Clause 8

Health Bill [Lords] – in a Public Bill Committee at on 18 June 2009.

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Duty of providers to publish informtion

Amendment proposed (this day): 159, in clause 8, page 5, line 24, leave out paragraph (c).—(Mike Penning.)

Question again proposed, That the amendment be made.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

With regard to the role of the Care Quality Commission and quality accounts, the commission receives a lot of data that will go into the quality accounts, and it will, of course, check that data. Other data, which it is not the commission’s role to check and oversee, will be put into quality accounts on a local basis. That is the responsibility of the organisation that puts that data in. The data required to be submitted to the CQC, which may well be in excess of the data that are required in the core of the information that has to be in the quality accounts, will be looked at by the CQC. However, I want to make it clear that there may be other things that the trust or another NHS organisation puts in that it will not be the responsibility of the CQC to audit, check or evaluate.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

I thank the Minister for that clarification. The matter was slightly confusing to me earlier. I am still not completely convinced that I understand what the role of Monitor will be within foundation trusts, but perhaps we will consider that as we progress. With that in mind, I am minded to accept the Minister’s assurances. I indicated at the start that this is a probing amendment. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

I beg to move amendment 88, in clause 8, page 5, line 26, after ‘publish’, insert ‘(electronically and in paper form)’.

Photo of Edward O'Hara Edward O'Hara Labour, Knowsley South

With this it will be convenient to discuss the following: amendment 174, in clause 8, page 5, line 28, at end insert—

‘(3A) The regulations may specify that the information relevant to the quality of NHS services is to be published within the annual reports of NHS Trusts and, subject to the direction of the Independent Regulator of NHS Foundation Trusts, within the annual reports of NHS Foundation Trusts.’.

Amendment 100, in clause 8, page 5, line 34, at end insert—

‘( ) In this section to “publish” includes to make available to the public in paper form, and by means of a website.’.

Amendment 157, in clause 9, page 6, line 6, at end insert—

‘( ) In subsection (4) “to make the document available” includes in particular—

(a) to publish electronically and in paper form;

(b) to take reasonable and appropriate steps to ensure that patients and the public are informed of the manner in which they may access the document;

(c) to take reasonable and appropriate steps to make the document readily accessible to patients and the public.’.

Amendment 162, in clause 9, page 6, line 6, at end insert—

‘(4A) In subsection (4) “to make the document available” includes in particular taking reasonable steps to ensure that the document is alternatively available in the appropriate form for any person that may have difficulty accessing an electronic or paper copy.’.

Amendment 160, in clause 9, page 6, line 19, leave out ‘2’ and insert ‘3’.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

Through amendment 88, I want to consider how the accounts are published each year. The Secretary of State can determine the form, content and timetable for publication. If the accounts are to be looked at each year in order to give some confidence about what progress or lack of progress has taken place, there must be some confidence that like is being compared with like as the years go on. I seek clarification on the role of the Secretary of State. The powers are here for him to make these changes, but I wish to know in exactly what circumstances he can do so. The impact assessment acknowledges that there is a risk to patients and that the public might be confused about the relationship between quality accounts, if the information is changed this year. The Government’s impact assessment acknowledges that fact. Will the Minister explain how he will square that circle?

Amendment 174 relates to concerns that people might have about cost and the multitude of publications. When the trusts—especially foundation trusts—publish their end-of-year accounts, they should be able to publish their quality accounts in the same document. That would make it much easier for the public to understand exactly what has been going on within that trust during the year. Of course, a comparison with the quality accounts would be in sight. At the same time, that would establish more of an overseeing role for Monitor in relation to the quality accounts, because foundation trusts would have to submit their end-of-year accounts to Monitor. As I said earlier, these are probing amendments to find out exactly what the Government intend to do with their Bill.

On amendment 100, the impact assessment states that there would be a risk if patients and the public were confused. Amendment 100 would, I hope, establish the exact form in which quality accounts should be published. Not everyone has access to electronic information. I am not being derogatory to the older population of the country, but if I were to ask my grandfather to go on a website and look at some quality accounts, he would wonder what planet I come from. It is important that access to quality accounts is included in the Bill so that everybody, whether they are a stakeholder, patient or Member of Parliament, can see them either electronically or on paper in the form of a written report.

Amendment 157 follows amendment 42 in the other place. Regarding the timetable for the publication of quality accounts, it will not be useful to have them dripping out all through the year from different trusts and parts of the NHS. It would be useful for those accounts to be published together and on time within a month, for example, so that the public can see them. That matter was looked at by the Department of Health’s impact assessment, as the Department was concerned about the myriad publications taking place throughout the year.

