To recap, the reason we have tabled the amendments is not semantics, but real concern that there needs to be clear and strong duties for the Secretary of State and, I remind Members, the national quality board and the commissioning consortia to improve quality.
My final point relates to what the Minister said about education, training and strategic health authorities. I am well aware that the Government are consulting on the proposed changes to education and training. My concern is that SHAs will be abolished under clause 28 before we know what is to happen in education and training. As that is so important to quality, I urge the Minister to be clear about the implications.
The hon. Lady rightly raises an important subject. We all want to ensure that the highest standards of education and training are maintained and that, where need be, standards are improved. As she rightly says, consultation is ongoing. I assure her that the matter will be resolved before the SHAs are abolished, because we do not want any hiatus whatsoever.
Division number 7 - 10 yes, 12 no
I know that members of the Committee are keen to make progress, so I shall be swifter in speaking to the amendment than to the previous group.
New section 1A(3) of the National Health Service Act 2006, inserted by clause 2, lists three outcomes that the Secretary of State should seek to deliver when having a view and having regard to securing continuous improvements in quality: the effectiveness of services, the safety of services and the quality of patient experience. Effectiveness, safety and patient experience are crucial elements of a high-quality service, but they are not the whole story. Amendment 38 would more clearly define the factors that make up a high-quality service.
Members of the Committee will recall that several witnesses who gave evidence last week emphasised how difficult it is define and measure quality. My right hon. Friend the Member for Rother Valley rightly asked Stephen Thornton of the Health Foundation, Jennifer Dixon of the Nuffield Trust and Julian Le Grand of the London School of Economics,
“what evidence do we have…that quality is something that can be measured, something we can put faith in, as opposed to a target, and something that is going to improve services?”
The responses to that question are important when considering clause 2 and the amendment. Stephen Thornton replied:
“As everyone knows, quality in health service delivery is notoriously difficult to get your head around and to define.”
He referred to standardised mortality ratios. Surely whether some is dead or alive is clear, but in fact, the point emphasised by Nigel Edwards was that it is difficult to get from those standardised mortality ratios a clear understanding of whether, for example, the issue is the case mix of a particular hospital. If a hospital deals with very difficult cases, its standard mortality ratio will be much higher. Dr Jennifer Dixon said that
“quality is not very observable”, and Julian Le Grand, who, as I am sure Government Members know, is in many ways a champion of the Government’s reforms, said that
“it is so difficult to measure quality. To some extent, we have to rely upon inferring improvements in quality from changes in other areas.”––[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 22-23, Q47.]
We need to look at inputs and processes as well as outcomes. That is rightly acknowledged in the Government’s outcomes framework, which says that there is no pure outcomes-alone approach that we can measure all quality on. I am not going to repeat the arguments about why it is important to define quality, but I believe that the provision would benefit from greater specificity and clarity.
Members of the Committee will be aware that a huge amount of work has been done in this country and internationally on the different elements that make up a high-quality service. The most groundbreaking work was done 10 years ago by the Institute of Medicine in the United States. Its report, “Crossing the Quality Chasm”, began the efforts to improve quality internationally and in this country. The Nuffield Trust report, “The Quest for Quality”, built on that report, and has been influential in shaping thinking, including that reflected in Ara Darzi’s report. Both reports identify six key areas that go to make up quality health services.
First, the reports specify safety, which the clause already includes, saying that care should avoid injuries to patients from the care that is intended to help them. The second element is effectiveness—in health care that usually centres around the need for services to be based on scientific knowledge, so that all who could benefit from them do, and to refrain from providing care from which patients are not likely to benefit.
The third element of quality is to do with care being patient-centred. I am sure that some people will again think that that is semantics. Patient experience is vital to measuring the quality of care, but a patient’s experience is not the only thing that makes care patient-centred. It is also about whether services are tailored to meet individual needs, whether they include the views and concerns of family members, and so on. Patient-centredness is a much better way of expressing those things.
The fourth element is that services should be timely. I am not going to open up a huge debate about waiting time targets and whether they are politically motivated; suffice it to say that the timeliness of services is vital to their quality. There have been big debates about the outcomes of cancer care and whether this country does worse than others. In fact, it is on the very first set of diagnoses that we often fall behind. Timeliness is vital not only in clinical care, but because patients want it—at the top of their list of concerns and priorities is the wish for care to be timely.
