Clause 51 - Annual reviews

Health and Social Care(Community Health and Standards) Bill – in a Public Bill Committee on 10th June 2003.

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Amendment proposed [this day]: No. 31, in

clause 51, page 18, line 5, leave out

'and approved by the Secretary of State'.—[Chris Grayling.]

Question again proposed, That the amendment be made.

Photo of Mr Win Griffiths Mr Win Griffiths Labour, Bridgend 2:30 pm, 10th June 2003

I remind the Committee that with this we are discussing the following:

Amendment No. 360, in

clause 51, page 18, line 6, leave out 'and approved'.

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

The Commission for Healthcare Audit and Inspection will develop and propose the criteria for performance ratings. It will use its professional judgment to devise and develop a better performance rating system with constantly improving criteria. The Government accept that we are only two years into an important journey and we want CHAI to continue that development process. My right hon. Friend the Secretary of State's only interest in this area is to be assured that that process reflects priorities that he has rightly set for the health service in the interests of all patient concerns. That must be right.

I did not think that the settlement was controversial until I heard some of the comments made today. The health service, which was founded by a Labour Government, has been accountable to Parliament through the Secretary of State in this place for more than 50 years. I am surprised, therefore, to hear arguments to take away the Secretary of State's attempt to have some nexus or relationship with those criteria as they are developed.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

But does not the Under-Secretary realise that it is precisely because so many health care professionals say that they are held back by undue interference from the centre that Opposition Members seek to reduce the influence of the centre?

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

No. Health care professionals say that they want to see investment going into the NHS and they are worried about proposals to cut that investment. As a result of my responsibility for

emergency services, for example, I know that they are pleased to see a Government prioritise emergency care and not regard it as the Cinderella service that it was considered before. Health care professionals want innovation and the spread of best practice, and that is being achieved through the Modernisation Agency and other things. They accept the need to drive up performance and to have a tough new inspectorate.

We are the Government who seek to take that forward, so I do not accept what the hon. Gentleman has to say. Independent inspection equals CHAI using its judgment in assessing NHS performance, but it must be right that the Government, on behalf of patients and the public as a whole, ensure that the criteria reflect priorities that we have rightly set.

The hon. Gentleman suggests that we are not concerned with health outcomes. I remind him—he should know this—that last year's performance ratings covered health outcomes. I do not know whether he had a look at those ratings. He will understand that mortality is clearly a health outcome, a very important one. Emergency readmissions are a health outcome, as is returning home from treatment. There are eight indicators in all to measure outcomes of clinical treatments. Again, the hon. Gentleman seems confused about performance indicators and whether they confuse health outcomes. For those reasons, and the reasons that I gave previously, it is right and proper that the elected Government are able to determine NHS priorities. CHAI should provide an independent assessment of how well NHS organisations have met those priorities.

Photo of Andrew Murrison Andrew Murrison Conservative, Westbury

I am grateful for the Under-Secretary's catalogue of health outcomes, and they are laudable, but he should accept that those that he cited concern not only the national health service. Some would argue that the NHS is only part of those health outcomes. In particular, mortality is multi-faceted and emergency re-admission also concerns social services. He must be clear about what he means by health outcomes in relation to the NHS.

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

I shall not go into semantics and a wider discussion of the clinical aspects of health outcomes. Clearly, mortality is a health outcome. How the hon. Gentleman seeks to determine and define that is a matter for him. The important point is that there is a range of performance indicators and I was seeking to establish—I hope that I did so—that as well as patient-focused outcomes and a capacity focus to some of the indicators, there are also clinical outcomes.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

The Under-Secretary referred to mortality in relation to health outcomes. Let me tell him a short story about a recent hospital visit, when I was told that an audited activity of general surgeons was the number of amputations they carried out. I should prefer the national health service to achieve a zero figure for the number of amputations carried out, but the saving of a leg, unlike its amputation, would not show up in the figures.

