of care given by hospitals—NHS providers and others—should not be confined to issues of clinical care. As the hon. Member for Wyre Forest pointed out, with practical emphasis, quality goes much wider and deeper than that. We simply want to allow the commission to conduct a wider range of inspections based on the expanded definition of the duty of quality.

We envisage ''environment'' covering, for the purpose of the clause—I am not giving an exhaustive list, but suggesting our thinking—the cleanliness of hospital wards, which would clearly not be covered by the current definition of health care; the cleanliness of waiting areas and other parts of the hospital; and the quality of the food given to patients. The hon. Member for Wyre Forest noted the importance of food, in his remarks about nutrition. Many aspects of the environment in which NHS care is given are relevant. The clause would establish a broader view of quality.

The hon. Member for Oxford, West and Abingdon wanted to know whether the Commission for Health Improvement would be able to consider the quality of commissioning. It can already do that. The commission can certainly examine the quality of commissioning by NHS bodies in reviewing arrangements for improving and monitoring the quality of NHS care under section 20(1)(b) of the Health Act 1999.

Hon. Members made important points about cross-infection and the importance of maintaining a safe, sterile environment in hospitals.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Will the Minister repeat his reference to the Health Act 1999?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I referred to section 20(1)(b).

The issue of cross-infection is important. I am sure that hon. Members will be conscious of the action that we have taken to bring about improvements in that respect. That includes issuing, in November 1999, national standards for hospital-acquired infection. Those standards are being reviewed by the Department, with the help of interested professional groups. I know that the chief medical officer is working on those issues. The Department of Health commissioned evidence-based guidelines for preventing hospital infection and those were published in January as a supplement to the Journal of Hospital Infection. The guidelines cover general principles for preventing infection in hospital, and for the prevention of infections associated with specific clinical procedures.

Hon. Members may know that all acute NHS trusts must, as of April this year, participate in the national surveillance of hospital-acquired infection. Data from that exercise will be available from April next year. That is the first stage in developing a comprehensive NHS surveillance service. One of the problems has been the lack of consistent definitions and data about methicillin-resistant staphylococcus aureus and other acquired infections. We are obviously anxious to ensure that the necessary information is obtained to allow us to make progress.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

When the Minister referred to section 20(1)(b), I thought that he meant section 21(b). Section 20(1)(b) refers to

''the function of conducting reviews of, and making reports on, arrangements by Primary Care Trusts or NHS trusts for the purpose of monitoring and improving the quality of health care for which they have responsibility''.

No specific mention is made of commissioning or, indeed, the Department of Health policies on which those commissioning policies must be based.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The commission is able, under section 20(1)(b) to examine the quality of the commissioning process. We are in no doubt about that, and neither is the commission. It is perfectly proper for the commission to focus on that, if it chooses.

We need to focus our concern on the amendment, and I hope that what I have said about health and safety legislation and infection control measures—with which the hon. Gentleman's amendment No. 160 deals—makes matters clear. We consider that section 18 of the Health Act 1999, once amended under the Bill, would enable those issues to be taken fully into account. NHS bodies are already required to comply with health and safety legislation, and the service is obliged to follow extensive departmental guidance on infection control measures; a matter that the Commission for Health Improvement can pursue. In view of all that, the amendment would have no practical consequence, as it would provide for exactly what is happening.

The hon. Member for Oxford, West and Abingdon raised an important issue that is not covered by the amendment, although he suggested that he might want to return to it later; perhaps on Report. He said that the Commission for Health Improvement should have a duty to inspect the quality of decisions made in the

Department of Health in the process of forming policy. We must be clear; that is our job. It should not be given to someone else. It is the role of Parliament and the job of Members in this place to hold Ministers to account for their decisions.

The hon. Gentleman raises a fair point about there being one standard for Ministers and one for the NHS, but he is confusing two separate issues. Ministers must be properly accountable to this place for the quality not only of their decisions, but of the care available to our constituents. In turn, we have a responsibility to put in place a range of measures designed specifically to improve quality of care. That is why we now have arrangements to set national standards through the national service framework. It is why we have the Commission for Health Improvement—it has been given an expanded role in the Bill to go into every corner of the NHS and consider the quality of care and the patient environment—and the National Institute for Clinical Excellence, which provides clear guidance to the service about the availability of new drugs and treatments.