Amendment 162 looks at the manner in which the documents are published. The impact assessment stated that there were concerns about possible confusion, and the amendment would address that. Amendment 160 looks at the aims of the Department regarding providers in cases where patients believe that the providers are falling short of the quality that they expect from the NHS. Earlier, the Minister spoke extensively about the top end and looked at how well the NHS is doing. No one praises the NHS and its staff more than me for their professionalism, but mistakes happen, and the amendment would address any shortfall in quality.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Amendments 88, 100, 157, 162 and 160 look at quality accounts and their means of publication, on a website as well as in paper form. Amendment 174 would enable NHS trusts and foundation trusts to combine their quality accounts with their annual reports and accounts.

The Bill requires providers to submit a copy of their quality account to the Department of Health. That is for the explicit purpose of making the quality account available to the public on the NHS Choices website, in addition to its publication by the provider. That will ensure that the public have access to all quality accounts published by providers through a nationally recognised website.

Clause 9 already addresses the manner in which patients and the public may access a copy of a quality account. It is important that we obtain the right balance between ensuring that patients and the public have easy access to quality accounts, without unduly increasing the cost and burden of quality accounts to the NHS. Our impact assessment estimated publication costs of around £180 for every 100 paper copies of a quality account published. These days, a local hospital of a significant size should be able to print off a copy of what is on the website on request.

Providers will need to estimate the number of requests for paper copies of the quality account that they expect to receive, based on a local knowledge of the likely needs of their community. We do not envisage that a record of a quality account will only be available on a website; it must also be available in written form. There will be no pass record, just a paper-based one.

The question was about what has happened over the past three, four or five years and how people will be able to access certain information. That is a valid point, but not one for primary legislation. That issue, along with much of the detail regarding how this will be done, will be addressed in the guidance. We will explain to providers that their reporting will bear greatest credibility if each year’s account bills someone and reports on its predecessors,  so that there is a follow-through in each report. Over time, a narrative arc will build up showing a dynamic improvement story in relation to quality within that NHS organisation. We are discussing with trusts, patient groups and regulators how best we can ensure effective public availability of quality accounts without overburdening the NHS. Regulations and guidance will set out how that can best be achieved. I entirely accept the point made by the hon. Member for Hemel Hempstead that not everybody has access to the internet. We need to ensure that people who do not have access to IT can none the less obtain access to quality accounts, and we intend to make sure that that happens.

As I noted in relation to the earlier amendments to clauses 3 and 5, the NHS routinely provides its documents in formats accessible to people with disabilities, and we intend to do that in future. There is no need for extra legislation on the face of the Bill. As I have said before, the Disability Discrimination Act 1995 already requires public authorities to take reasonable steps to provide disabled persons with an auxiliary aid, where that aid would facilitate receiving any benefits. A further duty is therefore unnecessary.

Although the Bill sets out a basic requirement for the publication of quality accounts, we will supplement that with subsequent guidelines, to which providers will need to have regard when drawing up their quality accounts. The default position of requiring a copy to be sent to the Secretary of State does not preclude our requiring foundation trusts to follow Monitor’s instructions and publish their quality accounts alongside their financial accounts. A parallel arrangement could be put in place for those trusts outside the FT regime. I hope that we can accomplish that laudable ambition as well as many other innovative and exciting ideas for enhancing public accountability. After our current design phase has concluded and we come to draft the guidance and regulations, we will be able to give some detail as to precisely how, and in what form, these quality accounts will be published.

I am sympathetic to the hon. Gentleman’s point about documents being produced at around the same time, so people know when documents are coming out and can access things reasonably simply. The best approach is to consult the various organisations and see whether there are problems that we have not anticipated. The idea that he is putting forward seems to be reasonably good. Let us see what those organisations say as part of the consultation. In due course, we can put what needs to be added into regulations or guidance.

I do not wish to set today’s good ideas in stone. We need to be flexible about what the NHS will look like and how it will behave, be managed and communicate in the future. I would not want to see tightly defined details about reporting methods on the face of the Bill. The hon. Gentleman has indicated that he wants probe how we intend to get that information out. I hope that I have reassured him that the Department is sympathetic to his points but wants to introduce them into the rules in a more appropriate way than placing them on the face of the Bill.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

I thank the Minister for that assurance, and for listening carefully to the arguments on this set of amendments. Perhaps as we progress through the Bill the Minister will be kind enough to indicate when he thinks the guidance from the Department is likely to be  published. As so much of this will not be on the face of the Bill, it is important to do so. With those assurances, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Photo of Mike Penning Mike Penning Shadow Minister (Health) 1:15, 18 June 2009

I beg to move amendment 99, in clause 8, page 5, line 33, at end insert—

‘( ) The Care Quality Commission shall, in a manner which the Secretary of State shall prescribe, review and report on the accuracy and completeness of any information contained in a document published in accordance with subsections (1) and (3).’.