The Under-Secretary should not be distracted by figures that show activity. What matters, as I keep

saying, is whether the NHS makes people better. At the moment, only a small proportion of the measurements have any clinical dimension and that is wrong. We need a system of assessment of our health care system that asks the basic question; is it making people better? We are too tied up with the process and not focused enough on outcomes.

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

Is the hon. Gentleman really suggesting to the 1.2 million people who work in the NHS every day that they are not making people better?

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

What is most extraordinary and demonstrates the challenge that we face in this country is that in a nation with some of the world's finest and most dedicated health care professionals, our system still fails to deliver the quality of health care that is available in other European countries. We should be ashamed of that.

I conclude by referring the Under-Secretary to two comments about the Government's approach that justify our amendment. First, Dr. Gill Morgan of the NHS Confederation said last year:

''The current level of micro-management of the national health service by government is worse than ever before. The Department of Health gets involved in far too much detail, which individual organisations have the capacity to sort out themselves.''

The BMA said:

''Artificial targets imposed on an overstretched service cannot be met without resorting to ingenious massaging of the figures. It does not fool, nor does it help, patients.''

We believe that the time has come for the Secretary of State to take a step back and to trust organisations such as CHAI to do the right job for patients in this country. A clause that includes the phrase

''approved by the Secretary of State''

in relation to the way in which we measure the effectiveness of our health care system is unnecessary and should be struck out of the Bill.

This is a matter that we have pursued throughout our debates on the Bill and we shall seek to return to it at some stage. However, for the moment, I beg to ask leave to withdrawn the amendment.

Amendment, by leave, withdrawn

Amendment made: No. 289, in

clause 51, page 18, line 16, leave out subsection (6).—[Mr. Hutton.]

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

Photo of Mr Jon Owen Jones Mr Jon Owen Jones Labour/Co-operative, Cardiff Central

I am sorry to take up more of the Committee's time, but I did not speak earlier and I want to make some general points about the arguments made against the clause and in support of various amendments.

The Opposition parties have argued against assessing performance, although they say that they oppose assessment of various aspects of performance. In effect, however, they argued against the accountability that the health service should have to the taxpayers, its paymasters, and the spokespersons on behalf of the paymasters; the Government.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

I must make it absolutely clear that we did not argue against performance assessment, but against an artificial and flawed rating system that distorts relationships between hospital institutions and is unjust to those that do good clinical work. That should not happen.

Photo of Mr Jon Owen Jones Mr Jon Owen Jones Labour/Co-operative, Cardiff Central

I am aware that the hon. Gentleman has made that point on various occasions. However, he has also argued generally against performance review. Both Opposition parties have in effect argued that prestigious professional organisations should not be accountable to the taxpayer or to the Government on behalf of the taxpayer. They should be allowed to carry on in their own way, trusting that they have the best interests of the taxpayer at heart without any direct accountability to the taxpayer. Producer groups will promote that argument in any circumstance.

It surprises me that the Conservative party chooses to be the champion of producer interests by saying that the producers are right and should be allowed to get on with the job, given the money; or, under a Conservative Government, given some of the money but with 20 per cent. taken off. In effect, it is saying, ''Let them get on with their work and don't worry your pretty little head about it.'' That system might have some merit if we had another form of accountability. If the health service was in such a good state that it had excess capacity in almost all areas so that its consumers had a great deal of choice about where they went for treatment, accountability could be given directly to them.

Unfortunately, that is not the world in which we live. We live in a world in which the health service has suffered decades of under-investment and has insufficient capacity to offer any realistic choice, except to people who can afford it. That sort of accountability does not exist, so we must have another sort of accountability; a set of indicators of performance that the Government of the day sets out on behalf of the taxpayer, to whom they are accountable. It is not a perfect system. I can agree with arguments against individual types of performance indicators on the grounds that they are distorted, but all too often the Conservatives and the Liberal Democrats argued against the principle of subjecting those esteemed professionals to any form of direct accountability to the taxpayer.