Such arrangements are precisely the right ones for Ministers to put in place. Ultimately, the accountability for decisions is inappropriate for the commission. It should rest with Members of Parliament in this place.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I am grateful to the Minister for the considered and thoughtful way in which he is responding, and I accept his point, to an extent. However, I shall give an example of my concern about Department of Health guidance. If the CHI has the power to consider commissioning policies that might be based on a direction from the Department that says, ''Thou shalt commission to ensure maximum waiting times that shall not be exceeded,'' can it take a view on whether that is a sensible, quality-based, patient-centred approach?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

In a sense, some of the hon. Gentleman's concerns may be the subject of a fuller debate on clause 14, which entrusts to the commission the responsibility for publishing an annual report on the state of the NHS.

The hon. Gentleman made a point about the role of the commission, which clearly will comment on the quality of patient care, in the widest sense of that definition. Through these measures, the commission is being given greater independence from the Department, an important step that contradicts the hon. Gentleman's obsessive theory about micro-management of the NHS. The debate has been full, and we have been over the course on this issue many times.

We should return to clause 11 or we will find ourselves in some trouble. It provides an important extension of the duty of quality, which I accept has the deliberate intention of expanding the remit of the commission to the consideration of patient quality. That has to be good for our constituents. We all know that we are as likely to hear complaints about hospital

food, cleanliness, general tidiness and civility—the hon. Member for Wyre Forest mentioned the last of those—as we are complaints about the quality of care.

If we start from the proposition that the commission is the right repository of the relevant functions, the right set of structures are in place to drive up the quality of care in the NHS, given that the commission is at arm's length from the Government, has the fullest remit that we can construct for it and is consistent with established lines of accountability, under which Ministers and their decisions are accountable to the House.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I congratulate the Government on making the Commission for Health Improvement more independent, and for recognising that that was the correct conclusion for the Kennedy report to recommend. However, I want to return to my specific point. Under the Bill or the existing powers, will the commission have the ability to judge whether the commissioning of services to provide maximum waiting times as an end-point is good for quality of care? Will it be able to comment on such policies? That is an example; I would not want to appear obsessed.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

We have to consider the subject in a slightly broader context. Inspection of the national health service is not a role only for the Commission for Health Improvement. For example, value-for-money issues are the remit of the Audit Commission, and I know only too well that that commission's writ runs freely across the value-for-money agenda of the NHS. Indeed, the commission has done so recently in relation to the issues raised by the hon. Gentleman, such as clinical priorities and setting reasonable targets to reduce waiting.

I, my colleagues in the Government and, I hope, my hon. Friends believe that our constituents' most important concern about the NHS is the length of time that they have to wait. We are travelling in absolutely the right general direction to so organise the services provided and funded by the NHS that we can reduce that time. I believe that it is possible to do that without distorting clinical priorities. We make it clear in guidance to the service that care should ultimately be determined according to clinical priority; indeed, that is the first sentence of the guidance. It is not the job of Ministers, nor should it ever be, to decide which patients are treated first, or last. That is the job of clinicians, as we have always tried to spell out.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health) 11:15 pm, 4th December 2001

The Minister is being a little naive in coming out with that pious point. He knows as well as anyone that under the discredited waiting list initiative of the previous Parliament, clinicians and hospital managers were under such pressure to meet the politically motivated number deadlines that clinical decisions were grossly distorted. That was done to ensure that Ministers, including the Prime Minister, were not embarrassed by a failure to meet promised targets.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman will not be surprised that I disagree with every word of what he said. He is wrong. It does not serve the quality of our debate for the hon. Gentleman to pretend that his Government were not interested in doing the same. We should not forget that the Conservative party set the original maximum waiting time of 18 months for treatment in the national health service in England. He cannot now pretend that his Government were not fundamentally concerned with that matter.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

We were talking about times, not about numbers.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman must follow the logic of that conclusion. I know the view of the hon. Member for Oxford, West and Abingdon, which could also be the view of the hon. Gentleman; we may yet find out. Perhaps the hon. Member for Oxford, West and Abingdon believes that even setting a maximum waiting time could distort clinical priority.—[Interruption.] That is his view. I wonder if that might be the view of the hon. Member for West Chelmsford, whose party set the original waiting times target.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The initiative of the last Parliament, which was based on numbers, distorted clinical priorities. However, I have sympathy with the Minister when he says that all of us—apart from the Liberal Democrats, it would seem—want people to wait less. I believe that having maximum times and then reducing them will improve and enhance health care for our constituents.