The fifth element of quality care—I am surprised that it has not been specified by a Government who are rightly concerned with spending—is the concern that services should be efficient and avoid waste, not only waste through bureaucracy but the waste of equipment, supplies, ideas and energy.
The sixth element of quality is that care should be equitable. It should not vary in quality because of a personal characteristic such as gender, ethnicity, geographic location and socio-economic status. I am sure that we discuss equality and the duty to promote it at greater length under the next clause. Although the new section 1A(3) that clause 2 would insert into the 2006 Act attempts to set out the key features of quality, I firmly believe that it does not go far or deep enough.
A health care system that made improvements in those six key areas would be far better at meeting patients’ needs. If quality is really at the heart of the Government’s plans for the NHS, clause 2 should spell that out in greater detail. The clause says only that safety, effectiveness and patient experience are key to quality. I think that we should go much further, and amendment 40 would achieve that broader and clearer definition.
I understand the hon. Lady’s argument. She made several good points and the additional four aspects of services—that they should be patient-centred, timely, efficient and equitable—are all extremely valid. I would add two or three others; they arise from my experience at Stafford, but I think that all right hon. and hon. Members will be aware of them. I have in mind the importance of care, respect and dignity—particularly respect and dignity.
Reports this week have revealed many cases from around the country of insufficient respect and dignity for elderly patients. Although I have a lot of sympathy with the points made by the hon. Lady, and acknowledge that the wording of the Bill could perhaps be improved if I could think of the correct word—I cannot—the phrase “quality of experience” includes those softer aspects such as respect and dignity that are not included in the harder, more measurable outcomes that she has set out in the amendment. I believe that Bill’s wording encompasses more of what we want to see in quality of care, even though I understand her reasons for proposing the outcomes listed in her amendment, which I think are important and need to be taken on board by anyone involved in the health service. I am sure that Ministers are doing that.
Amendment 38 would reword and extend the definition of quality. In a way, this debate is linked to the one we had on the previous group of amendments and it picks up on the concern expressed by the hon. Member for Kingston upon Hull East, who before lunch accused the Government of not defining quality or outcomes in the Bill. It is quite clear that early in the Bill—on page 2, in fact—we have done so.
What is interesting, and the reason why I welcome the conversion of the hon. Member for Leicester West and her party, is that Lord Darzi was desperate for the previous Government to define quality and outcomes in primary legislation, but that was resisted by the Labour Government. In one way, we are all taking a giant step forward because we—certainly on the Government side of the Committee—recognise the need to put down a comprehensive definition, so that no one can doubt our commitment to improving and enhancing quality and to ensuring that we, with everyone else in the health service, work in that ongoing endeavour.
The duty to seek improvements in quality sits at the very centre of the Bill and the definition of quality used is the one that was agreed and embraced by both clinicians and the public during the next stage review of the NHS. I accept that Opposition Members are seeking to improve the Bill, but I fear that the amendment would do little to bring clarity to the meaning of quality. In fact, it would make extremely unhelpful distinctions. I know that that they are not doing that deliberately, but there is always the law of unintended consequences. If the service is timely, it has to be delivered safely, effectively and in a way that improves the patient experience—it cannot be otherwise. Our definition of quality does not distort clinical priorities but supports our work on the outcomes framework. That is why our definition is the accepted one. It works, and it has the bonus of being recognised by both clinicians and the previous Government.
The three domains of quality—patient safety, patient experience and effectiveness—were identified following a review that was led by 2,000 front-line clinicians and other local health and social care staff, involving thousands more staff, patients and members of the public. Opposition Members will no doubt remember that. Given that the review was published in 2008, I suspect that the hon. Lady not only remembers it, but may well have been involved in the work leading to the publication of the review, as she had the distinction of being a special adviser to Patricia Hewitt in the Department of Health until the change of regime in June 2007. As she probably knows, the review concluded:
“If quality is to be at the heart of everything we do, it must be understood from the perspective of patients. Patients pay regard both to clinical outcomes and their experience of the service. They understand that not all treatments are perfect, but they do not accept that the organisation of their care should put them at risk.
For these reasons, the review has found that for the NHS, quality should include the following aspects.”