Photo of Gary Streeter Gary Streeter Shadow Minister (Foreign and Commonwealth Affairs) 2:45 pm, 10th June 2003

I am following the hon. Gentleman's argument; it is important to get the balance right. However, he should accept that we in the Opposition recognise the need for some monitoring and supervision of health care in the UK. We all want the same thing; the highest quality outcome. However, does he accept that the current method of assessment can be, and in many cases is, too bureaucratic, intrusive and centralised? The proposals in the Bill would make matters worse. It is that to which we are opposed, because we want the system to be better rather than worse.

Photo of Mr Jon Owen Jones Mr Jon Owen Jones Labour/Co-operative, Cardiff Central

I do not accept that, which is why I am discussing the matter in the clause stand part debate. I am not arguing about any specific performance

indicator. I accept that perverse incentives can be included in any system and I am sure that this system is not perfect. However, all too often, the argument that has been put forward has been against the principle of assessing professional organisations and making them accountable.

I am sure that it is not only the medical outcomes of a particular institution that matter to the taxpayer, but the efficiency with which it achieved those outcomes. It matters if a particular hospital is inefficiently run and is wasting vast amounts of money, or is performing particular operations far less efficiently than another institution. It must be made accountable for that. That is why, earlier in the debate, I expressed more sympathy than most of my colleagues for the idea of extending the role of competition.

However, if accountability cannot be achieved by increasing competition, it must be achieved by introducing a rigorous form of inspection, and performance targets for which people are accountable. That may not be the best form of accountability but, under the circumstances, it is better than saying that we trust the British Medical Association, the General Medical Council and the Royal College of Nursing to perform, and just give them the money. I do not believe that to be an adequate answer to give to the taxpayer.

Photo of Andrew Murrison Andrew Murrison Conservative, Westbury

I have listened carefully to the hon. Gentleman's remarks, and there is much wisdom in what he says. However, does he not agree that we have moved on? What he says would have been true 20 years ago, but it no longer is, because there is much more openness about the results of our hospitals. We briefly discussed the Dr. Foster software and similar examples. The results are there for everyone to see.

Photo of Mr Jon Owen Jones Mr Jon Owen Jones Labour/Co-operative, Cardiff Central

I could not be so sanguine. I was the Health Minister in Wales when we first saw the results of the Bristol scandal on infant deaths. We are only a couple of years on from that, and I could not say that we were in a position to trust the professional organisations to ensure that they alone should be the arbiters of standards and accountability in their professions. I do not believe that to be adequate; the taxpayer and the patient both need a better form of accountability. My colleagues on the Front Bench have not invented a perfect form of accountability, but I would not want to see it thrown away because of some peculiar new-found Conservative trust in producer interest.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health, Shadow Spokesperson (Health)

I shall make a response in this interesting clause stand part debate initiated by the hon. Member for Cardiff, Central (Mr. Jones). I shall quickly recap on the position that I took on behalf of my colleagues this morning. The point that we argued then, which I am recapping on now because of the hon. Gentleman's remarks, was that our amendment would have removed from the Bill an approval by the Secretary of State for the criteria to be drawn up by CHAI. The hon. Gentleman, from his remarks, still seems to think that the indicators are to be drawn up by the Government but, as I understand it, the criteria envisaged in the new system will be conceived—in the context of the standards and of

Government policy—by the commission and then approved by the Secretary of State.

The point that I sought to make to the Committee this morning, which the hon. Gentleman clearly mistook, was to draw a comparison with the Audit Commission and its responsibilities on just the points that he mentioned; the efficiency and effectiveness of the organisations that it audits. The Audit Commission is responsible for making decisions on what performance information it should seek. That is provided for in the Audit Commission Act 1988. In that earlier debate, I expressed my concerns about the way in which performance management in the NHS would be dealt with. That was an indication of why the welcome independence for that commission was not being extended to this commission. I do not think that the hon. Member for Cardiff, Central has done justice to his good points by misrepresenting the points that I put forward this morning.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

I echo some of what the hon. Member for Sutton and Cheam says. Some mutters have come from the Minister of State about effectively providing a justification for the producer side of the NHS. [Interruption.] He is muttering under his breath at this moment.