Photo of Mr Alan Hurst Mr Alan Hurst Labour, Braintree

Order. I am sure that hon. Members will be mindful not to stray too far from the amendment.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I must apologise, Mr. Hurst; I lured the hon. Gentleman into that. I generally give way when it suits me, and he does the same. I have given way when it did not suit me, and I have had to bear the consequences. However, we all make mistakes.

The amendments are unnecessary because they would have no practical consequence. I have explained that the issues are already subject to inspection and review. The amendments have served the purpose of winkling out a wider sense of what we mean by ''the environment''. I have tried to give practical examples of what that might mean, but it would have been a mistake to attempt to produce an exhaustive list.

The hon. Member for Wyre Forest was right that we need some laxity in the definition. That suits our purpose. However, we want also to broaden the concept of health care under section 18 of the 1999 Act—that is obvious from the Bill—so that the Commission for Health Improvement, in its inspection and monitoring role, can look at the issues, which are important to patients. I have tried to respond positively to the hon. Gentleman's points, but I am unable to accept his amendments.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I am grateful that the Minister gave some response to amendment No. 160, which relates to the quality of the environment. I am disappointed that he did not address human resources policies, which I

included in my introduction. The quality of such policies impacts indirectly—and directly—on patient care. I am not clear whether the Commission for Health Improvement has a remit to consider the quality of human resources policies and occupational health within the NHS. Will the Minister respond?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I am sorry. I assumed that the hon. Gentleman knew that the Commission for Health Improvement already has that responsibility and can look at those issues.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I am grateful. Perhaps I shall be able to see whether it does so in due course. I have spoken informally to the hon. Member for Wyre Forest and we would be happy to withdraw amendment No. 160.

The hon. Member for Wyre Forest expressed some sympathy towards amendment No. 161, which is tabled in my name. I am not convinced that the Government have addressed the issue. I am conscious that we should not stray too far from the amendment. The fundamental test posed by the amendment is whether the Commission for Health Improvement—which is the quality body, as opposed to the value-for-money body, which is the Audit Commission—has the ability to look at the impact on the quality of health care of policies that commissioners and providers are directed to follow by the Department of Health.

The decisions of Ministers should be accountable to this place in so far as they impact or might impact on the quality of health care. The expert body charged with investigations and reviews on quality should be entitled to give a view. In holding Ministers to account, the House should be entitled to reports and reviews from expert groups looking at those issues.

The Minister says that we have charged that a Department of Health policy of maximum waiting times distorts clinical priorities. That dismisses the distortion of clinical priorities that are not concerned with quality. The policy has a huge impact on quality if the most clinically urgent patients have to wait for more managerially, politically, directionally or policy-driven urgent patients, who may be less clinically urgent, who are subject to maximum waiting times. That is why our party has changed its view on maximum waiting times; we regret that the Labour and Conservative parties have not done so.

If the Minister will not give us a clear indication that the Commission for Health Improvement can look at those broad policy directions and the directions to commissioners and providers from the Department of Health, we will certainly have to revisit this issue. I accept that the phrasing of the amendment does not raise that issue, but amendments can be tabled that would clearly place that power with the Commission for Health Improvement. Today we have heard the Government say, ''No, the Commission for Health Improvement does not have the power to criticise what we do where it impacts on the quality of care and the functions of primary care trusts and NHS trusts, which are going to be inspected by the commission; nor do the Government want it to.'' That is a failure in terms of quality.