It went on to name them as safety, experience and effectiveness—precisely what we have put in the Bill. Because the wording is all-embracing in many ways, it should go a long way to reassuring my hon. Friend the Member for Stafford, who made some extremely valid points about the patient experience and how patients feel about their treatment by the NHS. Extending and rewording the definition of quality would only add confusion to a principle that is understood, accepted and owned within the NHS.
For those reasons, I believe the changes proposed in the amendment are wholly unnecessary. The issues raised are of course important, but the Bill already places a duty on the Secretary of State to reduce inequalities, as well as duties on the NHS commissioning board and commissioning consortia to reduce inequalities, to promote patient involvement and choice, and to exercise their functions effectively, efficiently and economically. The duty to seek to improve quality would need to be considered alongside those other duties, although I find it inconceivable that there could be quality alongside inequality, inefficiency or a service that did not take into consideration the needs of its users. The Royal College of Physicians picked up on that point in its response to the consultation on the NHS outcomes framework, acknowledging that health care that is not safe could not be described as efficient, effective, or sustainable.
The definition of quality is comprehensive and clinically owned. The amendment adds nothing. I ask my hon. Friends to vote against the amendment if the hon. Lady is not prepared to withdraw it. While she reflects, let me say that we are united with the previous Labour Government on the definition of quality and outcomes that we have chosen to put in the Bill.
The hon. Lady has not quite understood my point. I was saying that Lord Darzi wanted the previous Government to put a definition in legislation, but they were not prepared to do so.
Mr Hood, I am sure you want us to focus on the amendments, which is exactly what I will do.
I want to make two other points. The hon. Member for Stafford rightly raised the issue of respect and dignity. I am sure we could go around the houses about the meaning of patient-centred care and the patient experience and so on. I simply want to put on record that I absolutely support him in wanting to achieve that goal.
My third and final point is to put on record for Government Members that quality is difficult to define, and outcomes are difficult to define. We had a brief debate about politically driven targets. I believe that the previous Government’s targets were always about improving quality and outcomes for patients, but there are different ways to get those outcomes. Sometimes we have to measure what is called inputs, such as the time spent waiting for treatment, because the ultimate outcomes are often difficult to measure. I therefore respectfully urge hon. Members not to think that defining quality or outcomes is simple; it is a difficult process. The definition has to be as broad as possible if we want to improve patient care. On that point, I would like to press the amendment to a Division.
Division number 8 - 10 yes, 13 no
The amendment provides that when Secretary of State is discharging his or her duty to act with a view to continuously improve quality, he or she must consult local people before any significant changes are made to their health services. The Committee has been given clear evidence, and it has been the experience of the NHS over the past 10 years, that achieving a step change in quality, particularly of hospital services and care, will require significant changes to the way services are provided. We know that, for many aspects of specialist care, the chances of patients surviving and doing so with fewer disabilities are greater in specialist centres—I refer to services such as stroke and trauma care and children’s heart surgery, with which I am closely involved. Changes to services at regional level will also be extremely important if the NHS is to meet the efficiency challenge set by David Nicholson, chief executive of the NHS.
A couple of witnesses last week mentioned stroke care in London, which was also raised on Second Reading by the hon. Member for Ealing Central and Acton (Angie Bray). I shall go into that in a little detail to explain what we are seeking to achieve through the amendment. As some hon. Members will know, NHS London, which is the strategic health authority for the capital, went through a controversial reorganisation of stroke care in which eight hyper-acute stroke units were established. That was very controversial at the time, but in just five months those specialist centres have more than tripled the number of patients receiving clot-busting drugs to the highest rate of any large city in the world. It is estimated that that will save 400 lives a year, as well as significantly reduce the disabilities of people who survive a stroke.
As I said, that reorganisation was controversial, but the strategic health authority worked hard to involve patients and the public, as well as clinicians, to achieve those service improvements. I do not want to go beyond the scope of the amendment, but when we get to the provision abolishing strategic health authorities later in the Bill, people will rightly ask how those big regional-level service changes will occur if there is no longer any kind of regional tier in the NHS.
As witnesses have said to the Committee, commissioning consortia could take on such a role if they work together across larger areas. However, witnesses, including Stephen Thornton, said that the Health Foundation has done a lot of research into the issue, with initiatives that have involved GPs in commissioning. That research shows that GPs tend to be better at making changes in out-of-hospital care—community health services and so on—rather than at the hospital level.
