Health and Social Care (Community Health and Standards) Bill

Public Bill Committee, 5 June 2003.

Standing Committee E

Clause 41 - Standards set by Secretary of State

Win Griffiths (Labour, Bridgend)

I remind the Committee that with this we are discussing the following amendments: No. 471, in

clause 41, page 14, line 28, leave out 'crossborder' and insert 'Welsh'.

No. 472, in

clause 41, page 14, line 29, at end add—

'(5) The standards set out in statements under this section are to be taken into account by every crossborder SHA.

(6) The standards set out in statements under this section are to be taken into account for Northern Ireland when required.'.

No. 24, in

clause 51, page 18, line 1, after 'English', insert 'and Welsh'.

No. 25, in

clause 51, page 18, line 17, after 'English', insert 'or Welsh'.

No. 26, in

clause 53, page 18, line 38, after 'English', insert 'or Welsh'.

No. 27, in

clause 53, page 18, line 42, after 'English', insert 'or Welsh'.

No. 29, in

clause 53, page 19, line 2, leave out 'Secretary of State' and insert 'appropriate authority'.

No. 28, in

clause 53, page 19, line 4, after 'English', insert 'or Welsh'.

No. 32, in

clause 55, page 20, line 19, after 'English', insert 'or Welsh'.

No. 33, in

clause 56, page 20, line 28, leave out from 'trust' to end of line 29.

No. 38, in

clause 65, page 24, line 22, leave out 'Secretary of State' and insert 'appropriate authority'.

David Lammy (Labour, Tottenham)

When we adjourned yesterday we were discussing the amendment that deals with the establishment of the healthcare inspection unit for Wales. The hon. Gentleman the Member for Epsom and Ewell (Chris Grayling) was concerned that this would mean unnecessary duplication, and in strong terms questioned why we could not have the Commission for Healthcare Audit and Inspection as an inspectorate for Wales. Much of

what the hon. Gentleman said surprised me, even though he said it so strongly. The nature of the amendment also surprised me, because these health matters have been devolved to Wales for some time. In a sense, this is a settlement of an argument that Parliament heard about devolution in 1998–99.

Chris Grayling (Conservative, Epsom and Ewell)

If this is a devolved matter and the issue has long been resolved, why are we debating it today and why is it in this Bill?

David Lammy (Labour, Tottenham)

Let me make some progress and I will explain why.

Broadly, the amendments would extend the Secretary of State's standard-setting role and CHAI's various review and investigation functions to Wales and England, including the annual review, other reviews and investigations, co-ordination of those reviews and the power to require explanations.

The hon. Gentleman has forgotten that the National Assembly for Wales is responsible for health care in Wales. Clause 66 confers similar functions on the Assembly, as it is important for the Assembly's drive to improve the health of the Welsh people by ensuring that health priorities specific to Wales are addressed and monitored locally.

Chris Grayling (Conservative, Epsom and Ewell)

Can the Minister give me an example of one of those health priorities that is exclusive to Wales?

David Lammy (Labour, Tottenham)

As I was going on to explain, the National Assembly for Wales does not have primary legislative powers, only secondary ones. Nevertheless, much of what the hon. Gentleman said pertained to devolution. If I can extend the argument, he will understand why the Assembly has those powers. The Commission for Health Improvement currently undertakes these critical function reviews, but in so doing it has not been able to take fully into account defined Welsh health priorities and other issues specific to Wales.

Chris Grayling (Conservative, Epsom and Ewell)

Such as?

David Lammy (Labour, Tottenham)

The hon. Gentleman will understand that the demography of Wales and the history of the valleys, factors such as the high incidence of smoking and teenage cessation, and the Welsh industrial heritage, mean that Wales has its own characteristic demography and health economy. For those and other reasons the Welsh have chosen—as is their right—to pursue a course of action in the health economy that is specific to their needs. That is why their national service frameworks are specific to the Welsh. The coronary heart disease NSF published in July 2001, the diabetes NSF published in 2002, and the children's NSF published in 2002 are all specific to Wales.

Andrew Murrison (Conservative, Westbury)

My hon. Friend the Member for Epsom and Ewell asked for specific examples of differences in Wales. The Under-Secretary responded with generalities, and pretty poor ones at that. Will he explain how Welsh diabetes differs from English diabetes?

David Lammy (Labour, Tottenham)

I must always be careful to defer to the hon. Gentleman's clinical expertise. Having said that, I would have thought it patently obvious that the multicultural heritage of cities such as London,

Birmingham and Leicester means that the incidence and demography of diabetes is profoundly different from that in much of rural Wales.

Health care in Wales is different for several reasons, which is why the Assembly takes an interest in it. The hon. Member for Epsom and Ewell said yesterday that the Assembly was not the right place for such interest, and he challenged the scrutiny powers of the Assembly. I am sure that Members of the National Assembly for Wales would have been surprised at what was said here about their effectiveness and their powers of scrutiny. As the hon. Gentleman knows, they take scrutiny very seriously and have subject and Select Committees similar to ours.

