National Health Service Reform and Health Care Professions Bill

HL Deb 21 March 2002 vol 632 cc1551-88

House again in Committee.

Clause 11 [Duty of quality]:

Baroness Northover

moved Amendment No. 93: Page 17, line 29, after "quality)" insert— ( ) in subsection (1), after "or there is inserted "the Department of Health"; and The noble Baroness said: This amendment was first proposed by my honourable friend Dr Evan Harris in another place. It seeks to include the Department of Health itself in the inspection process.

The purpose of the amendment is simple. The danger is that CHI will spend its time inspecting the work of hospital and primary care trusts; but the trusts are simply doing what the department is asking of them.

Obviously, the Government must set priorities in the NHS. That is what they are elected to do, and they will be called to account at election time. But quite how their policy towards the health service is implemented depends a great deal on how the department itself operates.

If, as the Government claim, they do indeed manage to de-centralise, and also—as we seek—more proposals are brought directly to Parliament for approval, or if the NHS is put at arm's length from government, the role of the department might not be so critical. However, that is not the case—and will not be the case even if this Bill as drafted completes its passage. Therefore, the amendment explores the idea that it is also of key importance to patient care to see whether the actions of the Department of Health are also in the best interests of patients.

The Audit Commission has a remit over the Department of Health in terms of how resources are spent. So, for example, the Audit Commission has commented adversely on resources used to reduce waiting lists when these did not greatly assist in patient care. It was also argued by the Minister in the other place that CHI could comment on the commissioning procedure. But that is at a stage down the track from the Department of Health.

We in Parliament clearly have a key role to play in bringing the Government to account for actions within the Department of Health. But if it is indeed appropriate for the Audit Commission to assess whether the department is spending its resources wisely, then surely it is also worth considering having expert assessment of whether the Department of Health, in its priorities and procedures for running the health service, is actually acting at all times in the best interests of the patients.

It is often difficult to gain access to that information as parliamentarians. I point to a report in today's Guardian on the Commons Science and Technology Committee, investigating what is happening to resources for cancer. I have raised this matter previously, and sought Written Answers from the Minister last September. My question was: precisely what happens to money earmarked for cancer since so little of it seems to be reaching its intended target—this despite a government fanfare on the matter. The Guardian article quotes Gordon McVie, of Cancer Research UK, as wondering whether the money, has been absorbed like creosote into the fence post of the administration of the health service". Quite so.

The Science and Technology Committee reports the difficulty of getting any information on this matter cut of the Department of Health. Clinicians on the ground dare say little, lest they offend against all the rules barring them from commenting. Surely there is a case for an inspection body having the right and the duty to go into the Department of Health to make its own investigations and recommendations. It might well say that the department had failed in the way that it had dispatched the money to protect it from marauding administrators trying to fill black holes. Or it could conclude that ring-fencing, when there were so many desperate needs in the health service, was inappropriate. Either way, its expert investigation and report would help to inform both parliamentarians—and indeed the electorate—who are supposed to be able to bring the Government to account.

I do not expect that the Minister will consider the amendment to be a very good idea; nor may those advising him. But while we seek ever more transparent and effective scrutiny procedures in the rest of the NHS, and of those working in the health professions, surely the Minister must also give consideration to such scrutiny closer to home. I beg to move.

Earl Howe

I add my support to the amendment. I completely endorse everything that the noble Baroness has said. The odd thing about Section 18 of the Health Act 1999 is the narrowness of its compass. The duty of quality created in that section falls on health authorities, PCTs and NHS trusts. It is expressed as a duty, to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care which it provides to individuals". That section is one of the most important in the Act, yet something big appears to be missing from it. Like the noble Baroness, I am struck by the absence of any duty on the Department of Health or the NHS as a whole to promote quality in healthcare.

The Minister's reply is likely to be that the department as such does not deliver healthcare services. There are two rejoinders to that. One is that, while it may not deliver services at the front line, it is instrumental in providing those services—which is the term used in Section 18. I am thinking in particular of the public health role of the CMO. When we debated public health earlier this week, the Minister made it clear that the CMO was ultimately accountable within the body of the NHS for the effective delivery of the Government's public health policy. It seems strange that only lower down the NHS chain of command should a duty of quality be laid down. I might have expected a government amendment to this Bill creating a duty of quality on the NHS as a whole, including the Department of Health, accompanied by a power for the Secretary of State to devolve or delegate that duty to NHS bodies at the front line.

If the Department of Health has been exempted from the duty of quality because it does not commission healthcare services, the same could be said of strategic health authorities, but I take it that they, as successor bodies to health authorities, will be subject to the duty. Perhaps the Minister could clarify that point.

The second rejoinder to what I suspect the Minister will say is to point to the multitude of powers that will continue to reside with the Secretary of State, notwithstanding the devolutionist flavour of the Bill. Those powers include an ability to intervene directly in the affairs of PCTs, the power to impose targets on the health service, the power to dispense or withhold money according to how well or badly those targets have been met and so on. If there is no duty of quality on the Department of Health, as I read it the centre can legally direct PCTs and trusts in a manner that need take no account of the duty of quality, yet expect PCTs and trusts nevertheless to adhere to that duty. An obvious example springs to mind—the waiting list initiative. If such an initiative obliges PCTs and trusts to override clinical priorities so that those waiting longest, and not necessarily the sickest patients, are treated first, it is very difficult to see how PCTs and trusts can claim, while fulfilling that directive, to be improving the quality of healthcare that they provide.

The noble Baroness has pinpointed an interesting and potentially far-reaching anomaly in the Bill and in the 1999 Act. It will be illuminating to hear what the Minister has to say.

Lord Hunt of Kings Heath

I have been rather surprised by the suggestion that quality is not at the forefront of all the department's thinking in its strategic leadership for the health service. That is why we have set up so many of the bodies that the noble Baroness, Lady Noakes, referred to earlier, such as the National Patient Safety Agency and the Commission for Health Improvement and various other mechanisms. One of the Government's key aims, through the department, has been to improve the overall quality, safety and standard of services to the public.

Section 18 of the 1999 Act came up with the duty of quality to rectify an anomaly that had existed in the NHS for far too long. Although there were financial duties on NHS organisations, before 1999 Act there was no statutory duty on the NHS relating to the quality of the patient care that it provided. That is but one action that we have taken to improve quality generally in the health service. The department has set and implemented an integrated programme of measures to monitor and improve the quality of the healthcare provided by the NHS, as set out in A First Class Service in 1998, strengthened in the NHS Plan in 2000 and taken further still through the recent listening exercise involving patients and the public in healthcare. It is why we also established the quality taskforce in the department, under the co-chairmanship of the Chief Medical Officer and the Chief Nursing Officer. Quality permeates all the department's thinking and policy development. The noble Earl, Lord Howe, has debated waiting lists with me on a number of occasions. He will know that we have made it abundantly clear to the health service that, in meeting waiting list targets, clinical priorities must always come first.

On the duty of quality and the issues that the noble Baroness has raised, surely we need to go back to Section 1 of the 1977 Act, which in large part replicates the original 1946 Act, setting out the key aim of the health service. It states: It is the Secretary of State's duty to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—

1. a) in the physical and mental health of the people of those countries, and
2. b) in the prevention, diagnosis and treatment of illness,

and for that purpose to provide or secure the effective provision of services in accordance with this Act". I emphasise the words "designed to secure improvement in". That is a broad description of what we are seeking to do, which entails within it issues to do with quality and everything else that is important to the development of the National Health Service.

As for Amendment No. 93, the risk seems to be that it would get in the way of the Department of Health's accountability, via Ministers, to Parliament on all aspects of securing healthcare for those who need it. My experience of the past three years is that Department of Health Ministers are very accountable to Parliament. When I think of the number of Parliamentary Questions answered daily, the number of debates in your Lordships' House, the vigour of the Select Committee hearings that I have attended, I am absolutely certain that Parliament has endless opportunities to hold Ministers to account and for Ministers to come to both Houses to explain their own performance.

Although of course I accept that parliamentary scrutiny of a publicly funded NHS is crucially important, I do not believe that the amendment as proposed would help that. I think that, in some ways, it would detract from ministerial accountability to Parliament. Surely our parliamentary democracy must rest on that direct line of accountability.

Baroness Northover

I thank the Minister for that reply, and the noble Earl, Lord Howe, for his very detailed support. The Minister's comments seemed to bear out some of what I was saying. He referred to the original 1946 Act and also to the 1977 Act, and yet, in the 1999 Act, it was felt necessary, despite that previous legislation, to establish a duty of quality. As the noble Earl pointed out, it is very striking that it includes health authorities, primary care trusts and so on, but does not include the Department of Health, which established the duty. It seems a trifle odd that the department should not be included.

Lord Hunt of Kings Heath

The department's overriding responsibility was enshrined in the 1946 Act and confirmed in the 1977 Act. The duty of quality was established for NHS organisations because, as experience has shown, discussions in the boards of NHS organisations revolved primarily around management, finance and human resource issues but only very rarely touched on quality issues. Consequently, the specific duty of quality was introduced. In its reviews of clinical governance, CHI has focused particularly on the degree to which the boards of those NHS organisations have addressed clinical governance and quality issues. That is why NHS organisations were dealt with in that way.