Photo of Edward O'Hara Edward O'Hara Labour, Knowsley South

With this it will be convenient to discuss the following: amendment 120, in clause 9,page 5, line 41, after ‘Authority’, insert ‘or a Local Involvement Network’.

Amendment 121, in clause 9, page 6, line 6, at end insert—

‘(4A) If a patient or member of the public notifies the provider of an error or omission in a document published under that section, the Secretary of State must within 21 days make an amended document available to the public.’.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

With your indulgence, Mr. O’Hara, I will deal with amendment 99, and my hon. Friend the Member for Eddisbury will deal with amendments 120 and 121.

Amendment 99 deals with the whole issue of what exactly the Care Quality Commission is to look at within quality accounts. In the other place, Earl Howe addressed that with amendment 38. I want to press the Minister a little more on what part of the accounts will be validated when they are published. I like referring to the health impact assessment because it is the Government’s document and gives their concerns about the legislation. It says that the public can hold providers to account for the quality of NHS care services and demand action from them when they

“believe that providers are falling short on quality”.

We must therefore have confidence that the accounts are audited by people who have the clout and powers to deal with them.

The Government’s inquiry into the terrible situation in the Mid Staffordshire trust set out the intention to stipulate a legal requirement for the commissioners to validate providers’ quality accounts before they are published. I am sure that the Minister will correct me if I am wrong, but to my knowledge, nothing in the Bill addresses the recommendations of that inquiry. Why is that, given that the Government accepted the inquiry’s findings?

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

The aim of amendments 120 and 121 is to give patients a role in scrutinising quality accounts, by giving first local involvement networks and then the public at large the opportunity to review the information in a trust’s quality account, along with the CQC and SHA. The driving force behind quality accounts should not be limited to the enhancement of performance monitoring by clinical teams and commissioners. The principal motive behind the introduction of the accounts should to improve patient access to information on care.

If patients were given a stake in the information in quality accounts, trusts would have to ensure that the accounts could be understood by the wider audience of patients under their care, not just by commissioners, the Department of Health and clinicians. The Bill should not only enable the Secretary of State to monitor quality, but allow patients to hold the trust to account for the care it provides. In “High Quality Care For All”, Lord Darzi stated:

“We should be seeking to create a more transparent NHS. It may be a complex task, but we should develop acceptable methodologies and then collect and publish information so that patients and their carers can make better informed choices, clinical teams can benchmark, compare and improve their performance and commissioners and providers can agree priorities for improvement.”

If I understand that correctly, one purpose of quality accounts in Lord Darzi’s eyes is to inform the choices of patients. They will facilitate patient choice only if they can be clearly understood by patients. By giving patient representatives early sight of the document and powers to point out errors in the account, trusts will have an incentive to ensure that the accounts can be understood by a non-NHS and non-clinical audience.

In June 2008, the then Secretary of State for Health pledged that easy-to-understand comparative information would be made available online through quality accounts. Surely, if ease of understanding is one of the key characteristics intended for quality accounts, that should be enshrined in primary legislation, with mechanisms to ensure that patients are consulted on the contents of the accounts.

I was struck that the Minister’s response to the first group of amendments on clause 8 invoked the fact that LINks can have an input into what trusts include in quality accounts, because that is not in the Bill either, nor in the explanatory notes. That is the rationale for pushing amendments 120 and 121. They relate to clause 9, but they have been selected in this group for the convenience of the Committee.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I want to clarify exactly what the hon. Gentleman proposes the role of LINks should be. It is clear that quality accounts will have to contain data, which will be provided by the NHS. Those who have data, are able to deal with them and, in effect, own them will be able to intervene to say that the quality accounts are right or wrong. He is proposing a role, as I understand it, for LINks, which do not own data, somehow to intervene. Will they provide data? I am not clear what role he is proposing. For clarification, our proposed role for LINks is to suggest to the NHS organisation what ought to be included in the local quality accounts. That is different.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am grateful to the Minister for that intervention because, as I hasten to explain, the amendments actually relate to clause 9, and we are taking them now for convenience. It might have been clearer if they had been set in the context of clause 9.