The reporting process of the National Assembly for Wales ensures transparency and accountability, and the Assembly has set up mechanisms to ensure that the establishment of the HIUW is rigorous, and at a remove from the executive powers of the Assembly. These include the appointment of the head of the inspectorate in Wales through a process outside the Assembly; editorial control for the head of the inspectorate in Wales; simultaneous provision of reports prepared by the inspectorate to the Assembly's Health and Social Services Committee, which is similar to our Select Committee; rights of independent access for the inspectorate to the Minister for Health and Social Services; a separate complaints procedure to ensure independence; and other measures including working protocols and delegated functions.

The National Assembly for Wales takes seriously its responsibilities in this area. The hon. Gentleman's new Conservative colleagues in the Welsh Assembly will surely be surprised, as I am, at how quickly their colleagues in England are pouring scorn on their ability to scrutinise health care. Perhaps the hon. Gentleman will say that his colleagues should resign their posts because there are no differences in the health economy of Wales.

Chris Grayling (Conservative, Epsom and Ewell)

I am working on the assumption that the Minister believes that the patient should come first. Returning to the earlier example of the hospital in Chester, let us take the case of a consultant who treats a patient from England at 11 o'clock and a patient from Wales at 11.30. Should that doctor use a different approach to treatment for those two patients who may have an identical condition—one to conform with the NSF in England and another to conform with the NSF in Wales?

David Lammy (Labour, Tottenham)

The scenario that the hon. Gentleman paints is simply not correct. We are talking about an inspectorate that should pertain to the local demography of Wales. The hon. Gentleman's view is that we do not need that.

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

As I understand the Bill, that problem would not arise. The Chester hospital consultant would be subject to an inspection that reported to the Secretary of State here. He would not be subject to an inspection that reported to the National Assembly.

David Lammy (Labour, Tottenham)

That is right. My hon. Friend asked me some important questions about cross-border inspection yesterday, and I hope to come to those shortly.

Chris Grayling (Conservative, Epsom and Ewell)

I appreciate that we will debate this issue more fully later, but may I draw the hon. Gentleman's attention to clause 66(1)(b), which says that the Assembly has the power to conduct:

''reviews of, and investigations into, the provision of health care for a Welsh NHS body''.

In other words, provision could be made by an English NHS trust for a Welsh primary care trust in the case of a border hospital. So why would the Assembly not have the power to inspect a hospital just across the border that provided a service to a substantial area in Wales, such as the hospital in Chester?

David Lammy (Labour, Tottenham)

I wish that the hon. Gentleman would let me make some progress. The Bill clearly includes a duty of co-operation between the inspectorates in England and Wales, and both could inspect work commissioned by Wales.

As to the earlier point, there is no difference between the treatment given in England and the treatment given in Wales; nothing that I have said this morning suggests different standards of treatment. I have concentrated my remarks on differences in demography. We have already had a discussion in this place about devolution, and we have had a settlement, and that pertains to the amendment.

Andrew Murrison (Conservative, Westbury)

For the Minister's benefit, he must clarify in his mind exactly what the NHS is all about—it is about treatment. If he is saying that there is no difference between treatment in England and treatment in Wales, why on earth is he making these different arrangements for England and Wales?

David Lammy (Labour, Tottenham)

There are already different arrangements for England and Wales. The old health authorities still operate in Wales. I have explained that the NSFs in Wales are different. The hon. Gentleman makes an interesting point, but he should perhaps have made it a few years ago. Things have moved on, and there are already different arrangements in Wales. That is why the amendment does not get us far at all.

Under clause 43, CHAI will be under a duty to provide information and advice to the appropriate authority about the provision of health care in Wales, as may be requested. The Bill provides that the Assembly and CHAI must co-operate with each other where it seems appropriate to them to do so for the efficient and effective discharge of any relevant function, but it would not be proper for CHAI alone, unless under agreement with the National Assembly for Wales, to undertake those reviews. That is the duty of co-operation that I referred to.

The National Assembly for Wales has already announced its intention to establish a health inspectorate for Wales to exercise the Assembly's functions.

That will ensure that there is a strong focus on defined Welsh health priorities and that performance quality and regulation issues are fully and rigorously addressed. It will be for the Assembly and the Welsh

inspectorate to best determine the annual inspection regime. Reviews and inspections undertaken by the Welsh inspectorate will be carried out using the joint review for social services model, including the Audit Commission for Wales. Effectively, the two inspectorates will examine two separate health services. That arises as a result of the devolution settlement.

I remind the hon. Member for Epsom and Ewell that, under section 1 of the NHS Act 1977, the Secretary of State has responsibility for providing a comprehensive health service. However, by virtue of section 22 of the Government of Wales Act 1998, by council order the functions for providing a comprehensive health service for Wales pass to the Welsh Assembly. That must be the right place for that.

My hon. Friend the Member for Cardiff, Central (Mr. Jon Owen Jones) raised an important point about cross-border inspections in towns such as Shrewsbury, Chester and others. Welsh people use hospitals and medical services on the English side and vice versa. The duty of co-operation means that the English and Welsh inspectorates may establish protocols and carry out studies of issues that are pertinent to those hospitals. However, the relevant inspectorate must conduct the study and work in co-operation with colleagues across the border.