Baroness Northover

I thank the Minister for that comment. I should be very interested to see the agendas within the Department of Health, but I do not suppose that they are available. I also wonder whether they include items contributing to the quality debate.

Lord Hunt of Kings Heath

I assure the noble Baroness that quality and patient safety issues are paramount in the many discussions held on the fourth floor of Richmond House. As I said, the Chief Nursing Officer and the Chief Medical Officer—who are very powerful individuals with very distinguished records on quality and safety—are leading our quality programmes. I can therefore assure the noble Baroness that quality is a full part of all our considerations in developing policy and managing performance in the NHS.

Baroness Northover

I thank the Minister for that reply. I would not in any way wish to detract from what has been done in trying to introduce a duty of quality in other parts of the health service. If anything, as I said, I should like that duty to be extended. I shall read what the Minister had to say. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Northover

moved Amendment No. 94: Page 17, line 31, at end insert "including the provision of accessible information for patients, and monitoring the provisions of health and safety legislation and infection control measures The noble Baroness said: This amendment seeks to ensure the provision of accessible information to patients and also the monitoring of health and safety legislation and infection control measures. All those elements are important to the quality of patient care. We should perhaps have dealt with them in separate amendments, but, if we had, it would have made the night even longer.

Clearly it is vitally important that information is accessible not only to parliamentarians but to patients. As we shall undoubtedly hear when we discuss patient complaints, things often go wrong because information is not available. Not only should patients be physically well treated, but their more general welfare should be addressed. Access to information is a part of that.

Health and safety regulations relate particularly to staff, and it is essential that they are properly addressed and assessed. The BMA has concluded, however, that, despite existing legislation and guidance, health and safety are still not universally guaranteed throughout the NHS. The NHS has a responsibility under the Health and Safety at Work etc. Act 1974, and various other regulations on the management of health and safety, to ensure the safety of all employees, contractors, and members of the public as patients and visitors. Each NHS trust and primary care trust has a statutory duty to provide an environment that is safe, as far as is reasonably practicable", to use "the best practical means" to achieve its objectives, and to use the best available technology not entailing excessive cost". I am rather concerned by those provisos.

As part of its inspection process, CHI would be in a prime position to observe whether premises, equipment, practices and procedures in each trust are sufficient to enable best clinical practice. It seems reasonable, therefore, that the Bill should be amended to ensure that that function is covered by CHI.

Although infection has—as Nightingale made clear—always been an issue, it has become a key one in recent years. However, post-antibiotics, there was certainly an optimism that infection was well and truly under control. That optimism has long since passed. Problems such as new variant CJD have introduced areas of concern. It is clearly essential that infection control is properly monitored. One issue which arose in dealing with the problem of disposable instruments, once it became evident that instruments could be a means of infection, was that many hospitals simply did not know which instruments had been used on whom. However, some did know. Clearly, one of CH l's functions should be to spread and encourage best practice. I beg to move.

Earl Howe

I am delighted, once again, to support the noble Baroness, Lady Northover, in this amendment. In reading Subsection 4 of Section 18 of the 1999 Act—again we are hampered by not having the wording fully in front of us—I cannot help thinking that much hinges on the meaning of the word "services". Healthcare is defined in that subsection as, services for or in connection with the prevention, diagnosis or treatment of illness". The noble Baroness seeks to add to that definition, the provision of accessible information for patients". I should have thought that, on a strict legal interpretation, that was a service, and that that part of the amendment is therefore unnecessary. If the emphasis is on the word "accessible", again, I should have thought that accessibility was bound up with the notion of quality. However, having uttered that caveat, I have much sympathy with the suggestion that those words should be included. It is not so very long ago that patients were expected to accept the treatment they were offered by doctors and be grateful for it. The idea of informing patients about the treatment they were receiving or might receive or about services that they could access was considered somewhat eccentric. So, despite any strict legal interpretations, I am in favour of making this provision explicit, if only as a means of recognising that we are trying to move away from paternalist medicine.

The next part of the amendment has an even stronger claim to our attention. Monitoring the provisions of health and safety legislation and infection control measures does not seem to me to be a service. However, it is an integral part of being a good employer, as the noble Baroness pointed out, and providing public health services in the broadest sense. As we were informed by the Minister on Monday, much of the monitoring function in the public health context will rest with the PCTs. My only faint worry here is that if we pursue the amendment to its logical end there would be a duty on PCTs and trusts to make arrangements to monitor the quality of monitoring. It is perhaps for discussion what we might understand that to mean.

While the duty of quality already extends to monitoring the quality of healthcare, the noble Baroness made a good point in drawing our attention to health and safety requirements—which surely do not constitute healthcare—and measures which might be in place to deliver the public health agenda, which again need not in all cases fall under the heading of healthcare.

9 p.m.

Baroness Masham of Ilton

I support the amendment and, in so doing, ask the Minister who will be in overall charge of infectious control and send out the guidelines to our hospital trusts? With the increase of tuberculosis, it must be a health and safety issue to nurse someone in an open ward. I am sure that the Minister knows of the case of the young girl a few weeks ago who was diagnosed with pneumonia. She had tuberculosis: she was sent home and died. This is an important issue. Such infectious diseases are on the increase.

Can the Minister tell us the position regarding matrons? We were promised matrons. I believe that someone has been appointed in Birmingham. Matrons have much to do with cleanliness, which concerns the importance of the amendment.

Lord Clement-Jones

I rise briefly to strongly support the amendment tabled by my noble friend Lady Northover. I do so firstly because of my connection with Cancer Bacup, which has a strong ethos of provision of information to cancer patients, not only by telephone, which is accessible, but through written printed information available in hospitals. It is important that hospitals ensure that such information is available. That seems to me to be a key function to allay some of the fears cancer patients have about the treatments they are undergoing. My second reason is to point out a number of issues which the Improving Lives coalition has brought to my attention in relation to those who are visually impaired.

There is a clear link between how well health services meet disabled people's requirement for accessible information and the quality of care offered to such groups. Indeed, failing to provide accessible test results or to ensure that patients have timely and accessible information about appointments or information leaflets about their condition can have a potentially devastating impact on the health of visually impaired patients and their ability to manage their own health effectively. It is their belief that the performance of the health service in that area is wholly inadequate. The existing duties under the Disability Discrimination Act to provide information about services in an accessible format do not appear to be biting.

A number of surveys have been carried out. One in 1997 by the RNIB demonstrated that less than half of the health authorities which answered the questionnaire had guidelines for meeting the health information needs of blind and partially-sighted people. An RNIB survey of over 200 visually impaired eye clinic patients found that six in seven people attending ophthalmic patients' outpatients' departments receive their appointment letter only in normal-size print. One in four people had to get someone else to read their appointment letter for them.

The latest research by the RNIB on accessible information should provide a severe jolt to all health service policy makers and practitioners. It found that more than one in five of the total adult population struggle to read labels and instructions on medicines or letters from their doctor. That rises to two in five of those who are 75 or over and to three in four people with sight problems.

The consequences of inaccessible health information can be severe. There are a number of cases of mixing up medication; taking the wrong drugs and missed appointments. Sometimes, patients are in the position of undergoing procedures or operations without accessible information explaining what will happen to them. On the other hand, the provision of accessible health information has been shown to result in more effective and appropriate use of health services, reduced stress, improved recovery of illness and operations and increased compliance with medication and treatment.

I believe that the case for the visually impaired is particularly strong. The health service is not responding adequately to their needs. It should not be left to charities to be responsible for monitoring provision in this area. We should not place the onus on individual disabled people to continually complain and threaten legal action under the DDA. For those reasons, I strongly support the amendment.

Lord Filkin

I agree with the objectives of most of those who have spoken on the amendment. However, I believe we have adequate statutory provisions in place to address them.

The department strongly recognises the importance of provision of accessible information for patients. The noble Earl, Lord Howe, put it clearly: moving away from a paternalistic service which doled out what professionals thought was appropriate to a much more informed dialogue with patients so that they understand what is happening and are able to participate in that process. That clearly is the goal of the health service to which we are strongly committed. We have taken steps to ensure that NHS bodies make such information widely available. We do not for one second imply that we are where we want to be in terms of fully realising that.

On health and safety, we also recognise the importance of the NHS having in place both arrangements for, first, monitoring the provision of health and safety legislation and, secondly, measures for infection control. Enforcement of the provisions of health and safety legislation which are statutory requirements, is already carried out by the Health and Safety Executive in relation to the NHS. CHI is working to develop a memorandum of understanding with the Health and Safety Executive to further cooperation between the two bodies.

On infection control, the NHS Plan implementation programme makes it clear that hospitals must have effective systems in place to prevent and control hospital acquired infections. This is a core requirement underpinning the targets in the NHS Plan and the department has already taken a number of actions to ensure that these systems are in place. The national standards for hospital acquired infection (controls assurance standard) was revised in December 2001.

Hospital infection control guidelines were published in January 2000 and community infection control guidelines are currently under development. The first two quarters' data of the mandatory surveillance of MRSA were published for the department by the Public Health Laboratory Service in February this year as part of the development of a comprehensive National Health Service surveillance service.

The control of healthcare associated infections was recently highlighted in the Chief Medical Officer's strategy for combating infectious diseases, Getting Ahead of the Curve, and an action plan is currently being developed. The noble Baroness, Lady Masham, asked who is in overall charge of infection issues. Clearly the Department of Health has the overall responsibility. On the distressing case of a nurse with TB in an open ward, the chief executive of every hoard in that situation is responsible to his board for achieving the appropriate quality and preventing infection in such circumstances.