The important point about giving a role to a patient representative organisation, such as LINks—where there may be errors or in any form of communication—is that the input test for information is to give the earnest to what Lord Darzi has said about making it patient-friendly. That means data can be readily understood by  patients. There is a danger, which I am sure that he accepts, that if a lot of data—which he claims are sourced in terms of ownership—are put in by people who are highly qualified clinically and used to NHS-speak, they could be very alienating and difficult for lay people to understand. We need to ensure that the information is written and input in such a way as to ensure the ability to communicate at a lay level. That is as important as the raw data that go in, which may be heavily clinically biased.

The essence of the proposal is to get that sense of ownership of the communication standard, as much as the raw data. I hope that that interaction helps to clarify the thrust behind the proposal, which is important because in “High Quality Care for All”, the Government stated:

“For the first time, all organisations will account publicly for the quality of care they provide”.

It is the word publicly that I want to pick up on. Surely, if the aim of quality accounts is to create a public document that conveys the quality of the trust’s services, the public should be involved in reviewing the contents of the document each year—hence my point about the input rather than just the output. The public are the service users; they are most heavily impacted on by the services that a trust provides. I will not rehearse further, as we had a long outing during discussion of the NHS constitution, the role and merit of LINks and the need to enshrine them more explicitly. That was covered in our earlier interactions.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

So the hon. Gentleman is suggesting that LINks’ role—in addition to suggesting what might be in the quality accounts—would be to have an input into how the accounts are presented, so that they can be clearly presented in a way that the public would understand. That is what he is looking for, rather than that LINks would be able to challenge the validity of the data with alternative data that they would provide themselves. Am I correct?

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am grateful to the Minister for trying to understand this carefully. He comes from the right point of view. The previous Secretary of State—and, I believe, the new Secretary of State—mentioned a more patient-centred and delivered NHS. Part of the patient experience will involve not just the objective data—although we would argue that data on improving health care and social care outcomes should always be included—but the subjective data that patients provide about the journey that they have had. It has always been admitted across the House that the patient journey, measured properly and particularly when allied to outcomes, will be both subjective and objective. The danger has been that it will be ridiculous that we could be only subjective—we could not have just what the patient believes; we must have the objective clinical data to make sure. That is the thrust of his proposal.

There should be not only an input to ensure that things are readily understood by those who are not expert data managers, controllers and inputters, but a readily available communication. That would also carry over time the message—to whatever degree is decided—that subjective patient journey and experience data are also important. The account is therefore intended to drive and demonstrate and to be a forcer and an audit. As I  understand it, that would tie in the subjective patients’ experience with the more important thing, which is the ability of patients to understand and accept it. Therefore, there will be a degree of ownership, to take the analogy on face value. I hope that that makes it clear. I will not rehearse the conclusions, and I look forward to see whether the Minister finds some merit in the proposal.

Photo of John Horam John Horam Conservative, Orpington

I am delighted that my hon. Friend the Member for Eddisbury mentioned local involvement networks, which are in danger of being downplayed or overlooked in the context of quality care—even though I fully accept and support what the Government are trying to do. None the less, there is a danger that the local element, which is represented by the local involvement network, is somehow neglected or downplayed, and that would be a great mistake.

For example, in my own area of Bromley, the Minister will know that we have just had the merger of three big hospital trusts, in Bromley, Bexley and Greenwich. That has inevitably meant a lot of centralisation. It is a huge trust, with 4,000, perhaps even 6,000 employees, that extends over a wide area of south London. Inevitably, therefore, the intimate relationship that used to exist between the LINk and its predecessors, Bromley council and the trust—they were all within one borough—was broken and the local element was in danger of being devalued. It is important that we maintain that, and I seek a reassurance from the Minister that that is the intention.

To return to the point made by my hon. Friend, as the Minister said, not only should LINks be involved in looking at what input they make into the information that is provided, but, as my hon. Friend said, the input should be clear. We are all familiar with jargon. Every profession has jargon—Parliament has jargon to the nth degree, so we are all guilty in that respect—but NHS jargon is particularly obscure sometimes, and it takes a long time for people to understand what is being said. Clarity, which is my hon. Friend’s second point, should also be there.