We also need to remember that commissioning consortia will not hold contracts with providers until April 2013. Strategic decisions that can improve the quality of care should be being made now, but they are being delayed because people are uncertain of what the reorganisation will mean.
I turn back to the amendment. If we are going to have a duty to improve quality continually—whether that relates to the Secretary of State, the national commissioning board or GP consortia—that will inevitably mean changes to services. Sometimes there will be very significant changes to services, such as the one I described in stroke care in London. Those big changes must involve patients and the public, as well as clinicians.
I have, perhaps wrongly, anticipated the point that will be made against the amendment. I know that further on in the Bill we will discuss the duty to involve the public and patients in more detail, but I hope that the Committee will see why including a duty for public consultation should also be identified early on, up front and at the top of the Bill, where this very important duty to improve quality is contained.
Thank you, Mr Hood. That is very helpful. On the issue of quality and the amendment that we are discussing, the Minister was right to say that the next stage review was the next stage on from where the previous Government had the national health service, to bring in a better measurement of quality.
I asked the Minister whether he had received any feedback from the pilot scheme that was taking place in the north-west. That pilot scheme was based on a United States health provider called Premier—a not-for-profit provider—and considered in great detail how we could measure better quality in our system, as opposed to the quantity that we have been good at measuring for many years. I want to ask the Secretary of State—sorry, the Minister of State, although he may have some ambition—whether he can help me in relation to the clause and, in particular, subsection (4), which states:
This will be crucially important if we are to advance a best practice in the NHS. Indeed, in the evidence we took last week, both the chief executive of the NHS and the Secretary of State spoke about improving quality by the use of National Institute for Health and Clinical Excellence guidelines.
In clause 218 (5) the Bill says that
“A quality standard… must be endorsed by the relevant commissioner”.
I assume by that that the commissioner—whether it is a GP consortia or a national commissioner endorsed by the national board—will have to endorse the quality standard. That is my reading of it. I ask the Minister how that relates to clause 4, on duty as to promoting autonomy, which says that persons
“exercising functions in relation to the health service or providing services for its purposes is free to exercise those functions or provide those services in that manner that it considers most appropriate”.
So the Secretary of State has to take regard to it, and it must be endorsed by the relevant commissioners, but clause 4 tells us that commissioners do not have to endorse it—
“A quality standard… must be endorsed by the relevant commissioner”, and how that relates to clause 4 of this Bill, that says commissioners have autonomy—there is a great contradiction in that. I may not have to debate anything on clause 4 if the Minister can tell the Committee what this means.
I will be very brief on amendment 40 that the hon. Member for Leicester West put forward. I listened very carefully and with great respect to what she said, particularly on the issues surrounding stroke care. My observation is that—certainly in the case of Enfield—there was not actually any consultation about the proposed changes to stroke care. This came about because the acute hospital chose not to apply to be considered and GPs were not consulted. That is the situation we are coming from, and it is worth registering that the extensive local democracy and accountability that appear later in the Bill will address the issue. I support local engagement but there is a wealth of clauses that address that—I was going to list them but frankly I do not think there is time.
I am aware that there are time pressures so I will try to be disciplined and confine my remarks to the wording in amendment 40. I speak in support of this amendment, which essentially seeks to give some additional responsibilities to the Secretary of State in respect of responsibilities on consultation. As the Bill stands, the duties of the Secretary of State, if not entirely conferred or devolved onto subordinate bodies, could be weakened. Clause 2, subsection (1) says that the Secretary of State must act
“with a view to securing continuous improvement in the quality of services provided to individuals” and indeed
This includes his public health functions, those functions the Secretary of State exercises in relation to the NHS and its commissioning board, and the GP commissioning consortia. The amendment would add a significant but fairly simple function that Members could support irrespective of party, especially given the remarks made by the hon. Member for Enfield North and his fellow Government Members on the need for full public consultation about various issues that affect the delivery of local health services.
As we know from our discussions on clause 1, the current duty on the Secretary of State to provide or secure the provision of services for the health service has in effect been removed. Opposition Members are, therefore, genuinely concerned that there might be a democratic deficit, whereby Members of Parliament of all parties are unable to hold the Secretary of State to account on issues related to the health service.