The noble Baroness also raised the important issue of what is happening with modern matrons. A considerable number of them are in post. They are highly relevant to the issue of cleanliness and infection control, as the noble Baroness made clear, and there are positive signs that they are having a good effect. The Department of Health also conducts spot checks on cleanliness, which we believe are necessary.

Turning to monitoring and the improvement of infection more generally, Section 18 of the Health Act 1999 places a duty on those National Health Service organisations providing healthcare to individuals to put and keep in place arrangements for the purpose of monitoring and improving the quality of that healthcare.

The extension of the definition of "healthcare' in Section 18, by Clause 11, means that there will be a general duty on National Health Service bodies, pursuant to Section 18, to monitor and improve the quality of the patient environment. That implies a duty to have regard to the availability of information to patients. I concur with the noble Earl, Lord Howe, that services undoubtedly have to incorporate not just the provision of a technical product or service but the totality of the patient relationship that encompasses the dialogue of requests for information and understanding. One cannot deliver good services for any sector without that sort of relationship being in place. By reason of the extension of the definition, CHI will also clearly be able to comment on these matters in its reports, although enforcement of the health and safety legislation will be a matter for the Health and Safety Executive.

The noble Lord, Lord Clement-Jones, raised the extremely important issue of visual impairment. That is an example of the sort of issue on which we would expect and hope patient forums to focus. They would look at the quality of service provision, not just to the public generally but to those who need access to a different form of service from the standard service that is good enough for the vast majority. Those who are visually impaired are four-square within that definition. We very much hope that the patient forums will attend to those issues.

NHS Direct also has some relevance. It is by no means a total panacea, but it clearly helps those who are visually impaired to have access to high quality information and advice. As the Committee knows, the progress so far is not perfect, but the service is extremely highly valued by many members of the public. We want to take it further and make it better, which is of enormous relevance to the visually impaired.

Patient surveys are being undertaken in every acute trust, and we expect them to pick up on some of those issues of whether the particular disadvantages suffered by some people are being adequately met by the current services. As the clause already refers to the environment in which services are delivered in general terms, which includes having regard to the provision of information and any hazards or risks of infection, I suggest that the amendment to Clause 11 is not necessary and should be rejected.

The issue is not one of having more statutory definition, which is in place, but having the persistence, resolution and drive from the department, together with the commitment of managers, to make some of those goals that already have statutory effect commonplace and universal throughout the service.

Baroness Northover

I thank the Minister for that sympathetic reply. I also thank other Members of the Committee who have participated in the debate.

Clearly more needs to be done to make information accessible. I am encouraged by the Minister about the direction in which the Government are heading. It also sounds encouraging that CHI will be doing more regarding health and safety.

One of my concerns about infection control is that there are various other bodies looking at the issue. With these new structures there is a danger that things may become fragmented. I hope very much that the Minister is right that with persistence and resolution the Government will move these matters forward. I shall read in Hansard what the Minister has said. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 11 agreed to.

9.15 p.m.

Baroness Northover

moved Amendment No. 95: After Clause 11, insert the following new clause— "INDEPENDENT HOSPITALS The Secretary of State shall by regulations extend the functions of the Commission for Health Improvement set out in section 20 of the 1999 Act (functions of the commission) to any independent hospital as defined by section 2 of the Care Standards Act 2000 (c. 14) (independent hospitals etc.). The noble Baroness said: Amendment No. 95 seeks to include private hospitals in the same inspection system as the NHS. I declare an indirect interest as my husband, as well as being an NHS surgeon, is also in private practice at the London Clinic and the King Edward VII hospital.

I was astonished when I first discovered that private hospitals were not inspected in the same way as NHS hospitals. That is quite wrong. The case for bringing private acute care within the same inspection system as that for the NHS has long been argued by my noble friend Lord Clement-Jones. I should not be surprised if Members of the Committee thought that they would hear from him on this amendment. The noble Earl, Lord Howe, has also argued this case and the Chamber has approved the proposal. So this issue may be quite familiar to many noble Lords today.

From these Benches we welcomed CHI when it was set up in the Health Act 1999. However, we felt strongly that patients should receive the same high quality care wherever they were treated. Therefore, we felt that it was appropriate for CHI to inspect acute care in private as well as NHS hospitals.

In the Care Standards Bill 2000 we welcomed the regulation and inspection of social care, and private and voluntary healthcare premises. But we argued again that acute care in private hospitals should be inspected to the same level as in NHS hospitals.

Patients really do deserve the best possible protection, whether they are being treated in the NHS or the private sector. I noted earlier with great interest that the Minister, in relation to medical registration and training, stated that there should be the same entry requirements wherever a doctor intended to practise, whether private or NHS. The same principle should apply here.

The Commission for Health Improvement covers independent institutions where NHS patients are treated and private care within NHS hospitals, but not private care within private hospitals. We were concerned that neither of the earlier Bills gave the assurance that a duty of quality identical or similar to that required for the NHS was required for the independent sector. But it is only when things go wrong that people discover that that is so. When one thinks of some of the cases that have come up in recent years, it is clear that those being treated in the private sector thought that they were buying not simply a nice hotel room with its own telephone and TV but the consultant of their choice, backed up by an institution with the highest possible standards.

Many institutions have such high standards, but it remains highly inappropriate for them to be inspected as though they were nursing homes. There are over 200 hospitals in the private sector which comprise approximately 10,000 beds. There are some 800,000 treatments carried out by 17,000 doctors, most of whom also work in the NHS.

As I have mentioned, in the relevant health Bills in 1999 and 2000, noble Lords supported the proposal that independent hospitals should be brought within the scope of the regulations. In the end the point had to be conceded in the face of government opposition in the other place.

We believe that every patient deserves common minimum standards of care. The Government have a responsibility to ensure that minimum standards are maintained and seen to be maintained. We need consistency in those standards and consistency in enforcement.

The Government have argued in the past that the two healthcare systems under which NHS and private hospitals operate are different; that one is a managed system and the other is a regulated system. But inspection is to do with regulation. It must be right that the Government take appropriate measures to protect their citizens within the private sector and for that sector to come within the thorough inspection system that we have now come to expect, and welcome, within the NHS.

In January, Mr Milburn's response to the Kennedy report was that there would be a coming together and better co-ordination of NHS inspection systems; and that the CHI is to be strengthened and made more independent. Now is surely the time, if not before, to ensure that the private acute sector is properly brought within the same kind of inspection system as that which applies to the acute sector of the NHS. I beg to move.

Baroness Noakes

We fully support the intent of the amendment—as with the earlier amendment about merging the function of the National Care Standards Commission and the CHI. In Committee on 18th March, the Minister mentioned, in respect of the Care Standards Act 2000, bringing Section 9 into force".—[Official Report, 18/03/2002; col. 1203.] I understand that that would bring the inspection of independent sector hospitals within the remit of the CHI. What precise effect would that have—and to what extent would it meet the excellent points made by the noble Baroness?

Baroness Masham of Ilton

I, too, support the amendment. Patients can be at risk in a private hospital when they are in single rooms. In an NHS hospital, other patients are around. When a person gets into difficulty and there are no staff around—which often happens when there is a shortage, as there is now—patients help each other. My husband has been treated in NHS hospitals and in a private hospital. In the latter, he got a thrombosis in his leg and was discharged without a proper check-up, which could have been avoided. I feel strongly that minimum standards should apply in all hospitals.

Lord Hunt of Kings Heath

I have great sympathy with the broad thrust of the noble Baroness's arguments but it is a question of timing. The amendment is rather premature, in view of the amount of work that must be undertaken to take forward the rationalisation of inspection agencies at national level to which my right honourable friend the Secretary of State referred following the Bristol inquiry report.

We made provision in the Care Standards Act 2000 for the CHI to exercise functions of the National Care Standards Commission in relation to the independent sector. The noble Baroness kindly reminded me of the debates on that subject. She will recall that, when we enacted the Bill, we considered it right that the regulation of private health care should be different from the arrangements for the independent review of NHS bodies by the CHI.

Life moves on and there have been considerable developments since we debated that point. The Bill gives the CHI a new function of inspection against published standards. That responsibility will extend to services for NHS patients wherever they are treated, including those provided by the independent sector. It is clear from Government action in the past few months that an increasing number of NHS patients are being treated in the independent sector. It is clear also that—particularly during the transitional period, as we try to build capacity in the NHS—we will continue to use the independent sector. While we are clear that private and voluntary health care must remain under a system of regulation or licensing, the time is right for the CHI to inspect independent hospitals on behalf of the National Care Standards Commission.

The noble Baroness, Lady Noakes, reminded me that I made it clear on Monday night that we will bring Section 9 of the 2000 Act into force shortly and make regulations, so that the CHI may exercise the commission's function of inspection in relation to indpendent hospitals.

The noble Baroness, Lady Noakes, asked me to fill in some of the detail. Of course, we are still considering that and it will be contained in the regulations. However, essentially, the regulation of private healthcare institutions remains the responsibility of the National Care Standards Commission. We propose that the inspection function itself should be undertaken by the Commission for Health Improvement, but acting within the ambit of legislation that gives the overall responsibility to the National Care Standards Commission. It is a halfway house, as it were. We are trying to get as much consistency as possible in the inspections process, bearing in mind that the current legislative requirement is for the National Care Standards Commission to have the ultimate responsibility for private hospital regulation.