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

It is difficult to remember exactly what was said yesterday, but I recall that I was concerned about the need to have comparable standards so that we could examine how each branch of the health service was performing in important areas. It would benefit hospital services in both England and in Wales if comparable standards were set and published so that we could judge performance. I understood that that would happen. I was seeking reassurance from the Under-Secretary that we would try to ensure that such comparisons were made.

David Lammy (Labour, Tottenham)

I hope that standards used in Wales and by CHAI in the English regions will be equally high and that inspections undertaken in Wales will take place against a framework determined by the Assembly and including both national English and Welsh standards and standards developed by the Assembly. National standards such as the national service frameworks underpin many of the standards determined by the Assembly just as the national service frameworks determine standards on the English side.

My hon. Friend raised an important point. I should like Hansard to put on record that standards are high on both sides of the border. That is important. The duty of co-operation means that it is pertinent and important that the chairpersons of the English and Welsh inspectorates work closely in the early days to ensure that those protocols, cross-border issues and standards are ironed out.

Chris Grayling (Conservative, Epsom and Ewell)

I must say, Mr. Griffiths, that that is completely bonkers. The Under-Secretary's words describe a thoroughly bad deal for health care in this country; the United Kingdom, of which we were all still a part when last I looked.

The Bill provides for the establishment of health care standards in Wales that differ from those in England. We are not talking about an island somewhere out in the Atlantic; we are talking about a country that is part of our nation and shares facilities. When asked to address the issue of commonality of standards, the Under-Secretary said that he hoped that they would all marry up. He was asked to rationalise that, and he talked about the distinctive nature of the demographic situation of health care in Wales. My hon. Friend the Member for Westbury (Dr. Murrison) rightly pulled the Under-Secretary up; he could not name a single example of a health care condition that was exclusive to Wales. That is because there is none. Actually, there is one exception. During the debate on the Health (Wales) Act 2003, it was pointed out that there were specific instances of health problems in Wales related to the limestone mining industry in the north of that country.

David Lammy (Labour, Tottenham)

I refer the hon. Gentleman to the publication ''Health in Wales—Chief Medical Officer's Report 2001/2002''. Page 82 states that against every measure—including circulatory disease, cancer and respiratory disease—health in Wales is worse than it is in England.

Chris Grayling (Conservative, Epsom and Ewell)

That is ironic, since we know that the national health service spends more on each person in Wales than it does in England. Unless I am mistaken—my hon. Friend the Member for Westbury captured the moment perfectly—there is, of course, no difference between medical conditions in Wales and in England. The illnesses are the same, and they require the same treatments and the same medical expertise. We ought to judge the quality of treatment in the same way.

The Under-Secretary said a couple of days ago that the establishment of the NSF for particular diseases, such as diabetes, was one of his proudest moments since becoming Under-Secretary. What is different in Wales that means that his NSF is not good enough for the people of Wales and that they need something different? Why is it not applicable to them? Why is it necessary to duplicate it? Why is it necessary to spend public funds, which would otherwise have been available to treat patients, to create a second NSF for Wales?

David Lammy (Labour, Tottenham)

Do the hon. Gentleman's Conservative colleagues in the Welsh Assembly share his opinions?

Chris Grayling (Conservative, Epsom and Ewell)

My concern is about what is right for the patients. We are the Parliament of the United Kingdom.

David Lammy (Labour, Tottenham)

Does that mean that the Welsh Conservatives are patently wrong?

Chris Grayling (Conservative, Epsom and Ewell)

The Under-Secretary may have missed the point, which is understandable; as he said yesterday, the role is new to him. I should like to remind him that he is an Under-Secretary in the United Kingdom Parliament, not an English Parliament. I was under the impression, Mr. Griffiths, that it was our duty in this place to make decisions in the interests of the people of the United Kingdom.

I do not understand how it can possibly be in the interests of the people of Wales to create a second NSF, with people putting together information, secretariats assembling documentation and expenditure being provided for the communication of that NSF to medical practitioners across Wales. That money could otherwise have been spent on operations and on reducing the ridiculously long waiting lists that most patients in Wales currently experience. This is an absolute nonsense.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I do not wish to intrude on this interesting discussion, but suppose that the Welsh Assembly—including Welsh Labour—took the same view as the Audit Commission in its report this morning and decided that, as far as possible, it did not want those targets and their associated standards imposed on the Welsh people. Does the hon. Gentleman accept that, if that were the case, the way in which the Bill is written provides an escape—at least in Wales—from the imposition of what is a very poor policy, according to the Audit Commission? That is one benefit of devolution.

Chris Grayling (Conservative, Epsom and Ewell)

The hon. Gentlemen is more of a pessimist than me. I very much hope that the weight of argument that will come from the Conservative Benches and the Liberal Democrat Benches in the next few days about the roles and responsibilities of CHAI will encourage Ministers to step away from imposing such a huge burden of target pursuit on the health service and from forcing the inspectorate to use those targets as their prime reference point.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I share the hon. Gentleman's hopes, if not necessarily his optimism. He will agree that if we were able to change the Bill in the way for which we both voted last time—which would mean that CHAI would set the standards after consultation with the Department of Health and the Welsh Assembly—at least different political opinions on setting standards could be channelled through one organisation. We could then have a more transparent process, which would solve some of the problems that he has identified.