The Minister said that my hon. Friend was suggesting that the validity of data might be challenged by a LINk—yes. Because we are talking about a rather impressionistic course of things, local people may well have a different take on whether a particular indicator is the right one for that profession or speciality, and their view should be taken into account. I agree with the Minister that they will not necessarily have other sources of data, but they may well be able to challenge, out of their personal experience, whether the trust is producing the data in a right way or the right data. Those are the three elements—clarity, being asked to say what people want and looking at whether the data provided by the trust can be challenged. I think that there is a large role for LINks to play, and I hope that the Minister will take that into account and push it down the line, as something that should and will continue to be valuable.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health 1:30, 18 June 2009

Amendment 99 would give the CQC a formal role in auditing a provider’s quality account. Amendment 120 seeks to extend to local involvement networks the role in correcting quality accounts. Similarly, amendment 121 would give a role  to patients and the public to correct those accounts. The function is currently limited to the CQC and strategic health authorities.

Two reasons underlie the original choice. The first is affordability and the second is achievability. We limited the number of correcting agencies to the CQC and SHAs, because the information in question is reported to them for regulatory, registration and contracting reasons. Contractual information is, of course, primarily reported to PCTs, but many providers will have multiple contracts, and we do not want to complicate the relationships. Thus the two agencies—the CQC, which oversees quality standards, and the strategic health authorities, which oversee commissioning and contracting—can cover the whole spectrum of correctable information without overburdening any part of the NHS system. That is our proposed affordable solution.

Those agencies are in a good position to do that, because they have a better overview of the local health care system, which makes the correcting function more achievable. By way of contrast, there is some concern that patients and members of the public do not “own” any of the data involved in producing quality accounts. They are therefore not in a position to fulfil the role envisaged for them in amendment 121, but LINks will have a role in setting out what local people want to see in quality accounts.

The hon. Member for Orpington made the point that people will want to have some ownership of the information that they receive in order to know whether their part of the community is getting a service. They might go to the NHS organisation, such as a local hospital, and say, “What are you doing for this part of Orpington? We would like you to state that in your quality accounts. Remember we are focusing on the issue of quality. How are you seeking to improve the quality of a particular service?” That is the sort of role that LINks can play. Before a quality account is published, and indeed afterwards, people can go to the organisation and say, “It would be better if you had done it this way. Next time, can we make sure that you do? And by the way, you have got a website. Can you not update it?”

So there are ways in which LINks, and indeed other patients’ organisations, could be involved. The other way is the one suggested by the hon. Member for Eddisbury, who said that they could ensure that the presentation of the data is done in a way that is easily accessible for members of the public to use and that allows them to bring forward their views about how presentation could be improved.

I part company with the hon. Member for Eddisbury on the introduction of subjective data from members of the public. There are ways of ensuring that the patient journey, and the quality of that journey, are included in quality data. Indeed, part of the assessment of the quality of a service is how good that patient journey is. My noble Friend Lord Darzi has made it clear that that is part of the assessment. But the way to do that is to ensure that appropriate surveys are carried out and that there is an assessment of the level of complaints and the response to them.

There is a range of ways in which the quality of the patient journey can be examined. There can be evaluations of the quality of cleanliness and the way in which the  organisations have responded to public concerns about that. The public can have an input in ways that do not rely on people saying what their subjective feeling is, or what their personal experience is, and being able to go to the organisation and say, “You have to put in a paragraph now about how I feel about my treatment on x ward on this date.” That is not the way in which we envisage quality accounts proceeding.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

Clause 8(5) gave rise to the thinking on the amendments:

“The Secretary of State may by regulations provide that subsection (1) or (3) does not apply to prescribed bodies, persons or services, or to bodies, persons or services of a prescribed description.”

To include or not include who is consulted is obviously a wide power for the Secretary of State, and there is a danger. Patients will be given a sense of shared ownership, with the ability to understand and scrutinise the data. A full quality account, as the Minister rightly says, must include, crucially, patients’ sense of the quality of care that they receive. Despite the Minister’s very reasonable approach in his answer so far, that, coupled with the Secretary of State’s power, seems to carry with it the possibility of a more whimsical choice of who might or might not appear. For instance, a Secretary of State might say, “I really don’t think we want to hear from homeopathic medicine,” despite the fact that some in the medical profession think it important, and that could become an excluded item. That is what gave rise to the amendments.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Whatever party the Secretary of State comes from, I hope that mere whimsy would not be the criterion by which such things are determined. We have some precedent in terms of quality accounts. Cambridge University Hospitals NHS Foundation Trust has had an early shot at putting together a quality report for 2009-10. I will see whether I can get copies of it for Committee members, because it is an early attempt to put one together.