I said that that is a transitional phase because, as my right honourable friend the Secretary of State made clear, we are seriously considering have to obtain closer working and, over time, organisational integration between CHI, the Social Services Inspectorate, the National Care Standards Commission and the Audit Commission so that health and social care services are subject to common standards, whether they are provided by public, private or voluntary sector organisations.

That is clearly an extensive piece of work to be undertaken during the next few months. That is why it would be premature to legislate in the Bill to bring together CHI and the National Care Standards Commission. As I said, we are bringing Section 9 into operation as a means of having as much consistency as possible between CHI and the National Care Standards Commission. I hope that I have made clear our intended direction of travel. Although I do not recommend that we accept the amendments, I hope that the noble Baroness will accept that we are going in the same direction, but that a considerable amount of work will need to be done.

Lord Clement-Jones

That is about as close to an apology for previous legislation that I have ever heard a Minister give. If the Minister wants to achieve such integration, will not further primary legislation be necessary?

Lord Hunt of Kings Heath

I was simply seeking to suggest to the noble Lord that, since our debates a couple of years ago, life has moved on and there have been developments. The relationship of the National Health Service with the independent sector has evolved. For that reason, it is right to reconsider the issues.

I accept that primary legislation will be required at the end of the journey to integrate national inspection systems against common standards. It would be premature to legislate in the Bill, because much work needs to be undertaken.

Lord Clement-Jones

I have one further question. Will that be before the National Care Standards Commission is even formed and up and running?

Lord Hunt of Kings Heath

That is because we generously allowed such a long lead time to allow the commission to establish its work.

Baroness Northover

I thank the Minister for his reply. We shall obviously share many more late nights here in future. I also thank the noble Baronesses, Lady Noakes, and Lady Masham of Ilton, for their support. I am intrigued and encouraged and shall have to read what the Minister said. To know that he is sympathetic to the amendment is obviously extremely nice. However, he says that it is premature to legislate at this point. Given that we are so busy setting up primary care trusts with all their duties, it strikes me as strange that the amendments should be regarded as premature while we rush ahead in other areas.

9.30 p.m.

Lord Hunt of Kings Heath

In his speech my right honourable friend did not confine himself to the National Care Standards Commission and the Commission for Health Improvement. He also referred specifically to the Audit Commission and the Social Services Inspectorate. The speech followed up our response to the Bristol inquiry.

These are complicated matters that need full consideration. Even if we wanted to wave a magic wand and say, "Yes, we'd love to legislate in this Bill", it would not be possible to bring forward carefully thought-out legislation at this stage.

Baroness Northover

It strikes me as ironic that it is fine to change the structure of the NHS fairly rapidly, which is a complicated thing to do, but in this area, where the lives of individual patients are affected, it is said to be premature to take action on the proper inspection of hospitals. That surprises me.

Lord Hunt of Kings Heath

The proposals in the Bill arise from the NHS Plan and Shifting the Balance of Power. They have been given careful thought and consideration by the Government over a considerable period of time. My right honourable friend's speech only a few weeks ago arose directly from the recommendations of Professor Sir Ian Kennedy in the Bristol inquiry, which reported only a few months ago. That is why it is important that we have time to reflect on the best way to achieve integration between these different bodies.

Baroness Northover

I thank the Minister for that reply. However, I point out that in this Chamber, which may not be the fastest-moving place, a decision was taken in 1999 and 2000 to include private hospitals in the inspection system. It is a shame that it is taking a while.

I am encouraged by the Minister's comments. I hope that when the inspection is extended—it certainly sounds as if it will be—it will cover the whole of the private acute sector and not simply those parts in which the NHS is involved. It is important for citizens as a whole—for all patients—to know that they are safe in the institutions in which they are treated. I look forward to reading the Minister's comments in Hansard. On that basis, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 12 [Further functions of the Commission for Health Improvement]:

Baroness Noakes

moved Amendment No. 96: Page 18, line 11, at end insert— ( ) In subsection (2), at the end of paragraph (b) there is inserted "including co-ordinating visits to general practitioners, Primary Care Trusts or to NHS trusts with other bodies carrying out monitoring or inspections of those premises". The noble Baroness said: The amendment seeks to amend Section 20(2) of the Health Act 1999, which deals with the functions of the Commission for Health Improvement. The amendment would allow the regulations made under that subsection to include CHI taking into account the co-ordination of CHI's own visits with those of other bodies carrying out monitoring or inspecting the same premises. Trusts, OP surgeries and so on face a multitude of visits and inspections from various bodies in addition to CHI. There are visits by the Audit Commission, the Royal Colleges, CHCs and, if the Bill is passed, patient forums, and many other bodies, such as the Modernisation Agency.

My noble friend Lord Peyton of Yeovil told us on the second Committee day that the multiplicity of inspections was described to him as, death by a thousand visits".—[Official Report, 18/3/02; col. 1203.] The British Medical Association feels strongly about the issue and supports the amendment. I hope that the Minister will say whether the Government intend to do anything to streamline the visits and relieve the burden on doctors, other health professionals and their staff.

The bottom line is that every minute spent on such visits is a minute not spent on patient care, and anything that can he done to minimise their impact will he welcomed. The amendment does not seek to cure the totality of the problem but seeks to co-ordinate visits which are focused on monitoring and inspection. It is a modest contribution to the problem and I hope that it will commend itself to the Minister. I beg to move.

Baroness Northover

I support this amendment. We all agree that CHI is a welcome creation doing a good job. However, given the duplication—no doubt other Members of the Committee will have a copy of the chart from the I3MA of the various ways in which doctors can be assessed, monitored, checked, revalidated and so forth—the complexity is obvious. We should do all we can to ensure that that duplication and that kind of complexity is made simpler.

Most of the visits made by those bodies are of course appropriate. But we can try to ensure that there is coordination and that inspections by the various organisations do not cause disruption. An interesting analogy was drawn in the other place where they talked of the digging up and re-digging up of roads. If we can simply co-ordinate the various bodies who have to dig up the roads, it would make more sense than endlessly having one digging up a road this week and another digging it up next week. On the basis therefore that we seek co-ordination of this kind of inspection, I support the amendment.

Lord Hunt of Kings Heath

From my remarks on our intent to rationalise the inspection mechanism at national level, Members of the Committee will understand that I am sympathetic with the broad arguments of the noble Baroness in terms of a rationalisation of inspectorates at local level.

I make two points. First, the reason why various organisations visit the NHS is to ensure that quality and safety—issues we have already debated—are paramount. One makes no apologies for the extension of those inspection agencies into primary care. However, I fully accept that there must be coordination and rationalisation, and that the burden put on busy people operating front-line services is as light as is possible consistent with a rigorous approach to safety and quality.

The Commission for Health Improvement is at the moment piloting its inspections of primary care trusts. Part of those inspections will involve visits to some individual GP surgeries. In the discussions that the department had with CHI we came to a mutual understanding that those visits will he light touch, for the very reason the noble Baroness put forward.

The CHI has also taken other steps to co-ordinate activity with relevant bodies. It has already agreed a draft statement of principles for consultation covering how it plans to improve co-ordination with the Audit Commission, including external audit, NHS internal audit, the Health and Safety Executive and the NHS Litigation Authority, including the clinical negligence scheme for trusts. CHI also has a memorandum of understanding with a number of relevant bodies including the commission, the Audit Commission, the Health Service Ombudsman, the General Medical Council, the UKCC, the National Clinical Assessment Authority and it is working to develop others, including the Health and Safety Executive. My understanding is that copies of those memoranda have already been placed in the Library.

Therefore the Commission for Health Improvement is well exercised of the need to ensure that there is co-ordination and to avoid duplication. We will encourage the commission to continue that good work, which is entirely consistent with what we seek to do at national level. We do not need the amendment as it is tabled. The Secretary of State already has the powers to encourage CHI to continue this process of co-ordination and I am satisfied, from my meetings with CHI, that it is fully cognisant of the need to move in the direction the noble Baroness suggested.

Baroness Noakes

I thank the Minister for that. Would he just say how long CHI has been trying to coordinate its visits? I ask this because the complaints about the duplication of visits, the multiplicity of visits, and the serial visits, are of relatively recent origin. The source of this amendment was not some long-forgotten complaint; rather it relates to current complaints, in particular by the British Medical Association. Even if CHI has been doing it for some time, it has not been doing it very well; and that makes one think that perhaps an amendment is needed.

Lord Hunt of Kings Heath

The Commission for Health Improvement has not been in existence for very long, so it is not surprising that there is, inevitably, a learning curve. One expects CHI to learn from some of the concerns that have been expressed. In recent discussions with officials in the department, I have discussed the particular issue of the piloting of the clinical governance reviews of primary care trusts where the issue of light-touch visits to GP surgeries has been raised. I am satisfied that CHI is fully cognisant of the need to try to rationalise these as much as possible.

The process is developing. It takes time to gain experience and for the inspection agencies to learn from that. I believe that learning is taking place. Noble Lords' comments tonight will certainly feed back to CHI and I think they will be very helpful.