The terms of the Kennedy report were clear; for example, waiting list policies in the early 1990s were partly responsible for the problems at Bristol; they were ultimately problems of quality. The failure to follow the spirit of the Kennedy report is that the Commission for Health Improvement will have no remit even to look at the Department of Health's policy, rather than at its decisions per se.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman prayed the Kennedy report in aid, but Professor Kennedy did not make those particular recommendations.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I read the Kennedy report with great interest. It cited the waiting list policies—the professor described them as policies ''of 10 years ago'', but they are still with us—as a cause of quality failures. The waiting times target is just one example of Government policy; I do not want the debate to be solely about that. However, when waiting times are decreasing, more and more patients will be considered urgent in terms of waiting list management and will be able to jump the queue at the expense of clinically urgent patients. Kennedy was clear about the need for expert quality checks. Hon. Members may think that they are experts, but they are not always in command of the detail. Expert quality checks on the possible detrimental impact of Government policy on the quality of provision, whether it is intentional or unintentional, are necessary.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I agree with the hon. Gentleman's comments on Professor Kennedy's report. Professor Kennedy welcomed the Government's measures for improving quality. However, the report, which the hon. Gentleman cited in aid of his arguments, did not recommend giving to the Commission for Health Improvement the power that the hon. Gentleman says it should have.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Professor Kennedy did not recommend against giving the Commission for Health Improvement the power that I recommend, either. [Hon. Members: Oh!] It is true that the professor did not specifically recommend that the commission should be given such a power. However, I am sure that we could enter into an interesting correspondence with the professor and his colleagues about whether they think that the Government should have carte blanche to implement policies that may run counter to the patient's best interests, simply because the policies conform to those of the politician. That would apply whichever party was in government, and it is an important power.

I do not intend to divide the Committee on the amendment, but I hope that, after consulting outside bodies, we will be able to return to the matter later. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I do not want to detain the Committee for long, but I have an important point to raise with the Minister. The clause is about enhancing the quality of

care and the definition of the duty of care. I was reassured by the Minister, who seemed to suggest that the vagueness of the term ''environment'' was for the common good. I should be interested to hear the Minister's comments on the points raised by the Royal National Institute for the Blind about the care and treatment of blind and partially sighted people in the NHS. As the Minister will be aware, there is great concern among the blind and partially sighted that the health service fails to understand their predicament and introduce the appropriate measures to help them.

Surveys have revealed the extent of the failure of most trusts and health authorities to provide information accessible to blind and partially sighted people and other people with disabilities. The RNIB's recent survey shows that only 4 per cent. of test results are made available in large print. Only 2 per cent. of test results are provided in Braille or by tape. Information about treatments and medical conditions is made available in alternative formats by fewer than half of NHS trusts. Some 86 per cent. of blind and partially sighted patients in eye clinics receive appointment letters in normal-sized print—a format that most find difficult, or even impossible, to read. It would not take much to tackle those sensitive issues, and I hope that the clause will lead to an improvement if and when the Bill becomes law.

The absence from many eye hospitals of trained workers to provide those facing a diagnosis of sight loss with emotional support and information is also of huge concern to the RNIB and its members. We are all fortunate enough to understand that sight is the sense that the vast majority of people most fear losing. When individuals confront that unfortunate possibility, they experience considerable fear, stress and distress. It is important that staff who provide health care have the means to help people through an especially difficult and emotional time. Practice should reflect that in other sectors of the health care system, which deal with highly distressing and emotional conditions by providing back-up support when patients are diagnosed and throughout their treatment.

All too often, those who suffer from conditions such as blindness and partial sightedness are forgotten. Sighted people tend to take it for granted that everyone is like them and to push the concerns of others to the back of the queue, as shown by the experiences in the surveys that I cited. I hope that the clause and the activities of the Commission for Health Improvement will help not only blind and partially sighted patients but patients in other forgotten areas of the health service, where fit and able-bodied individuals in the medical profession and outside it tend to forget the needs of others.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health) 11:30 am, 4th December 2001

I do not intend to go into further detail about clause 11. I hope that I spelled out the issues a few minutes ago. The hon. Gentleman raised the

important issue of access to and around NHS sites for people with a disability. He gave the example of people who are blind. I strongly agree with his sentiments.

Given the extension of the definition of health care to the patient environment, the issues that the hon. Gentleman raised will fall well and truly within what we are trying to achieve. Issues such as providing signage sites and ensuring that blind and other disabled people have proper information to help them to get around sites fall four-square within the definition of the patient environment that we seek to add to clause 18. The hon. Gentleman made a fair point, and the commission will want to consider it.

Question put and agreed to.

Clause 11 ordered to stand part of the Bill.