Chris Grayling (Conservative, Epsom and Ewell)

I very much agree with that. The hon. Gentleman will recall my expression of disappointment that the Bill appears to leave greater political control in one part of our country than in others. My view, and that of my colleagues, is that politicians do not have the expertise to inspect and establish health care standards.

David Lammy (Labour, Tottenham)

There is a precedent in Wales for separate inspectorates; they already have separate inspectorates for social services and for education. Does the hon. Gentleman's remark also pertain to those?

Chris Grayling (Conservative, Epsom and Ewell)

I fear that I would be treading on your patience, Mr. Griffiths, were I to steer the discussion towards social services and education. I am interested solely in the best interests of the patient, and particularly in the best interests of those in the border areas—either just in Wales or just in

England—where services do not stop at the boundaries, but cross over. In those areas, patients from England may go to a hospital in Wales because it is nearest, and vice versa. Patients may even go to a GP across the border. There is a danger that those patients in particular will lose out. That will happen partly because of the waste that I have described from creating parallel structures, parallel administrations and parallel NSFs. Patients will lose out because of the nonsense of doctors having to pursue one NSF with one patient and a different NSF with another. If those structures are to be different, doctors will have a duty to do precisely that.

If the Under-Secretary thinks that that is a mythical possibility, let me give him a real example of something that occurs in the NHS today. Different purchasing patterns in different primary care trust areas mean that doctors have to ask patients where they live before their treatment can be decided on. I know this because I have talked to doctors in London who have said that they have to ask those questions. Returning to the Prime Minister's area of interest, I have talked to diabetes specialists in London—[Interruption.] I apologise to the Under-Secretary; I do not want to ruin his prospects any more than they already have been by the rumours about his future career prospects. Diabetes consultants in London tell me that different primary care trust spending patterns mean that they can prescribe to one patient something that they cannot prescribe to another. The NSF for England may make a specific recommendation about a drug, a form of treatment or a device that should be part of the treatment for that condition, but the NSF in Wales might not do that and may recommend something different.

In that case, a doctor may have to give one treatment to one patient and something else to another, even if they come from adjoining villages and have consecutive appointments in the calendar. Is that honestly in their best interests, let alone those of the doctor who must remember where each patient lives and work out what to do? That would be an absurdity.

My concern is not whether politicians in Wales or England have decision-making powers, but that an absolute nonsense will be created for patients. Duplication and confusion will provide only a disservice, and that is surely not the best way to work.

My last point concerns the one-way nature of the exercise. I refer the hon. Member for Cardiff, Central to my point about clause 66. The Under-Secretary will correct me if I am wrong, but the Bill provides the Welsh Assembly with the power to mandate inspections of English bodies that provide health care services in Wales. Therefore, a hospital in Chester may face two inspections rather than one. Can the Minister assure me categorically that that will not be the case? I doubt that he can, and additional bureaucracy will be imposed as a result.

The same is not true in reverse. The Bill does not give CHAI the right to ask whether a decent job is being done for English patients whose local hospital

is in Monmouth, Newport or mid-Wales. That is also an absurdity. If there are to be two-way inspections—I do not believe that there should—it is nonsense that they go one way and not the other. Is it necessary to have a situation whereby a hospital might be inspected twice? Any hospital manager will confirm that a CHAI inspection is onerous and challenging and requires a considerable investment of management time that could be better used in running the hospital. For that to happen twice, rather than once, is unnecessary.

That part of the Bill is bizarre and unnecessary, and devolution would not be damaged if it were set to one side. Certainly, the management of the health service in Wales and deployment of resources rest with the Welsh Assembly. My colleagues in Wales will be delighted to endorse that contention. However, is it necessary for the United Kingdom Parliament to set up two inspectorates when one can, and should, do the job? The Under-Secretary's arguments have been unconvincing, and I ask my hon. Friends to back me by challenging the Government's ludicrous assumptions and by voting for these amendments.

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

Understandably, those Members of Parliament who do not represent Wales have a patchy knowledge of how Welsh affairs are arranged. It is true that the health service in Wales is organised separately from that in England. To answer the question raised by the Member for Oxford, West and Abingdon (Dr. Harris), targets set in Wales are different from those in England. I have no difficulty with that.

My concern is that, without some mechanism to ensure comparability, two inspection regimes will be wasteful and will not provide the best service to people on both sides of the border. There should be such mechanisms to ensure co-ordination and comparability, but they do not appear to be in the Bill. I suspect that well-informed peers in another place will want to scrutinise that.

Before CHAI is established, the body known as CHI—chaired by Dame Deirdre Hind, the former chief medical officer for Wales—is currently conducting a joint inspection in England and Wales. Contrary to what my hon. Friend the Under-Secretary said, I do not believe that that body has expressed any difficulty in inspecting services in Wales.