Baroness Noakes

I thank the noble Lord for that, and I thank the noble Baroness, Lady Northover, for her support for this amendment. I am not convinced that the words actually match up with actions on the ground, but I am sure that those who have been particularly concerned about this matter will look carefully at the Minister's words in Hansard, as indeed shall I. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Northover

moved Amendment No. 97: Page 18, line 12, after "(2)", insert— (a) paragraphs (a) and (h) are omitted, and The noble Baroness said: Amendment No. 97 seeks to delete two paragraphs of the Health Act 1999 in relation to powers held by the Secretary of State in regard to CHI.

As Professor Kennedy has said, it is essential that CHI, should be suitably structured so as to give it the necessary independence and authority", to carry out its work. The paragraphs that we seek to delete from Section 20 of the 1999 Act are ones which allow the Secretary of State by regulation to make provision, as to the times at which, the cases in which, the manner in which, the persons in relation to which or the matters with respect to which any functions of the Commission are to be exercised … [and] as to the matters to be considered or taken into account in connection with the exercise of any functions of the Commission". The Government say that they are making CHI more independent. If so, how does this fit with these lines? They give the Secretary of State power to restrict the ability of CHI to talk to the people to whom it needs to talk, to make investigations and reviews when it wants, and to consider cases as it wants. Nothing, and certainly not a Secretary of State, should threaten the remit, independence, scope and ability of CHI to make such investigations.

When my honourable friend Dr Evan Harris introduced this amendment in the other place, the Minister there argued that removing these provisions cut across the Secretary of State's ability to coordinate inspection. However, they do not look to me like a series of powers which ensure co-ordination and, drawn as widely as they are, there has to be a risk that they could be used to undermine the independence of CHI. I therefore flag up this amendment as indicative of the kind of area which must be addressed if CHI is to be, and to be seen to be, independent of the Secretary of State and not controlled by him. I beg to move.

Baroness Noakes

I rise to speak briefly in support of this amendment. To some extent it anticipates a later amendment dealing with the independence of CHI, and we fully support that direction of travel. Indeed, one might say, looking at Section 20 of the 1999 Act, that this amendment singles out paragraphs (a) and (b) but one might even extend it further and look at the whole of Section 20 to discover why a Secretary of State should keep any of the powers to direct CHI in such a detailed way if it is decided to give CHI more independence.

I do not know whether the Minister is going to say that the powers need to be kept in reserve and would be used only in exceptional cases. If he does say that, I think that we have to take it with a pinch of salt because the mere fact of the existence of such powers, whether or not they are used in a formal sense, subtly undermines the independence of such bodies. If a body knows that the Secretary of State can issue directions or make regulations telling it what to do, the mere existence of that power tends to induce compliance and reduce independence. We support the amendment.

9.45 p.m.

Lord Hunt of Kings Heath

I should state clearly to the Committee that we are very keen to enhance the independence of the Commission for Health Improvement. There is no reason for the Government to wish to inhibit that independence. The whole rigour of what we are seeking to achieve—namely, to drive up standards in the health service—depends to a great extent on the credibility of the commission and on the way it is regarded by both the public and those working in the health service.

There simply would not be any reason for the Government to wish to undermine the independence of the Commission for Health Improvement. When we debate Clause 14, Members of the Committee will discover that we are making moves to remove the requirement, for example, for the Secretary of State to consent to the appointment of CH l's chief executive, and the Secretary of State's direction-making power in respect of the terms under which the commission employs people. That is why we are providing for certain of CHI's functions in relation to the collection and analysis of data and performance assessment to be carried out by the Office for Information on Healthcare Performance.

At the same time, the performance ratings that we published last year will, this July, be jointly produced by the department and CHI. In July 2003, the performance ratings will be produced by the commission. We are most anxious that CHI should perform as rigorous a role as possible. There is no question of seeking to interfere in the inspection process that CHI undertakes. We have discussions with the commission about its workload because, from the department's point of view, we have been encouraging CHI to undertake as many inspections as is possible.

Regular meetings take place between the chair and the chief executive of CHI to enable us to engage in mutual discussion about its work and the issues that have arisen. The department's Ministers are most concerned to learn from CHI what it has discovered in the health service. I particularly commend the CHI reports that comment on how much clinical governance, for example, is ingrained within the work of boards, and, indeed, whether boards have information strategies. Many other issues are identified in CHI reports, and that information can then help the department in its performance management of the NHS.

I turn to the purpose of the amendment. It seems to me that the noble Baroness, Lady Noakes, sought to forecast what I would say in response. She is absolutely right in that respect. Ultimately, the Secretary of State is accountable to Parliament for the performance of the Commission for Health Improvement. In the very unlikely event that any serious problem should arise in the way that CHI performed its functions, or in its general operation, the Secretary of State must have a power of intervention. That is why the power is in the Bill. It is no different from many other non-departmental public bodies.

I can assure the Committee that that is why the power is there; it is not there to intervene and to dictate to CHI what should be mentioned in its reports. The power forms a necessary part of Ministers' accountability to Parliament. For that reason, I urge the noble Baroness not to press the amendment.

Baroness Northover

I thank the Minister for his reply, and the noble Baroness, Lady Noakes, for her support. I reiterate that we welcome CHI; indeed, we very much welcome the developments that have come in its wake. However, we should consider what might happen as we come up to an election, for example, or consider the case of the Chief Inspector of Prisons. For a while, an inspector's reports may be welcomed, but, later, he may be out in the cold. The first inspections may be considered useful, but if there are repeated poor reports on hospitals, as we approach a general election, the temptation for a Secretary of State who has some direct control over an institution such as CHI will be intense.

Lord Hunt of Kings Heath

There are two safeguards against that. First, there is the integrity of the chairperson, chief executive and non-executive directors of the Commission for Health Improvement. Anyone who knows Dame Deirdre Hine, the chair of CHI, or Dr Peter Homa, the chief executive, would quickly come to the view that they are people of great integrity who would not bow to any influence of that kind.

Secondly, if powers of direction had to be issued, that would be in the public domain. I should have thought that that would create a much bigger noise than any adverse report by CHI on an NHS trust. CHI has already produced a considerable number of reports. Some are outstanding reports on hospitals. For instance, CHI produced a report on Addenbrooke's NHS Trust three or four weeks ago, which indicated that the hospital was outstanding in many ways. The reports on other hospitals have been disappointing and negative and have identified areas in which improvement must take place.

The purpose of setting up CHI was to have a rigorous, independent process that indicated to the public and to the NHS that we had a system that really got to grips with problems in the health service. It is inconceivable that Ministers would wish to interfere with that process.

Baroness Northover

I thank the Minister for those comments. The Government certainly deserve credit for setting up CHI, given that no previous government did so. I am happy to give the Government that credit.

However, if we consider the model of the Chief Inspector of Prisons, we can see what may happen down the track. The Government might be relieved to see the amendments proposed by the noble Baroness, Lady Finlay of Llandaff, which really would remove CHI from the control of the Secretary of State and make it answerable to a Select. Committee of Parliament. If it were directly answerable to Parliament, there would be no temptation for the Secretary of State to exercise—or otherwise—any influence over CHI, should pressures arise down the track. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Noakes

moved Amendment No. 98: Page 18, line 15, leave out subsection (5). The noble Baroness said: Amendment No. 98 is a probing amendment. It would remove subsection (5) of Clause 12.

At first sight, the clause is innocuous, simply requiring the Audit Commission to consult the Commission for Health Improvement on its programme of value for money studies in relation to the NHS. However, the Audit Commission is a fully independent body with statutory duties to carry out audit. In arriving at its programme, it consults many people and organisations, as one would expect a responsible public body to do. I hope that few would argue with the proposition that the Audit Commission is an effective and responsible public body.

Why do the Government feel that it is necessary for statute to prescribe whom the Audit Commission should consult? Do the Government feel that the Audit Commission is not doing its job properly? Will the Minister say what the Government's view is? Why is the Audit Commission treated differently from the National Audit Office? The National Audit Office is not required by statute to consult over its audit programme.

Such clauses raise concerns about other agendas. We know from the Government's response to the Bristol report, which has been quoted several times during our deliberations in Committee, that the Secretary of State does have an agenda with regard to the relationship between the Audit Commission and CHI, because he said that there needed to be closer working and, over time, organisational integration between CHI and, inter alia, the Audit Commission. That raises very serious issues about the integrity of public sector audit.

I ask the Minister to explain what are the Government's precise intentions in relation to the Audit Commission. I ask him also to say what is meant by "closer working" and when "organisational integration" might take place. Can he confirm that no changes are intended which would undermine the independence and effectiveness of the public audit function in relation to the NHS? I beg to move.

Lord Hunt of Kings Heath

The question of the intention of my right honourable friend since his speech concerning the integration of inspection functions has been made clear in my response to the amendment moved a short while ago by the noble Baroness, Lady Northover. I said then that I thought her amendment was premature because the detailed work that will have to be done to develop ideas about future integration has only just started. That is because the Bristol report is not old and we have had to consider our comments on the work programme that needs to follow. In a sense, therefore, I do not think that I can answer the questions raised by the noble Baroness because this is work in hand and we shall need to consider these matters very carefully.