The amendment would strengthen democracy in the NHS, although not by far enough. It would ensure that the Secretary of State consults local communities where significant changes to health services are to take place. The function of the Secretary of State is to act
“with a view to securing continuous improvement in the quality of services provided to individuals”.
So significant changes may well occur that affect services within or across communities.
As clause 2 addresses the Secretary of State's duty to improve the quality of services it seems appropriate that, as part of the Government’s slogan or mantra, “No decision about me, without me”, there should be local involvement in service changes. I understand that we will be moving on to the issue of service providers failing, perhaps due to market conditions, later in our consideration of the Bill. Therefore, I do not intend to address it now, but it might exercise local communities that are considering these issues.
Where there are service changes, perhaps as a consequence of the Secretary of State, or a local authority acting on his behalf, seeking to secure improvements in outcomes, why should there not be a safeguard in place to ensure further accountability? My fear is that some aspects of the Bill will in certain circumstances remove the voice of elected officials such as Members of Parliament and, by default, our constituents. So I would urge Members on both sides of the Committee to support the amendment.
The hon. Member for Leicester West will probably be told by the Minister in a few minutes that the amendment is redundant, which is a common ploy when amendments are moved in Committee. One could argue that the legislation actually provides what the hon. Lady is seeking, it just does not ask the Secretary of State to ensure that it is there. One could also argue that there is something rather odd about asking the Secretary of State to see that the law is enforced, because one assumes that is what the Secretary of State would like to do. The hon. Lady, however, seems to have a point, so I will address what I think is the real nub of the matter.
The amendment is work in progress. If the hon. Lady wishes to move it on Report, it is probably advisable not to press it to a Division now. She is suggesting that there should be a level of consultation on regional services. It is not obvious that the amendment applies exclusively to regionally important services, but one can see why people would want to be consulted on regional services.
The hon. Lady mentioned children’s services. She might be aware that some time ago it was proposed that Alder Hey, which is a significant children’s service in the north-west, would move out of Liverpool. People have a right to be consulted about such things, but it is not clear what rights people currently have if such proposals are made, or what rights they will have under the Bill. Obviously, such matters would not necessarily be dealt with by health and well-being boards.
There is a question about what voice people have when services that might not be distinctly local—they might be bigger than that—but are important to all local people are subject to a reconfiguration proposal of one kind or another. The Alder Hey case is one that leaps to mind.
The amendment does not focus sufficiently precisely on that. It uses words such as “local area” and “significant changes”, which obviously are debatable. What is a local area, and what is a significant change? In dealing with the legislation, we have to bear in mind when we talk about local areas that the concept of area is up for debate as well. At one time, under the primary care trust arrangement, it was possible to talk about a health area and a local authority area, but now the commissioning units will not be area-based, and that problem will go right through this legislation as we try to read through the implications.
The hon. Member for Leicester West has a perfectly valid point. I dare say the Minister will put us at ease in respect of some of the issues that she raised, but we need an explanation from him, in terms of the legislation, of exactly what will happen when services of enormous regional popularity and significance get modified in some way. For example, what will happen if Alder Hey decides in the future to move out of Liverpool and go to Widnes, as it has said it may? What voice will the public have, and how will it be expressed?
My point follows on from the one made by the hon. Member for Southport. In essence, it is a simple point about strategic planning. The amendment seeks to offer an additional safeguard in respect of strategic planning, which is an aspect of the NHS that we feel will be undermined as a result of the changes being made elsewhere in the Bill, notably the abolition of SHAs and PCTs.
The concern we have is that services may be reconfigured, either as a result of changes in demand by GP commissioning consortia determining that they want to change the nature of the services, or the nature of the provision that they can access locally—Sir David Nicholson seemed to suggest in his evidence that that might happen—or supply-side changes, whereby NHS trusts determine that they want to change the nature of the service that they offer, perhaps through merger or reconfiguration in other respects.
Our concern is that the only way in which those potential changes might be held up is if they are deemed by Monitor, the economic regulator, to be in breach of competition law. However, there may be other reasons not related to competition law such as clinical reasons or political, with a small “p”, long-standing views on the part of the local population which lead them to believe that it is important that services be locally held, or that the current configuration ought to be maintained.