The Welsh Assembly has decided, however, that it wants a separate inspection. That is all very well, but the Bill should contain some guarantee that we can compare, contrast and co-ordinate the two inspection systems, even though I do not think that two separate systems are necessary.

David Lammy (Labour, Tottenham)

I respect my hon. Friend and hope that he is satisfied with clause 132. If he is not, I shall be happy to reconsider.

Question put, That the amendment be made.

The Committee divided: Ayes 6, Noes 17.

Win Griffiths (Labour, Bridgend)

The hon. Member for Ealing, North (Mr. Pound) has just voted in Welsh. Although the debate concerns England and Wales—and even though I recognised the other language—I remind Members that, while we are in London, we will vote in English.

Dame Cheryl Gillan (Conservative, Chesham and Amersham)

On a point of order, Mr. Griffiths. Just as the Division was called, the hon. Member for Cardiff, Central inexplicably left the Committee Room, so that he was not able to vote on a Welsh matter. Is it in order for a Member to leave the Committee after a Division has been called in order to avoid voting on a measure that affects the country of which he is a representative?

Win Griffiths (Labour, Bridgend)

That is not a point of order. The hon. Gentleman might have had to deal with some urgent personal matter.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I beg to move amendment No. 394, in

clause 41, page 14, line 22, after 'consult', insert

'the royal medical colleges and the CPPIH and'.

Win Griffiths (Labour, Bridgend)

With this it will be convenient to discuss the following:

Amendment No. 395, in

clause 41, page 14, line 22, after 'appropriate', insert

'and must publish a draft statement for consultation'.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Given the Government's answers, yesterday's debate was unsatisfactory. Many of the issues touched on by this group of amendments have been raised before, and I do not expect a long debate.

We have been seeking to ensure that the targets and standards—or milestones or whatever the latest spin word is—that the Secretary of State will force CHAI to use, unless the Bill is amended, are clinically relevant. Our concerns are based on a view that I outlined yesterday about a target-based culture, or even a culture based on standards and not targets. If those standards or targets are neither evidence-based nor relevant to real and important clinical outcomes, as opposed to political outcomes, it will lead to a bad situation.

Some care must be taken in clinical terms before standards and targets are imposed on the national health service, whether it be directly, as now, by the Secretary of State in his name, shame and blame culture, or—even worse, in a sense—through CHAI, because that seeks to legitimise an illegitimate process.

It is reassuring that there is support for our position, not only from groups such as the King's Fund—which operates very much from a patient-focused point of view—but from organisations such as the British Medical Association, the royal medical colleges and, especially, the Audit Commission, whose report, issued this morning, states:

''Targets that frontline clinicians and managers perceive to be unrealistic, inappropriate or not the real priorities can become obstacles to change.''

That is putting it mildly. The report goes on to state:

''Rather than becoming an integrated part of day-to-day management, such targets risk being seen as an irritating distraction . . . For example, some doctors have questioned whether clinical priorities are being distorted by the focus on waiting times (by making patients who are clinically more in need wait for their treatment because a relatively non-urgent patient is approaching the NHS Plan target maximum wait).''

The Under-Secretary has dismissed and failed to address that opinion. Indeed, he said that this Committee was not the place in which to discuss a clause entitled ''Standards set by the Secretary of State''. He must address—

David Lammy (Labour, Tottenham)

I did not say that.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The Under-Secretary says that he did not say that.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

If my hon. Friend reads yesterday's Hansard, he will be interested to note that, during an exchange with me about questions as to the effectiveness of the Bill to deliver scrutiny of the Government's decisions and their impact upon health care, the Under-Secretary said:

''The hon. Gentleman should direct that question to those who will head the new organisations if the Bill is passed and they are established.''—[Official Report, Standing Committee E, 4 June 2003; c. 497.]

In other words, questions will be answered after the event.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Yes, that is the problem. I am grateful to my hon. Friend, because when the Government is faced with such questions on the Bill, they refuse to answer. They say that this is not the right place or that we must wait until the Bill is law. It will be too late, therefore, to scrutinise before questions of the victims of poor legislation are addressed.

If this section of the Bill is to have any credibility—indeed, if the Under-Secretary is to have any credibility in his defence of it—he must address the question raised by the King's Fund, the British Medical Association, the royal colleges and now by the Audit Commission. The Audit Commission is the Government's independent watchdog—perhaps it is more independent than the Government wanted—concerned with the proper use of resources, let alone the proper treatment of patients.

That is the basis for this group of amendments, which is yet another attempt to limit the damage that the imposition of the political targets, and the political standards upon which they are based, will have on patient care.

To recap briefly, the standards and targets that we are discussing are not the national service framework targets. Those are promulgated by a group—many of whose members have relevant clinical experience—after it has studied the strength of the evidence for specific standards and policies. In that respect, I doubt whether there would be any difference between NSFs in England and Wales, for example, given that the evidence base will be similar.