The aim is to ensure that people have access to the account and that local organisations have some input. Page 12 of the quality report, as the Cambridge trust calls it, states that the Cambridgeshire local involvement network was involved. Such organisations were included in how the document was put together, and they were consulted. I will see whether I can get copies of that document, but it is not necessarily identical to what we envisage quality accounts will eventually become. We will want to consult fully on that; this is just an early shot at seeing what sort of thing could be put together and published. East Anglia and East of England appear to have done a lot of consultation in putting together their documents. We will be considering how local communities were involved in order to learn some lessons from the documents and hopefully to improve them in the future.

Photo of Andrew Turner Andrew Turner Conservative, Isle of Wight

I am worried. The problem is that it is moving away from the ordinary person, the consumer of the health service, to something up at the top. One can imagine something from Cambridge setting out what is right for Cambridgeshire. That is all very well, but the problem is that it will be sorted out by the kind of people who work in the NHS rather than by the consumers. How will the Government ensure that it is the consumer, not the NHS person, who is represented?

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

In a sense, the document gives information from the NHS to the consumer—the patient and members of the public who are potential patients—to give them some idea how their local NHS is operating. The aim is not for the consumer to provide the data, except through recognised ways, but for the NHS to make available information that it has now but that is not readily available to members of the public.

Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

The Minister has said that the NHS has this information now. I have just been reading Lord Darzi’s comments when quality accounts were discussed in the other place. He admits that the way in which pharmacies and other small providers now collect data might not be same and that there might be an additional cost, but that we do not yet know the details. It is clear that, over time, extra information could be added.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I think that the hon. Lady was on the Health Committee this morning. I referred to the fact that a cost would be involved in relation to an acute hospital, for example, and we envisage an additional cost to a trust of about £3,000 in order to provide a report. I also mentioned this morning that dentists and others providing services to the NHS would, after three years, and following a period of consultation, be required to provide a quality account. However, I also mentioned that we are considering whether exemptions would be appropriate in relation to sole providers who might provide services to a very small number of NHS patients and whether, in such circumstances, it would be appropriate to require them to publish a quality account.

The hon. Lady makes a reasonable point, however, and it is one that we have considered already. We want to ensure that quality accounts fulfil a purpose, and do not merely require people to fill in forms for the sake of it. This is about ensuring that the public get the information that they are likely to want. There is not much point in having quality accounts from an organisation, if the public are not interested in knowing the quality of its service because it is so small or de minimis. We need to put this into proportion and ensure that local people get the information that they want.

We shall also ensure that the commissioners are legally required to validate the quality of the quality accounts. The hon. Member for Hemel Hempstead raised this issue. Prior to publication, the commissioners will have to show that they have overseen the documents and are satisfied with its validity. This is not just about providing a whole load of data, but about saying, “This is what we are good at; this is what we are mediocre at; and in both cases, this is where we shall make improvements during the coming period.” It will require the commissioners of the documents to exercise a degree of intervention and policy initiative. They will not simply provide information about the current situation. The purpose of that information is to improve the quality of NHS service delivery.

I do not envisage the CQC having quite the audit role envisaged in amendment 99. It will want to assess the quality of the data that it receives, but it will not be in a position to intervene in every single NHS provider, wherever it is and no matter how small it is. For example, in five years’ time, when all these dental practices are providing quality accounts, should it be the CQC’s role to validate them all? That is not how we envisage it  operating. The CQC has a role in validating the data that it receives, but it is important also that the provider of the data ensures that it is valid.

We need to strike the right balance—I think that we have—with regards to the involvement of local involvement networks in quality accounts. We are not far from the Opposition’s position on LINks. There is a difference of view on the extent to which subjective data ought to be introduced. I am not entirely clear as to how that will be done, but we want the public to be able to view and use the quality of the data in the document in a sensible, straightforward way. We also want the document to avoid unnecessary jargon, although there is always some jargon involved in providing such information. Furthermore, we want the document to enable members of the public to know what is going to be done in their local NHS, as well as the way in which it seeks to improve the quality of what it delivers in the future.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health) 1:45, 18 June 2009

I am grateful to my hon. Friend the Member for Hemel Hempstead for moving the amendment. The Minister listened carefully, but he is obviously still struggling with the idea that any kind of subjective patient information should be a part of the data input process, because he made an analogy that the other data on more professional and detailed clinical measures would be part of the ownership of others in clinical practice. I will not press the amendment to a vote, but I hope that our discussion means that the Minister and his officials will have reflected upon the issue by Report stage.