The amendment is simply about trying to put in an additional safeguard, and, in keeping with the spirit of localism that the current Government are so keen on in this Bill and elsewhere, it simply seeks to ensure that the Secretary of State observes that and makes sure that local people have a say if the services that they deem to be important to their local population are in jeopardy. For that reason, I support the amendment.
It is a pleasure to serve under your chairmanship, Mr Hood. I was stung into speaking by the Minister’s earlier comments about lawyers and solicitors. As a solicitor, I have to plead guilty. I was originally planning to speak about the amendment, but about the words “significant changes”. I spent many happy hours in my former career talking about what is or is not a significant change, but I see that the word “significant” is used later in the Bill, so I shall not talk about that.
I want to make some brief points about the amendment. I totally understand why the hon. Member for Leicester West proposed it, but it is in the wrong place in the Bill. My hon. Friend the Member for Enfield North spoke about the other duties in respect of public involvement later in the Bill which relate to the national commissioning board and GP commissioning consortia, and I think that that is the right place for patients to be involved in service changes.
The hon. Member for Leicester West spoke about reconfiguration occurring. That was recognised by those who gave evidence last week, and strategic decisions are currently being made. She spoke about heart services. I, too, am a Leicestershire MP and am also concerned about the future of children’s heart services at Glenfield hospital. Speaking as someone who was very involved in the campaign for the Loughborough walk-in centre, which is an essential part of the health service in Loughborough, my concern with the amendment is that it states that
“the Secretary of State must ensure the people…are consulted”.
The trouble is, as the hon. Member for Easington said, that there is a semantic difference between consultation and involvement. I am sure that we will speak about that a lot when we deal with patient and public involvement, but consultation is not involvement—involvement goes wider.
My concern about consultation in this context is that it is very easy for the Secretary of State to say that people must be consulted, but as we have heard today—all power to the Government’s elbow in relation to the dreaded word “forests”—we have heard people, we have listened and we have changed what we are consulting on. We are to be congratulated for listening to what people have said. That is something new and refreshing in politics in this country.
Finally, the hon. Member for Pontypridd talked about localism. I do not think that the Secretary of State has a place in localism; the whole point about localism is that services are delivered and decisions are taken closer to people. That is why the patient and public involvement parts of the Bill will deal with the concerns of the hon. Member for Leicester West. We will discuss those further when we get to the relevant clauses.
My hon. Friend the Member for Loughborough has covered most of what I wanted to say. I just stress the importance of going into some detail about public involvement and consultation later in our deliberations. There are some questions about what precisely public involvement and consultation means. Looking ahead, I see that public involvement can refer to being provided with information, and that alone. That, I believe, will not be sufficient. I rest my remarks there. I will not support the amendment, but the discussion will be important later, along the lines that my hon. Friend has pointed out.
The amendment, as has become abundantly clear during the debate, would require the Secretary of State to ensure that local people were consulted before significant changes were made to their health services. We fully support the involvement of local people in shaping their local health and social care services; that is why we have put forward proposals to enhance significantly the role of councils and local authorities in relation to health services and to increase their local democratic legitimacy in health.
We want far more local involvement and for the voices of local people to be fully considered. I do not want to stray beyond the bounds of this narrow amendment into the whole area of reconfigurations, Mr Hood, unless you allow me to, because I know we will discuss it in great detail during our discussion of subsequent clauses.
Mr Hood, I am very grateful for that ruling. I was hoping that you were going to say that, so that I would not get any trouble from Opposition Members.
The Government have done a number of things since last May and my hon. Friend the Member for Loughborough touched on one of them. When the Secretary of State was concerned that not enough consideration was being given to the views of local people and local clinicians with regard to reconfigurations, he strengthened the criteria substantially on any reconfigurations that had to go through, ensuring that when a consultation process is happening, those criteria are fully met before a proposal advances further.
To keep within your ruling, Mr Hood, I will stop there on that narrow point so that I do not explain the full procedures of reconfigurations in great detail. We will deal with those later. However, before coming back to the hon. Member for Leicester West’s overarching points, I will pick up one or two points raised by the right hon. Member for Rother Valley. First, he reiterated his point from an earlier debate about the north-west pilot scheme and what has been learned from it. I can tell the right hon. Gentleman that the North West Strategic Health Authority responded to the Department of Health’s consultation on the outcomes framework, and the Department is working with them to share best practice and learning as we continue work to develop the outcomes framework. I hope that that helps to clarify the situation.