We are not talking about those standards and targets, but about the political targets that this Government have imposed for, for example, waiting times and the time spent in accident and emergency departments. The target in accident and emergency departments is not even the time taken for a patient to be seen by a doctor, which has some clinical relevance, but the time taken for the patient to leave the department, even if that is the best place for the patient. That point was raised by the British Medical Association.

Andrew Murrison (Conservative, Westbury)

Is the hon. Gentleman suggesting that national service frameworks are being politically sanitised? They are surely not documents produced just by professionals; they come from the Department of Health. He may wish to reflect upon the status of those documents and consider whether they have been subject to political tweaking. I am sure that they have.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The hon. Gentleman makes an interesting point that should concern us. At least the process in developing national service frameworks is better and more transparent. We shall never know what happens to some of the drafts unless the people who write them point out that they have been sent back with changes from the Under-Secretary's desk, the Secretary of State's desk or—this is something that concerns us—the Prime Minister's desk.

I am relatively happy that it is appropriate to have a process that is clinically focused and that considers the evidence. Indeed, looking at the results, people will ask, as I have, whether clinicians working in the health service and in some of the groups that I mentioned have concerns about NSF targets. Generally, they do not. The NSF approach is one that my hon. Friends and I support. There is a question about which target comes first and its effect on areas for which priorities have not yet been set because of the tyranny of the appraisal. Nevertheless, one must start somewhere, and we are on record as supporting the process.

Our concerns are focused on the political targets. We have attempted to ensure that CHAI sets the NSF and other standards and that it publishes the evidence. We have also asked that if the Secretary of State sets the standards, he publish the evidence, and its strength. So far, both suggestions have been rejected.

We now come to our third attempt to improve this part of the Bill in the interests of patient care. We want to ensure that the Secretary of State is not given discretion to consult only such persons as he considers appropriate, because we know that that will exclude those who disagree with the Secretary of State. If the Secretary of State had consulted anyone on the standards and targets and had listened to the findings of the consultation, those standards and

targets would not have seen the light of day, given the huge number of organisations—including all those with a clinical focus—that oppose their imposition.

We would like the Bill to force the Secretary of State to consult at least—the list is not exclusive—those organisations that represent clinicians and the organisation that represents the patients' voice in the health service. That is why we propose in amendment No. 394 that the Secretary of State consult the royal medical colleges and the Commission for Patient and Public Involvement in Health, and then such persons as he considers appropriate.

In amendment No. 395, which has been grouped with amendment No. 394, we ask the Secretary of State to publish in draft the standards for consultation so that, in a transparent process, anyone can feed in their views on the questions. That ensures that no one is excluded, but that there is a minimum requirement to consult representatives of both sides of the clinical divide, because it is right that doctors and patients make decisions together.

Andrew Murrison (Conservative, Westbury)

I am interested by the hon. Gentleman's reference to ''royal medical colleges''; they should be referred to as ''medical royal colleges''. I am interested to know why he has put it that way round, but that is beside the point. Why has the hon. Gentleman specified medical royal colleges? In so doing, he will exclude from the consultation other non-doctor organisations. Indeed, that might skew the standards that will eventually result, particularly those for nursing-run procedures, physiotherapy and occupational therapy; even alternative therapies will be disadvantaged by the hon. Gentleman's proposal.

David Lammy (Labour, Tottenham)

Good point.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The hon. Gentleman can be reassured—not by the Under-Secretary congratulating him from a sedentary position; that should worry him—because no one is excluded from the consultation. If the amendment is agreed to, the Secretary of State will have discretion, after consulting the medical royal colleges and the Commission for Patients and Public Involvement in Health, to consult groups that he considers appropriate, and I would expect him to do so. As well as that, amendment No. 395, which the hon. Gentleman should not overlook, states that the standards will be published in draft for consultation. That will allow all those with an interest to be consulted and to feed in their views.

It is difficult to be too selective, but the alternative is not to make any amendment. Then the Government would probably seek to avoid consulting the key groups or representatives of those groups that have a clinical purpose. In saying that, I do not deny that other health care professionals have a view. If the hon. Gentleman wants to amend the clause to add specific groups or if the Under-Secretary wants to add groups to the initial consultation compulsory list, that is fine. However, my proposal does not exclude people from the consultation.

The hon. Gentleman asked why my amendment says ''royal medical colleges'' instead of ''medical royal

colleges.'' I shall return to my original scribbled draft of the amendment and perhaps give him some assurance on whether it was my error or a transcription error.

Andrew Murrison (Conservative, Westbury)

I have been listening with a great deal of interest to what the hon. Gentleman said about the wide consultation in amendment No. 395. That would, of course, eclipse amendment No. 394, which specifies medical royal colleges, or royal medical colleges. However, that would be eclipsed by the general, more eclectic consultation that he envisages in amendment No. 395. Does the hon. Gentleman agree?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

No, because it is a two-stage process. Amendment Nos. 394 and 395 should be read together—I am not arguing that they should not—but amendment No. 394 asks that the draft statement of standards be produced after consultation with three groups of people or institutions. Those groups should include the medical royal colleges and the CPPIH, both of which, in answering the consultation, would discuss the matter with constituent bodies. The CPPIH would discuss it with the patient forums for which they have responsibility, and the medical royal colleges would discuss it with the colleges. The third group to be consulted would be made up of those considered appropriate by the Secretary of State.