However, I can say to the noble Baroness that of course I greatly respect the work of the Audit Commission. I have had long experience of dealing with the commission and reading its reports. I know of the benefits that it has brought. Equally, as noble Lords themselves have pointed out, and just as the noble Baroness argued earlier, I believe that we need to sort out inspections at local level and national level. We need to avoid duplication. The whole purpose of including the clause in the Bill was not in any way an attempt to restrict the independence or decision-making process of the Audit Commission, but rather merely to ensure that consideration would be made of CHI's work programme so that the organisations themselves could best consider how to avoid duplication and hold general discussions about their respective work programmes.

I should stress that there is no suggestion whatever that in doing this we are seeking to undermine the independence of the Audit Commission, which I agree is an extremely important facet of its work.

Lord Clement-Jones

Perhaps I may pick up on a point just made by the Minister. I welcome what he has said about the Audit Commission because I am sure that he is aware that considerable value is put on the commission's value-for-money audits as a specific exercise, quite apart from any health aspect. It has that specialism. I believe that strong opposition would be brought to bear on any attempt to try to over-integrate in that respect.

Lord Hunt of Kings Heath

One thing that I have learned over the years is that the Audit Commission is a very powerful defender of its own interests. I am sure that in any discussions about its future role, it will be well able to put across its own point of view.

I should also have said to the noble Baroness, Lady Noakes, that I understand that in the relevant section of the Audit Commission Act 1998, we are adding to the names of the Secretary of State for Health and the Comptroller and Auditor-General in relation to the National Audit Office. Given the importance of the Commission for Health Improvement in relation to inspections in the health service, I should have thought that it was appropriate to add CHI's name to that list.

Baroness Noakes

I thank the Minister for that reply. I do not feel very much the wiser for it because I still do not quite understand why this particular consultation requirement needs to be put on to the face of the Bill. However, often when we urge the Minister to accept amendments which seek to make things clear, we receive a response which states in effect that of course the Government already do that and so it is irrelevant to put anything on to the face of the Bill. Here we are trying to take something off the face of the Bill in circumstances where a responsible Audit Commission would almost certainly consult, and yet we have the argument put back to us in a different way.

I am very surprised that the Secretary of State could have said what he did on 17th January in relation to the organisational integration between CHI and the Audit Commission, and yet here we are, two months later, and the Minister can give the Committee no details whatever. I find that surprising. I want to reflect further before Report stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

10 p.m.

Baroness Finlay of Llandaff

moved Amendment No. 98A: Page 18, line 17, at end insert— (6) The Commission for Health Improvement shall present annually its report to the health joint select committee. The noble Baroness said: In moving Amendment No. 98A, I shall speak also to Amendment No. 114A. I should make it clear that I shall not be speaking to the other amendments in the group. They will be addressed in due order later in the Marshalled List.

Lord Hunt of Kings Heath

It may help the Committee if I make it clear that the other amendments have been degrouped and that we are speaking only to Amendments Nos. 98A and 114A.

Baroness Finlay of Llandaff

I thank the Minister for that. I am grateful to the noble Baroness, Lady Northover, for having set the scene for the amendment. The Minister referred to the report, Learning from Bristol. That report states: The NHS is quintessentially a statement of political values. Thus, it is inevitable and right that central government should seek to lay down the parameters of the NHS's activities, particularly in the realm of finance and priorities. But, once this is don, the systems for monitoring the extent to which it is meeting its stated aims must, in our view, be de-politicised, so as thereby to rekindle and maintain public confidence in the NHS". It is this role that I wish to address.

I am grateful to the Minister for expanding on some of the increased freedom that CHI will experience. I understand that it will be able to appoint chief executives through the commission itself and that its reports are to be laid before Parliament. The Bill will enable CHI to undertake inspections, including where NHS services are provided from premises not directly owned by the NHS. The Minister has clearly outlined the need for CHI to be independent.

All the regulatory bodies concerned with the NFIS—which is a national service—must be answerable directly to Parliament. Other regulatory bodies—the professions' regulatory bodies—will be discussed in detail later.

I am suggesting that a parliamentary committee should be drawn from both Houses, ensuring representation from the four countries of the United Kingdom, and that such a committee shall never have a majority of members from one political party. In the event of a coalition of two parties, it would he important to ensure that it did not operate in such a way as to create a majority on the committee. Thus the committee would be politically neutral in terms of pressure prior to an election. It is anticipated that representatives of the government of the day would not constitute more than 40 per cent of the proposed health Joint Select Committee.

Such details are suggestions only at this stage; it is the principle that is of concern. Currently, there is no professional regulatory body for managers. May I preface my next remarks by stating that I work for an NHS trust with excellent management, which maintains an open dialogue with all staff at all grades. However, our recent debate involving research and teaching highlights the need for resources such as rooms, photocopying and IT facilities.

The CHI reports have been excellent. Like the Kennedy report, they have outlined that the state of the NHS is in the hands of managers, and good management is integral to clinical governance. I sincerely hope that the recommendations of the Kennedy report will be followed and that such regulatory bodies will be directly answerable to Parliament.

CHI inspects the service and recommends improvements. It must be free to exercise its functions with rigour. CHI must report to Parliament in such a way that it can be questioned—it should not simply lay a report before Parliament—and hence the idea of the committee.

Amendment No. 114A seeks to ensure that the organisation referred to in the Bill as the "patients forum", which will have an important function in obtaining the views of NHS users, will also be answerable in such a way. The patients forum must seek the views of NHS users—be they patients, relatives or carers—and it must be allowed to be independent of service providers. I believe that it should have equal standing with the inspection roles of other inspection bodies. Therefore, it should be able to present its report to such a parliamentary committee. While the patients forums will be working with trusts, they must have the ability to be completely independent of the trusts, and of the government of the day.

Fortunately, the consultation processes that have taken place in Wales, which were outlined earlier in our debates, have been very effective in some areas. We are fortunate to have retained community health councils. I know that we are not to debate community health councils, but the report from such patients forums must have the high status and standing that we have been able to retain in community health councils in Wales. They have recently been involved in two important research projects —one with the Organ Retention Advisory Group, where they sought the views of the general public, and another where they have been working on the standards that patients and their relatives require from the health services in Wales. I beg to move.

Baroness Northover

I welcome the amendment. The Select Committees of the Houses of Parliament have already developed an important scrutiny role. They should in future develop that function further, acting on behalf of Parliament, and be able to specialise in particular areas and report to Parliament.

If CHI answered to a Select Committee such as that suggested in the amendment, the Minister would not need to worry about needing to protest that no undue control or influence is exerted over what all agree should be an independent body. Therefore, I strongly welcome this proposal.

Lord Hunt of Kings Heath

This has been an interesting debate about the accountability to Parliament of CHI and of the patients forums, on which we shall no doubt have an interesting discussion in some four weeks' time.

The amendments proposed by the noble Baroness, Lady Finlay, seek to assume that Parliament would decide to create what is referred to as a health Joint Select Committee. Later, we shall debate also the group of amendments dealing with the council for the regulation of health care professionals in relation to this committee. What in effect the amendments would do would be to have the Commission for Health Improvement and patients forums present their annual reports to the Joint Select Committee.

The current position is that CHI makes an annual report on the exercise of its functions to the Secretary of State, like other non-departmental public bodies. But it is an important measure of its great independence that, under Clause 14(4), CHI will also in future be required to complete an annual report on the quality of services to NHS patients, which the Secretary of State will be under a duty to lay before Parliament. So, even if Parliament decided to set up a Joint Select Committee as proposed in the amendment, it would not add anything if CHI were to send its report there as well as to Parliament.

Equally, patients forums will make an annual report to the Commission for Patient and Public Involvement in Health, as well as to the Secretary of State. These reports will feed in to the commission's own annual report, which the Secretary of State will be under a duty to lay before Parliament.

I understand what the noble Baroness is getting at. However, we are in an extremely difficult position if we seek in the Bill to suggest how Parliament might establish Select Committees in the future. That is not the way in which Parliament operates, and it is not the way in which decisions are made about the agreement to set up Select Committees of either House or Joint Select Committees.

Of course, if Parliament decided to establish such a Select Committee, it would be the duty of NHS bodies to co-operate with it. That is what happens at the moment. For example, the Select Committee on Health is currently undertaking an inquiry into the work of the National Institute for Clinical Excellence. I spent two and a half happy hours before the committee a week or so ago undergoing what might be described as effective scrutiny. There is nothing to prevent Parliament holding organisations such as the Commission for Health Improvement to account through its normal processes. Our aim in the Bill is to enhance the reporting of those organisations to Parliament. For that reason, while I certainly understand what the noble Baroness is getting at, I urge her to consider not pressing the amendments.

Baroness Finlay of Llandaff

I am most grateful to the Minister for his reply and for his generosity in understanding what I am getting at, as I am a novice to the parliamentary system. I am grateful for his explanation. I shall consider the issues further and may return to them later. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 12 agreed to.

Baroness Noakes

moved Amendment No. 99: After Clause 12, insert the following new clause— "PUBLIC HEALTH FUNCTIONS OF THE COMMISSION FOR HEALTH IMPROVEMENT The Commission for Health Improvement shall have such further functions as may be prescribed relating to the management, co-ordination, provision or quality of public health services for which prescribed NHS bodies, service providers, local authorities or other bodies have responsibility. The noble Baroness said: The amendment would extend the remit of the Commission for Health Improvement to public health. It would enable the Secretary of State to prescribe functions relating to the management, co-ordination, provision or quality of public health services, for which a wide range of bodies have responsibility.