The Government are quite rightly exploring many areas and, as the Minister has admitted, are trying to move from the former, brutish target regime to a much more sensitive outcome measure regime. It is highly likely that, over time, LINks will become one of the key sources in a number of areas where patient outcome measures will be marshalled, understood and, above all, de-atomised from individual patient experience to a point where we can learn policy lessons from the more subjective parts of the patient journey. We recognise that the great thrust will be the objective test of clinical health care and social care outcomes, but the patient reported outcome measures will inevitably be part of that and will need to be input in order to have a full and—to use a word that was used earlier—holistic approach to an account of the delivery of quality in care in its broadest sense. In his report and reforms, Lord Darzi has urged us to look at care, meaning not just health care or social care, but a total care approach.

It would be disproportionate to press the amendment to a vote, but I hope that, by Report stage, the Minister will have reflected upon whether, in the absence of anything in the Bill, there will be enough expectation, as well as discretion under clause 8(5), to enable marshalled, sensible and almost semi-professional subjective patient reports and outcome measures to be part of the input process, which would help in all care.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

The hon. Gentleman has just stated that LINks and other patient organisations could provide data that are not merely the subjective view of individuals, but are, as he put it, de-atomised in order to provide more reliable data. That certainly would be the  sort of data that organisations might well wish to use in their quality accounts. I do not differ with him greatly on that.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am grateful for that clarification. It may or may not be necessary to take the issue further, but this exchange has given some clarification.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

We have had an interesting discussion, especially about the LINks issue, and I pay tribute to my hon. Friend the Member for Orpington for his thoughtful comments on that. LINks have had a bit of a struggle, to say the least, to get going in certain parts of the country, and, in order to feel confident about them, the public need to feel that they have some clout and rigidity in relation to holding the NHS to account. I also pay tribute to my hon. Friend the Member for Isle of Wight, because it is important that the public have confidence in the provisions under this part of the Bill.

I was slightly concerned that the Minister made no mention of Monitor in his remarks, although I will not push him on the matter. Monitor has a role to play in looking at the accounts, not least if a trust is asking to become a foundation trust. The quality accounts are one thing among others that should be looked at in those circumstances. With that in mind—I have listened carefully to the Minister’s comments—I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

I beg to move amendment 155, in clause 8, page 5, line 33, at end insert—

‘( ) The Secretary of State must undertake appropriate consultation with appropriate bodies listed under, but not limited to, subsections (2) and (3) before requiring them by regulation to publish in respect of each reporting period a document containing prescribed information relevant to the quality of services.’.

The amendment would require the Secretary of State to consult the bodies producing quality accounts prior to the regulations coming into effect. As I said earlier, the two consultations that have taken place cannot be described as full and satisfactory. The first had only 299 responses, of which 11 were from GPs, and clearly a lot of specialist NHS professionals were not consulted. The second consultation had only 39 responses, including 15 from NHS foundation trusts, four from NHS trusts, nine from primary care trusts and one from a strategic health authority. Other important groups responded, but they could not in any way be described as representing the NHS. The amendment would ensure that before the legislation is brought into effect, further consultation across the NHS would take place.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I assure the hon. Member for Hemel Hempstead that we intend to have extensive consultation on the development of quality accounts. We have already had an initial period of consultation. There has been a reasonable level of interest, but nowadays people often wait until the legislation has passed before engaging seriously with it, because then they know it is coming. We want to have an appropriate level of engagement with all the various stakeholders, including organisations such as LINks, on the way in which quality accounts will develop.

I must add that Monitor is the first line of regulation in NHS foundation trusts. It asks trusts to submit an annual plan and their regular reports and then monitors how well they are doing against those plans. Monitor has asked that foundation trusts publish, for example, their quality accounts with their annual reports, as I said. It has played a key role in the design of the quality reports that are being produced by foundation trusts this year. Details are on its website along with seven quality reports recently published by various foundation trusts.

Consultation is needed on the future development of quality accounts, not only for acute trusts—we are reasonably far forward in terms of what they will do—but certainly before we move to the next stage, when we look at GPs, consultants, dentists and other parts of the NHS. We will require quite extensive consultation to ensure that their views on what should be in quality accounts are taken fully on board.

Photo of Mike Penning Mike Penning Shadow Minister (Health)

I thank the Minister for his comments on Monitor. My question was not about what happens when a body becomes a foundation trust—I am very aware of the excellent work and monitoring that takes place after that happens—but about trusts that are trying to become foundation trusts. I asked him to make it clear that quality accounts are taken into consideration by Monitor when it is considering allowing trusts to become foundation trusts.