That would be the basis for the publication of the draft standards. There would then be a second process of public consultation in which groups that had been omitted by the Secretary of State would be given the opportunity to make their contribution before the final standards were published. It would be the Secretary of State who omitted those groups, not the amendment, because there is a catch-all to allow the Secretary of State to consult those groups that he deems appropriate. That offers the best of all worlds because it maximises the consultation on a critical issue.

The amendments would have stood even if our amendment on CHAI, instead of the Secretary of State, had stood. The promulgation of standards, which tends to dominate many of the questions about resource allocation and clinical decision-making, is so important that it must be got right. I hope that the hon. Member for Westbury accepts my assurances that the amendment does not exclude anyone; rather it increases dramatically transparency and consultation and the advice that the Secretary of State receives.

Of course, we cannot force the Secretary of State to take advice; indeed, this Secretary of State seems to disregard medical advice on targets and standards other than those in NSFs. In this way, however, we can at least guarantee that the Secretary of State is forced to receive it, even if he chooses to ignore it. I commend these amendments to the Committee.

Chris Grayling (Conservative, Epsom and Ewell)

I echo the hon. Gentleman's sentiments and share the direction in which he wishes to go. I wish that these amendments were not necessary, because if we could remove the words ''Secretary of State'' from subsection 1, the issue would not arise in the first place. Our original amendment said that CHAI should be the ''principle guardian of standards'' in the NHS. If the

Government had accepted that wording, none of this discussion would have been necessary.

I wholeheartedly support amendment No. 395, which would be a valuable addition to the Bill and would, quite rightly, open up a proper debate among professionals about the standards that the Government are putting forward. That cannot be done solely by a committee. We all know that committees can be populated by placepeople; I am not suggesting that they always are, but they can be. At least we shall be creating a process in which the full gamut of medical opinion can be brought to bear on an issue.

I share the concerns of my hon. Friend the Member for Westbury about amendment No. 394, which is too prescriptive and risks excluding several important parts of the medical profession from the process. I am much less uneasy about amendment No. 395.

Underlying all this, there remains the concern that the Government continue to manage a politicised NHS. Standards are set in Whitehall to stipulations set out by Ministers, and we know that that it is not working; the Audit Commission told us that this morning. No other country has such a high degree of political control of its health care systems. In every other European country there is much greater professional involvement, much greater decentralisation and much less political involvement and control. That system works significantly better. We must make Ministers understand that a core part of the path to improved health care in this country is for politicians to take a step back—

Win Griffiths (Labour, Bridgend)

Order. I had hoped that the hon. Gentleman would begin to speak to one of the amendments, but he is going into a very wide field of general issues. Important though he may feel those issues to be, I ask him to speak to the specifics of the two amendments.

Chris Grayling (Conservative, Epsom and Ewell)

I apologise. I thought that I had set out the reason that I felt that amendment No. 395 was right; it goes some way to counterbalancing the unwanted trend of centralisation. For the Secretary of State to be able to prepare and publish standards without even having to consult on them or without being open to a challenge in court is another piece of the jigsaw puzzle of over-centralisation and its consequences that we have described as we have gone through this Bill.

Although I do not know what the aspirations of the hon. Member for Oxford, West and Abingdon are in regard to these amendments, I could not in good faith ask my hon. Friends to support amendment No. 394, which is the lead amendment of this group. I am not persuaded that, in its present form, it is the right way to make an addition of this kind to the Bill.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I did not want to interrupt the hon. Gentleman earlier but, in discussing amendment No. 394, he said that it would exclude groups; I hope I am not misquoting him. I hope to impress on the hon. Gentleman that the amendment does not exclude any groups. By including the words ''as appropriate'', and

taken with amendment No. 395—which would allow a draft to be published even for those groups that have been excluded by the Secretary of State—the amendment guarantees inclusion for two groups, without excluding any groups.

I accept that the amendment treats groups unequally, but that is in the nature of the need to construct legislation that includes any sort of list. I hope that the hon. Gentleman will not say that it excludes people. I hope that he will reconsider that term.

Chris Grayling (Conservative, Epsom and Ewell)

Amendment No. 394 makes a subjective selection of organisations that are to have a statutory right of consultation. Several other organisations could be considered to have an interest in playing a role in such consultations. Should patient groups that represent those who suffer from diabetes also have a statutory right to be consulted on the formation of a NFS for diabetes? I do not think so. Equally, I do not see why such a group should have more or less of a right of representation than the CPPIH, for example. I would not wish to exclude either the royal colleges or the CPPIH, but I am not persuaded that they are the only two organisations that should have a statutory right of consultation in the Bill. The hon. Gentleman makes a good point when he says that amendment No. 395 permits everyone to be involved. That is the route that I wish to take. Amendment No. 395 does the job, whereas amendment No. 394 is unduly prescriptive.