The truth is that we believe in an independent inspectorate. One part of the complex jigsaw puzzle that will provide real improvements to health care in this country is a genuinely independent inspectorate. Some of the things that the Government have done in establishing CHAI are right. They have gone a step in the right direction, but their good work is being let down by the millstones that are still left hanging around the neck of the new inspectorate, including the fact that it cannot ultimately escape the veto, judgment and insistence of the Secretary of State on the criteria that the Secretary of State chooses, and the fact that it is still tied in to a flawed rating structure.

I accept many of the points that the hon. Member for Cardiff, Central made. We do not want to see measurement and assessment disappear from the NHS. Everyone in the NHS, as in any walk of life, should be subject to some degree of scrutiny over what they are doing. But we happen to think that the current scrutiny is skewed much too much towards process rather than quality of care and work. We would like to address that. The hon. Gentleman will recall that earlier in the debate I used the example of the eight-minute arrival time for ambulances.

Photo of Mr Win Griffiths Mr Win Griffiths Labour, Bridgend

Order. I appreciate that I was not here this morning and did not hear the debate, but there is no need to present the same arguments in the clause stand part debate. Perhaps hon. Members could find some different examples so that we do not just have a re-run of the debate on the amendments.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

That was not actually an example I used this morning, but one to which I referred on a separate occasion. That example makes the point well about the importance of balancing process and clinical. I am much more concerned that the NHS should look at where an ambulance trust succeeds in reaching a patient and reviving them so that they make a recovery, rather than simply at the eight-minute

target time for getting to an incident when a 999 call comes in. I would expect a truly independent CHAI to seek to include such examples in its criteria.

I am anxious about the inevitable pressures of politics; the inevitable pressure of a No. 10 policy unit that needs to be seen to deliver on behalf of its master. There is no doubt that there are too many reports coming out of Whitehall of enthusiasm, to put it kindly, from No. 10 to get things done as quickly as possible, which is leading to a drive for targets that is impeding professionals in their work.

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

The hon. Gentleman said he supports an independent inspectorate. Does he support its forerunner, the CHI?

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

Clearly, CHI has made a valuable contribution but it could be strengthened by having greater independence. None of us would say that the Government did a bad thing in setting up CHI. Governments do good and bad things; the establishment of the commission was a step in the right direction. If CHI were a truly independent body, that would be a step further in the right direction. We are anxious about the retention of ties to Whitehall.

Photo of David Lammy David Lammy Parliamentary Under-Secretary (Department of Health)

Does the hon. Gentleman agree with the CHI's report, about which a press release was issued yesterday, which described how national standards have led to better and more consistent care, and how investment in new and existing premises have made a difference? The chairman said:

''We do not reach a conclusion that everything is rosy in the NHS, but nor do we conclude that it is generally failing. The bottom line is the NHS as a whole is getting better.''

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

What is going wrong in the NHS is that the Government's huge additional investment is not delivering the quantum leap in health care that the country wants.

Photo of Mr Win Griffiths Mr Win Griffiths Labour, Bridgend

Order. The debate is running away from the content of clause 51.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

Thank you, Mr. Griffiths. I was trying to respond to the Under-Secretary, who is hanging on my every word.

I do not doubt the sincerity of the hon. Member for Cardiff, Central, but in return I ask him to accept the Conservative party's desire for as much independence as possible to be given to the new commission. The freer it is from Whitehall, the freer it will be from the Secretary of State's involvement in its work. Thus it will be a genuinely independent scrutineer and watchdog of the performance of the health service, from the work of individual clinicians in hospital units to the work and strategy of the Secretary of State. It can do that job only if it is independent. Too much of the clause, and the Bill, chip away at that independence, and that is not right.

Question put and agreed to.

Clause 51, as amended, ordered to stand part of the Bill.