I accept fully what the Minister said—he has been very open and honest about the amount of consultation he intends to undertake—and 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 Sandra Gidley Sandra Gidley Shadow Health Minister

I shall make a few general comments and I apologise if some of them were covered this morning, when I had to be elsewhere. I hope to use the opportunity, first, to get an assurance from the Minister that the quality accounts will not be used in any league table format. I do not think that that would be helpful in the greater picture, because trusts and hospitals tend to take their eye off the ball and concentrate on what they are being compared with.

Secondly, a slightly wider question is: why are we starting with family care trusts, NHS service trusts, special health authorities and NHS foundation trusts? I understand that it is completely right to wait a while to see how the quality accounts process beds down before incorporating the smaller bodies, but who will performance manage that? Who will ensure that quality accounts are useful? Where do strategic health authorities fit into the picture? Whenever I have written to the Department of Health about a problem with my local PCT, the Department has said, “It is nothing to do with us. You’ve got to go to your SHA, because they are responsible for performance managing.” To be blunt, the quality of performance management by the strategic health authorities has been very variable in the past, although that has improved, thanks to the reorganisation and the fact that there are fewer strategic health authorities.

Then we have the question of the Department itself. The impact assessment says:

“Part of the Quality Account will be specified by the Department of Health and the content will be set out in regulations.”

That is fine. Then it says:

“This part will focus on key Departmental priorities.”

I am not quite clear how we are monitoring the quality of the Department of Health. The assessment continues:

“The purpose of the DH-specified part of the Account is to ensure that patients, the public managers and clinicians have easy access to information on a provider’s performance against key Departmental priorities in a way which allows Account users to compare a provider’s year on year performance and to compare the performance of similar types of provider.”

We are getting into league-table territory there. What I want to home in on is

“easy access to information on a provider’s performance against key Departmental priorities.”

The other day, I was talking to a gentleman who voiced concern about the Department of Health managing the NHS Plus contract. I do not want to go into great detail, but there are quality aspects to the account of which the Department has failed to take note, and a note I have says that there have been no management quality issues on this contract managed by the Department of Health contract management board.

There seems to be no accountability of the Department. For example, the guidelines said that patient groups, with their specific knowledge, should have been involved, but they have not. The contract for the occupational health clinical effectiveness unit—I will follow this up with the Minister later—was placed with the Royal College of Physicians, but two specific quality requirements have not been enforced by the Department,

It seems a little rich for the Department to making trusts jump through hoops of producing quality accounts—although they are a good thing—when the Department itself is not being open and honest about how it is managing quality. Moreover, strategic health authorities, which might have a useful role to play, are being ignored.

Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health 2:00, 18 June 2009

The hon. Member for Romsey raised a number of issues, which I will take one by one.

First, there is no intention to have league tables, but a quality account will set out the various improvements needed in individual NHS organisations. As a result, there will be an ability to make comparisons, particularly across the core set of criteria, as opposed to the local set of quality criteria. That is part of the objective, in the sense that quality accounts are about driving up quality. Organisations will want to look at what other organisations are doing and measure themselves against them, but given the variability and the number of permutations that are possible across the breadth of quality accounts, I do not think that any sort of league table would be possible. I cannot guarantee what the media will do; on today of all days, it is appropriate to say that control over that force of nature does not lie with this House. However, the ability of peer groups to assess the quality of what others do, which exists across medicine now, needs to continue.

Who performance manages the documents? The strategic health authorities do not have a role in drawing up the quality accounts. That is done and has to be validated by the organisation that draws up the accounts. The  SHAs are able, however, to intervene if something in their data contradicts what is in a quality account. They will be able to examine and challenge the validity of the information presented in quality accounts.

The Care Quality Commission has a greater role. It will receive considerable amounts of data, which will form much of the core data that every organisation in that sector of the NHS—acute hospitals for example—has to provide. The CQC will examine those data and will be able to look at a quality account and say whether the data presented are appropriate. There will also be local information for which the CQC does not have data, and its role will not be to intervene in relation to that; that is the responsibility of the provider organisation.

The Department of Health will set out its priorities and seek to determine, as it already does, national policy, with the consent of Parliament. It will also be able to indicate what it wants to see in quality accounts to drive up particular areas of quality. The hon. Lady asks who checks that the Department of Health is providing quality. Well, she does, and so does every other MP in this House. The Public Accounts Committee does—it has produced a number of reports on many aspects of how the Department operates. It has issued its strictures where appropriate, and sometimes where it might not be entirely appropriate, but it is entitled to do that. Select Committees too, such as the Health Committee, have a responsibility for that level of oversight. There is a level of supervision of the Department and it is here.

Question put and agreed to.

Clause 8 accordingly ordered to stand part of the Bill.