CHI's functions under the Health Act 1999 are expressed in terms of healthcare, as are the amendments in the Bill. Notable by its absence from CHI's remit is public health, yet public health issues are as important as—some would say more important than—those involved in the delivery of healthcare.

The Committee has already debated the importance of public health in relation to the roles of the strategic health authorities, primary care trusts and regional directors of public health. It is fair to say that our debates on earlier amendments left a number of concerns hanging relating to whether those public health responsibilities would in practice be discharged effectively.

We know that the Government's intention is that PCTs will take the lead on health issues and that they will have a director of public health. We know that they will be encouraged to work in public health networks and that the directors of public health will come new to their responsibilities in PCTs from a variety of backgrounds, some medical and some non-medical.

It seems inevitable that the public health function of PCTs will need some strong oversight. CHI seems the obvious organisation to provide that. However, the amendment is not just about keeping an eye on PCTs and their new public health functions. We know that there are major public health issues to be grappled with. The amendment would give CHI, as an independent inspectorate, the responsibility for finding out what is being done on various public health issues to achieve public health aims, as well as disseminating best practice and reporting when not enough is being done.

I hope that the Minister will accept the amendment as one based on plain common sense. If he resists it, will he explain why public health must remain outside CHI's remit and what alternative arrangements would give the same oversight and rigour? I beg to move.

10.15 p.m.

Baroness Northover

I support the amendment. Several key issues are emerging as this Bill rolls along. Noble Lords are giving a guarded welcome to the notion of devolving resources and decision-making in the NHS, but there is enormous concern about the speed with which that is happening and whether PCTs are anywhere near being ready to take up their key tasks. There is increasing concern about matters that particularly require a national overview. Public health is one such matter.

Public health—like teaching and research, as we debated the other day—is too often likely to be squeezed out by what seem to be more pressing concerns. Devolution is one thing, but fragmentation is quite another. What we are hearing about the parcelling out of public health responsibilities to one lead official here and one there obviously causes concern; it is not a recipe for satisfactory coordination. Moreover, as has emerged too clearly from the Bristol inquiry, too little data are available in the health service to know what is happening where, and to know What has been happening where. The fact that public health is a key responsibility therefore has to be built into PCTs' remit.

Even then, however, the way in which PCTs exercise that responsibility will have to be carefully scrutinised. I fully agree with the noble Baroness, Lady Noakes, that that is where CHI may be able to assist. That is why it is being proposed that CHI's role should be extended to cover the monitoring, inspection, reporting, co-ordination, management and quality of public health. I therefore very much welcome the amendment.

Baroness Finlay of Llandaff

In supporting this amendment, I shall approach it from a slightly different angle: public health's importance, as we have discussed, to national defence. I know that Ministers have recently received many questions on smallpox vaccine. In the event of a sudden catastrophic epidemic of any sort, the public health services will be called on to he the plank on which catastrophic infections are controlled. The public health services co-ordinate, for example, the control of meningitis outbreaks.

The organisation of public health services is absolutely crucial in their ability to respond. I support the amendment because the organisation of such services must he in good order at all times so that they are not found wanting when called on in an emergency.

Baroness Masham of Ilton

Public health covers so many important aspects. There is a strong feeling that PCTs will be overloaded, but everyone working in the National Health Service and social care should be helping with public health. I am sure that the Commission for Health Improvement can help improve public health as it goes about its work. It can look, encourage and report if not enough is being done. I hope that the Government will support the amendment.

Lord Hunt of Kings Heath

I agree that this is a very important matter, although, as the Committee will know, I am more optimistic than some noble Lords about the capability of primary care trusts to accept the very important public health role they are being given. The term "public health services" goes very wide and might include protection against communicable diseases or other hazards to health and health promotion. The ambit of the expression is not entirely clear because the term is not currently defined in the Health Act 1999.

Noble Lords will recall that on 10th January the Chief Medical Officer announced proposals for a health protection agency to streamline the services involved in the prevention and control of infectious diseases. This agency will provide an integrated approach to all aspects of health protection, including chemical and radiological hazards as well as infectious disease control. The agency will take over functions currently performed by the Public Health Laboratory Service, the National Radiological Protection Board, the Centre for Applied Microbiology and Research, and the National Focus for Chemical Incidents. It will also assume responsibility for employing consultants in communicable disease control.

The new agency will work closely with regional and local services and the expert government advisory committees. It will also work with CHI where there are serious deficiencies in standards of infection control in hospitals, primary care or other health service premises. That will give us a great deal of confidence about the national arrangements and the integration of public health protection surveillance services, as well as infectious disease control, about which I know that noble Lords are anxious.

Alongside that we shall have robust performance management of the public health function throughout the National Health Service. From this April the regional directors of public health will design, develop and maintain public health networks. They will be responsible for the overall tackling of the root causes of ill-health inequalities through the health component across government policies. They will manage anti coordinate the health protection and emergency planning functions in their regions. The focus of the directors of health and social care performance management function will be to take a national overview of performance, negotiating performance agreements with strategic health authorities, holding strategic health authorities to account: for performance and supporting the development of individual organisations and the whole system to help them to deliver improvements to patients.

While not duplicating the work of directors of public health in primary care trusts or that of regional directors of public health, strategic health authorities will also have responsibility for performance management of public health action within primary care trusts and in hospital trusts. In future, we shall have a strong performance management system with clear performance management relationships corning down from the regional directors of public health, reporting to the directors of health and social care and to the Chief Medical Officer. That provides an effective way of ensuring that the public health function is properly integrated, managed and monitored.

However, I accept that the noble Baroness raised important issues in favour of giving recognition to the importance of public health service in the way that she suggested. I readily acknowledge that there are complex issues in terms of clarifying the range of public health services that might appropriately be brought within CHI's remit, the relationship between the bodies responsible for those services and those currently responsible for their inspection and regulation. I have already mentioned the creation of the new national agency.

The view that the Government take is that there are a number of important matters which need to be worked through over the next few months. While I cannot support the amendment tabled by the noble Baroness, I can assure the Committee that the Government are giving serious consideration to how the issues can best be taken forward and to the extent that CHI's remit needs to be revisited in these areas. I shall keep noble Lords fully informed on those matters.

Baroness Noakes

I thank the Minister for that response. Indeed, I thank the noble Baronesses, Lady Northover, Lady Finlay and Lady Masham, for their contributions to the debate. I was encouraged at the end of the Minister's comments that this was being kept under review by the Government. It might seem churlish of me to say that what I heard before that perhaps was not so encouraging as it seemed to resist the notion of an independent inspectorate reporting in the successful mode that the noble Lord described earlier today in relation to its other responsibilities. We were trying to take that success and the ability to penetrate to other real issues and to spread that across.

It is not right to pursue the matter today. We shall think further on it in the light of what the Minister said about the Government's future action. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clauses 13 and 14 agreed to.

Baroness Noakes

moved Amendment No. 100: After Clause 14, insert the following new clause— "PATIENT CHOICE It shall he the duty of the Secretary of State in carrying out his functions under the 1977 Act to ensure that so far as it is reasonable for him to do so, persons who receive services under the 1977 Act are given a choice as to the time, manner and location of those services. The noble Baroness said: The amendment would insert a new clause after Clause 14 and would place a duty on the Secretary of State to ensure that people receiving services in the National Health Service are given a choice as to time, manner and location of those services.

I shall quote from a recent speech, which states: The balance of power has to shift decisively in favour of the patient … Patients throughout the National Health Service, helped by their referring GP, will be able to make informed choices about how they are treated, when they are treated and by whom they are treated". That could easily have been said by my honourable friend Dr Liam Fox, and it could also easily have been an extract from Working with Patients—the White Paper which heralded the National Health Service reforms of more than a decade ago. But no, it is an extract from a speech made by the Secretary of State for Health in January this year.

Only a few days ago, the Department of Health issued a document entitled, Extending Choice for Patients, which deals only with the rather modest extension of choice to long waiters for heart surgery; but it is a move in the right direction and we welcome it.

Several noble Lords remarked on Second Reading and elsewhere that the Government's policies have moved on in several respects since they introduced the Bill. We think that it is unsatisfactory that when the Bill has completed its passage the National Health Service will still not have a definitive statutory framework representing current government policy. It is not satisfactory for the Government to announce a series of changes that are not reflected in the Bill.

I am sure that the Minister is aware that we have reservations about many of the Government's policies towards the National Health Service, but we think that this issue of patient choice is one thing that the Secretary of State has started to get right. We agree with it and we want to support him in his new conversion to our ideas by seeing a positive duty to achieve patient choice in the National Health Service legislation.

The Secretary of State said that patient choice would be achieved within four years and I do not believe that that is inconsistent with the wording of the new clause, which refers to, so far as it is reasonable for him to do so". If the Government would prefer a more definite commencement period, I am sure that the new clause could be amended to that effect. I hope that the Government will welcome the amendment. I beg to move.

Lord Hunt of Kings Heath

I warm to the habit of the noble Baroness, Lady Noakes, of referring to speeches made by my right honourable friend. I am glad that she finds them so interesting.