The right hon. Gentleman’s other point was about the identity of the commissioner. In that context, the commissioner is either the Secretary of State or the board, but it could be both. In that context the commissioner is either the Secretary of State or the board, but it could be both. NICE provides a quality standard when asked to do so—on matters of public health or social care if asked by the Secretary of State, and on the NHS if asked by the NHS board—but both can ask for a care pathway. The standard is set when the Secretary of State or the board endorses it, which is right, as they are accountable to the service and NICE is not. I hope that that goes some way to helping the right hon. Member for Rother Valley.
On the more complicated and slightly distracting amendment to clause 4, I hope that the right hon. Gentleman will forgive me; I shall respond to him, but I would rather do so on clause 4, as I do not want to fall foul of you, Mr Hood, and wrongly expand our debate when we are dealing with a relatively narrow amendment to clause 2. I hope that the right hon. Gentleman appreciates that.
I give the right hon. Gentleman the assurance, provided we do not canter too quickly towards clause 4, that by the time we reach it there will be a great deal of clarification that I hope will explain the situation and reassure him.
A specific question was asked by the hon. Member for Leicester West, who wanted to know how regional changes will happen without strategic health authorities, and whether clusters of consortia can manage. I shall explain the first point. NHS commissioning boards will consult on specialist services. If the proposal covers a number of local authority areas, the commissioning board will consult all the relevant local authorities—as she would expect. If appropriate, the local authorities can establish a joint scrutiny function to consider the proposals.
That is very helpful, but can we be clear about it? Why consult the local authorities if the collective view is that they wish to go a certain way? Would the board be bound by that decision?
Okay. In that case, the local authorities could write to the Secretary of State, asking him to refer the matter to the independent reconfiguration panel. I believe that I am right, but if not I shall let the Committee know as soon as possible.
I accept that this is a detailed point. I do not have a problem with it, but I want to be clear. What I am getting at is whether the mechanism is in place. It does not seem to be. I know that the Minister needs clarification on the matter, but he seems to be saying that if a proposal goes out—it is not necessarily a review—even if all the local authorities in the region decide that they want to go another way they cannot overrule what the board has said.
I do not need clarification. I now fully understand the point being made by the hon. Gentleman. If the board makes a recommendation, and if, after consideration, the relevant local authorities do not like it, they will have the power to write to the Secretary of State to ask for the matter to be referred to the IRP. [ Interruption. ] Let us not complicate it; that is the system. If the local authorities do not like the board’s proposal, they will have the opportunity to send it to the Secretary of State, asking him to refer it to the IRP. To all intents and purposes, that is what happens now. I hope that I have clarified the matter for the shadow Minister.
Will the Minister also clarify whether, in those circumstances, the board will be under obligation to consult in the first place? That would certainly be good practice and ideal, but is there a statutory requirement for it to do so when a significant change occurs in the regional services?
Yes, there certainly is. The changes are coming, which may lead to some of the need for clarification, because of the establishment and the role of the board. There will be consultations with the affected local communities, local clinicians and, more importantly, the local authorities. The shadow Minister may like to hear this, because it is quite important. That is, however, in the context of designated services. He might want to reflect on that.
Following that diversion towards later parts of the Bill—we will be coming to reconfigurations in great detail later—the reason that I am not desperately happy with the amendment is that it would duplicate the existing duties on NHS commissioners and providers to consult patients and the public when considering changes to services under section 242 of the 2006 Act. We are amending those duties to apply them to the new architecture, including GP commissioners and the commissioning board.
I am sure that Opposition Members will agree that that is absolutely the right thing to do, because with reconfiguration of services at whatever level—whether designated services in the case of the NHS commissioning board, local service provision through providers or something consortia-driven—there must be local involvement and the views of local communities must be taken into consideration.
The proposal for duplicating section 242 of the 2006 Act is in addition to our proposed changes to section 244 of the 2006 Act, which will enable us to retain existing duties to consult with respect to local authority scrutiny on proposals for significant service reconfigurations of designated services and to extend, for the first time, the regulation-making powers to enable scrutiny of all providers of NHS services, including private and voluntary sector providers. I hope that putting that on the record will help the hon. Member for Halton, because he perked up when I mentioned the whole question of designated services. I am talking about regional reconfigurations of services.
Taken together, the current duties and proposed modifications in clause 175 already ensure that there will continue to be legal duties to consult local people on proposals for substantial service reconfiguration. To accept the amendment would be to add to the duties unnecessarily, and I urge the hon. Member for Leicester West to withdraw it. If she will not, I urge my hon. Friends to join me in rejecting the amendment. Although there will not be a clause stand part debate, I hope that hon. Members agree that the clause has had full scrutiny through the debates on the amendments.
The hon. Member for Loughborough has rightly said that some decisions about big changes to services are taking place, such as to children’s heart surgery. Those are the responsibility of the national specialist commissioning board, so it has not been affected by the re-organisation. My point was that there are some decisions, both at local and regional level—particularly about the much-needed changes to trauma services that I was involved with when I worked at the ambulance service—being put on hold because they are tricky and they are difficult. I am concerned about that with regard to patient outcomes.
The point about regional-level decisions is important. Indeed, the chief executive of the NHS, in his evidence—not to this Committee, but to the Public Accounts Committee and the Health Committee—has been pushed many times to say that they are looking at whether there should be some kind of regional outpost of the national commissioning board. He, at least, recognises that there are going to be challenges with GP commissioning groups coming together to make a really big decision on issues such as the future of trauma services. So, we will come back to the issue of a regional tier, to improve quality and effectiveness, later on in the Bill.
I would like to return to a point made by the Minister. I do not want to stray, but it is important, because the Minister made it in his closing comments. At the moment, if local authority health scrutiny committees do not like a re-organisation, they refer it to the Secretary of State, and the Secretary of State refers it to the independent reconfiguration panel. I am not clear how what the Government propose is any different. We will come back to that point, but the Secretary of State has said that the proposals on patient and public involvement and local democratic scrutiny will transform patient and public involvement. The Minister has just said that the process will be exactly the same.
We will go into that in far greater detail, but briefly, so that the hon. Lady understands, there will be differences in reconfigurations at the local level that have been driven by providers or consortia. There will be a far greater involvement of local government, including the full council of the lead local authority voting on the views put forward by their scrutiny committees, in what shape or form it does. The structures and the procedures are more or less the same, except for a greater increase in the involvement of local authorities. The crucial thing that has changed already, which my hon. Friend the Member for Loughborough mentioned, is the change in the criteria, on 20 May 2010, that strengthened the rights and powers of members of the public and local clinicians in the consultation process, and having a check system to ensure that those criteria are adhered to during a consultation process.
The Minister may not know now, but may want to come back to me on that. Under those so-called strengthened criteria, would he like to tell Members how many of the proposals have still gone through, or how many have actually been stopped? Under the so-called strengthened criteria, how many proposals have actually been changed, or stopped, as a result?
As the hon. Lady will be aware, there are a number of consultations being carried out at the moment. A number were carried out in the second half of last year, and they are still at different parts of the process. Off the top of my head, one has been referred by my right hon. Friend the Secretary of State to the IRP. I cannot, off the top of my head, think of any others at the moment. The process is still ongoing, because, as the hon. Lady will understand, the consultation and the rest of the process are quite lengthy, relatively speaking.
I thank the Minister for that response. I shall just make the point that the so-called strengthened criteria by the Secretary of State are in fact the criteria that many services have used. It would be interesting if the Minister set before the Committee, when we come to the relevant part of the Bill, all the issues that have been rejudged under those criteria and say whether any have been stopped as a result. I am not yet convinced—we will come on to this point—that any of the changes on public scrutiny and accountability will make a difference if, in the end, the local authority still refers it to the Secretary of State, who refers it to the IRP.
I believe the debate has shown the strength of feeling among Labour Members, and equally among Government Members, who passionately believe, as do we, that greater patient and public involvement is needed. I welcome the comments of my hon. Friend the Member for Pontypridd, and of the hon. Members for Enfield North and for Loughborough. I would particularly like to thank the hon. Member for Southport, who made some very good points about the amendment. He understood that the purpose of the amendment was designed to look at strategic services at regional level, and he made some good points about how it could be improved. I will not press the amendment, but I will bring it back for consideration on Report, to see whether it can be improved and strengthened, based on the helpful comments made by Members on both sides of this Committee. I beg to ask leave to withdraw the amendment.