The question of patient choice is extremely important. Any vision of a modern National Health Service would need to involve patient choice. The noble Baroness, Lady Northover, referred earlier to information that helps patients to make informed choices. We all agree with that, but I do not think that it would be appropriate to put the matter on a statutory basis. It is much more a question of policy to be decided by the Secretary of State. We have signalled that greater choice is very much a part of what we seek to do.

By 2005 all patients will be able to choose the date, time and place of their treatment. One of the must-do targets set out in the National Health Service plan is that by the end of 2005, all patients will be able to seek treatment at a time that suits them. That is a clear and public commitment. Through the additional resources that we are making available to the National Health Service for the next year, we are demonstrating our commitment by piloting patient choice from July. At that time, patients with coronary heart disease will be able to benefit from patient choice. When a patient has been on an in-patient waiting list for coronary heart disease treatment for more than six months, he or she will be offered swifter treatment in a different National Health Service hospital, or in the private sector, or in another EU country. We are looking to extend the pilots across other specialisms and in different areas. It is important for the patients who will benefit from that pilot, but it will also be a valuable learning experience in terms of where we need to get to by 2005.

As part of our proposals for patient choice, we have made it clear that patients should be able to choose where they are treated. Patients and their doctors will be able to consider a range of options. That might be at the local NHS hospital or at diagnostic and treatment centres or in the private sector or overseas. We want patients to be able to compare different waiting times in different hospitals and across different specialties. We want GPs and referring consultants to be able to book appointments online.

That surely is, as I have said, the vision of a modern health service. I do not think that it is appropriate to place on the statute hook in primary legislation the wording that the noble Baroness has suggested. At the end of the day it falls to government Ministers in their accountability to Parliament to decide on the National Health Service. That is what we have done. I have made it clear that patient choice is a priority. I have no doubt that we shall deliver on that. But it is very much a matter for Ministers to make those decisions and in turn to he accountable to Parliament for so doing.

10.30 p.m.

Baroness Noakes

I thank the Minister for those comments. I am perplexed. I had understood him to be moving in the direction of patient choice—that is what he outlined to us—hut he said that somehow having the duty of patient choice was not appropriate. I did not hear why it was not appropriate, other than it was something to do with policy decided by the Secretary of State.

The Government show a great lack of commitment to the principle of patient choice, if' that is something that the Secretary of State wishes to keep to himself and to prioritise or de-prioritise from time to time. In the light of those comments, we should rightly be skeptical of the Government's apparent conversion to patient choice. I want to think about the matter further. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Noakes

moved Amendment No. 101: After Clause 14, insert the following new clause— Targets for patients (1) It shall be the duty of the Secretary of State to achieve the following targets for patients—

1. (a) no patient should wait more than 48 hours for an appointment to sec a general practitioner,
2. (b) no patient should wait longer than thirteen weeks from the time of referral from a general practitioner for a First appointment to be seen as an out-patient.
3. (c) no patient should wait longer than six months from the time that he is first seen as an out-patient for the procedure or other treatment decided upon,
4. (d) no patient should wait longer than one hour after arrival at an accident and emergency unit or similar unit before being seen by a doctor or a qualified nurse practitioner, and
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5. (e) no patient should wait longer than four hours for admittance to a hospital from an accident and emergency or similar unit after a decision has been made that he should be admitted to a hospital.

(2) The Secretary of State may by order define how the targets set out in subsection (1) are to be measured. (3) The Secretary of State may by order add to the targets set out in subsection (1) or alter those targets so that shorter times are specified. (4) The Secretary of State may by order set targets for shorter times than set out in subsection (1) for defined categories of patients or services. (5) An order made under subsections (3) and (4) shall not be made unless a draft of the order has been laid before, and approved by a resolution of, each House of Parliament. The noble Baroness said: In moving Amendment No. 101, I shall speak also to Amendments Nos. 102 to 104.

The amendments are important because they deal with patients' experience of the NHS throughout the times that they have to wait at various points in the system. The amendments focus on the areas of patient experience which the Government believe to be important, because they included them in the NHS Plan.

Amendment No. 101 introduces a new clause which sets up the basic framework of targets for patients. It provides that the Secretary of State has a duty to achieve some basic waiting time targets for patients: namely, not having to wait more than 48 hours to see a GP, 13 weeks for an outpatients appointment, six months for an inpatient or other treatment. more than a hour in accident and emergency before being seen or waiting more than four hours for admittance from accident and emergency.

Those are largely the targets which were spelt out in the NHS Plan. The plan referred to a "war on waiting". These targets in the light of our current experience of the NHS might well seem ambitious. However, if one looks to the experience of other European countries the acceptable times are much shorter than the times that we have included. So these are not perhaps very ambitious targets.

Regardless of whether or not the targets are ambitious, it is far from clear whether those set out in the NHS Plan will be achieved. Last year the Audit Commission reported on accident and emergency performance. It noted that waiting times had got worse since 1996.

Professor John Yates, recently writing in the Health Service Journal, noted that some of the waiting time data are showing some worrying trends. One of his conclusions was that the rate of sustained waiting time reductions needed to deliver the targets has never been achieved in the past, with the implication that the targets are likely to be missed.

Patients need to know that these minimum standards will move from aspiration to reality. That is why the proposed clause lays the responsibility on the shoulders of the Secretary of State. It allows him to introduce additional targets and set shorter targets. It is not the Government's intention, I imagine, that the targets in the plan are desirable end states.

Simply placing a duty on the Secretary of State to achieve a target says nothing about what should happen if he fails. Amendment No. 102 requires the Secretary of State to set up compensation arrangements. Patients want to be treated, not compensated for non-treatment—but some form of compensation, which it is left to the Secretary of State to make by order, should concentrate the minds of service deliverers and make it clear to patients that it is their right to receive treatment within certain minimum periods.

The compensation scheme would take effect in 2004, except for the 13-week and six-month targets, which are given a date in 2003. I am sure that the Minister will say that those deadlines are tough compared with the 2005 of the NHS Plan but I doubt that dates alone will be the sticking point with these amendments.

The Secretary of State cannot be expected personally to achieve patient targets so Amendment No. 103 allows him to delegate the duties and compensation scheme to primary care trusts, NHS trusts or strategic health authorities.

It is no exaggeration to say that patients have been let down by the Government who have promised much but delivered little. The amendments put patients at the heart of the Government's responsibilities to the NHS. I beg to move.

Lord Hunt of Kings Heath

I am surprised that the noble Baroness should say that the Government have delivered little. I invite the Committee to consider the huge increase in capacity and in the number of medical training places; the 30,000 extra nurses working in the health service; the development of services such as NHS Direct; and the development of a new safety and quality culture. Much has been achieved and we are indebted to NHS staff for their hard work.

I share the noble Baroness's desire to see waiting time targets achieved and we are determined that they will be. That is best done by the setting of targets and effective performance management rather than by laying down limits and targets in statute law. In the NHS those matters have always been the responsibility of Ministers to determine and that will continue—which is why the NHS Plan clearly sets out the maximum waiting time targets that we expect to be delivered.

By the end of March this year, the maximum waiting time for a first outpatient appointment will reduce from more than six months to an absolute of six months. The maximum wait for inpatient treatment will be cut from 18 months to 15 months. Maximum waiting times will continue to fall on a staged basis each year. By 2003, the maximum wait for a first outpatient appointment will be five months; by 2004, four months; and by 2005, three months.

Similarly, for inpatient treatment the maximum wait will be 12 months by 2003, nine months by 2004, and six months by 2005.

Subject to other NHS Plan targets for increasing capacity, the Government's eventual aim is to reduce the maximum waiting time for all stages of treatment to three months by 2008.

The latest figures for the end of January show that many trusts are on the way to meeting the initial targets that we set. We will continue to press the health service to do everything it can to increase its capacity and to get more doctors, more beds into use and more facilities, with increasing use of the independent sector where it can provide greater capacity. All those efforts are being made by the health service to deliver on the waiting time targets.

The question arises of whether it is appropriate to put a compensation scheme for patients on the face on the Bill. I do not believe that that is the appropriate way forward. It would be wholly a departure in the enactment of health service legislation. I note that when the Conservative Party developed the Patient's Charter, it never proposed that failure to meet Patient's Charter targets should be placed in a statutory framework. If it had, it would have cost an awful lot of money.

Meeting targets is best left to the performance management system of the health service. I am confident that the NHS will deliver on those targets. We as a Government will ensure that the NHS has the resources in terms of training places, money and facilities. I hope that on consideration the noble Baroness will agree that her amendment is not appropriate.

Baroness Noakes

I thank the Minister for that reply. He began by parading some successes of the NHS, as I would have expected. But the plain fact is that non-elective activity reduced last year and the number waiting more than 13 weeks rose by 27 per cent in the first nine months of this financial year. Things are not all moving in the direction of success.

The Minister again says that the amendment is not appropriate. We are told to leave things to performance management, but I put it to the Minister that that is an internal perspective, whereas the amendment would put patients at the centre by firmly rooting a duty to deliver things for them, not considering internal management processes. I feel, as I did about the previous amendment, that the Government have a lot of rhetoric about wanting to meet targets. They have a whole structure based on the plan and its implementation. But when we ask them to put a little more commitment behind that in the form of a statutory commitment, we are told that that is inappropriate.

I am disappointed. I shall reflect further. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 102 to 104 not moved.]

Lord Filkin

Now may be a convenient moment to end our consideration of the Bill in Committee today. I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.