The attempts made by Opposition Members to deal bit by bit with this jigsaw puzzle of centralised control—these two amendments, particularly amendment No. 395, are one small part of that—reflect a shared aspiration and view on these Benches that the direction of many parts of this Bill is not right.

David Lammy (Labour, Tottenham)

The hon. Member for Oxford, West and Abington is confusing standards with targets. I explained yesterday the need to recognise this distinction, and I do not wish to rehearse those arguments today, even though the hon. Gentleman feels the need to do so. He listed the King's Fund, the BMA and the Audit Commission, as well as the report that the Commission published today. Those groups are not included in the amendment. That supports the point that I made yesterday, and which I wish to make again today, that it is difficult to determine where such a list should begin and where it should end. For example, the hon. Gentleman has chosen, through amendment No. 394, to list the CPPIH in the Bill. The amendment would add bureaucracy, delay and division to the health service, and I hope that the hon. Gentleman will withdraw it.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I interrupt the Under-Secretary because I am waiting for him to respond to amendment No. 395, which is also in this group of amendments. I note the point that was made by the hon. Members for Westbury and for Epsom and Ewell, and by the Under-Secretary, that any list of statutory consultees would give those groups a greater right of consultation than others.

I invite the Under-Secretary to comment on amendment No. 395. After all, we are here to debate

the amendments and to hear the Government's response. I ask the Government to publish in draft, for public consultation, the standards that it is forcing on the NHS. I should be grateful to the Under-Secretary for a response. I can then judge which amendments, if any, I should press to a Division.

David Lammy (Labour, Tottenham)

As I said, those arguments were rehearsed yesterday. We have heard them replicated in slightly different language, but they are the same arguments. The Secretary of State has a duty to consult, and that is sufficient. For the reasons of bureaucracy, delay and division that I mentioned, I would resist amendment No. 395 as well.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I am keen to press amendment No. 395 to a Division. However, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: No. 395, in

clause 41, page 14, line 22, after 'appropriate', insert

'and must publish a draft statement for consultation'.—[Dr. Evan Harris.]

Question put, That the amendment be made:—

The Committee divided: Ayes 8, Noes 13.

Win Griffiths (Labour, Bridgend)

I request hon. Members to bear in mind that sometimes during Divisions it is difficult to hear what is being said because of a slight undercurrent of noise in the Room.

Clause 41 ordered to stand part of the Bill.

Clause 43 - Information and advice

Simon Burns (Conservative, West Chelmsford)

I beg to move amendment No. 510, in

clause 43, page 15, line 7, after 'to', insert

'make regular reports available to the public about, and'.

Win Griffiths (Labour, Bridgend)

With this it will be convenient to discuss the following:

Amendment No. 511, in

clause 45, page 15, line 36, after 'to', insert

'make regular reports available to the public about, and'.

Simon Burns (Conservative, West Chelmsford)

The amendment deals with the beginning of clause 43, which refers to the general functions of CHAI, and to the information, advice and instructions laid down for it.

In relation to clause 43(1), the amendment seeks to ensure not that CHAI must keep the appropriate authority informed on the provision of health care, but that it should make regular reports available to the public on the information that it gathers and the reports that it produces. In this subsection, the appropriate body in England is the Secretary of State; in Wales it is the National Assembly for Wales. The amendment would improve the Bill because it would make the process much more transparent. I have no problems, in the context of the Government's intentions, with CHAI keeping the appropriate authorities informed.

However, I do not see why it cannot go one step beyond the appropriate bodies to the public. It is the people's health care system and national health service, and they should be entitled to know exactly what is going on. Furthermore, if one were to make the reports public, one would know what was going on at all times. There is a possibility that although CHAI might keep the appropriate authorities informed, those authorities might not pass that information on to others.

I hope that the Under-Secretary will see the amendment as a move to open out the process and to make it more transparent. I hope that that will be an attractive proposition to him.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I support the group of amendments, as they are useful additions to the Bill. They enable the Government to give substance to one of the things that the Secretary of State said last April, when he introduced the report ''Delivering the NHS Plan'', which was that if commissions are to act as judge, the public will be the jury. It is hard for a jury to act in its proper capacity if it does not have access to information and if information is not freely provided to it. To include a clear requirement in the Bill that such information should be published in this way is a useful addition.

It would be helpful to hear the Under-Secretary's thoughts on how the two commissions will discharge that responsibility and, specifically, if he could set out how he envisages the public being kept informed about health care and social care, about the activities of the two commissions and about the findings from their inspections of health and social care.

David Lammy (Labour, Tottenham)

Amendments Nos. 510 and 511 will place a duty on CHAI to make regular reports available to the public on the provision of health care by and for NHS bodies, and on a par with what it also provides to the appropriate authorities. The function set out in the Bill is necessary to ensure that the appropriate authorities are kept informed on the provision of health care for which they are responsible. As a way of demonstrating its increased independence, the Secretary of State will not have the regulation-making power that he has over CHI on the publication of reports.

Such a power enabled my right hon. Friend to specify the means and manner in which the old CHI disseminated its findings to the NHS and to the general public. I cannot accept this amendment, as it would, in effect, compel the new CHAI to do that. The

public rightly expect the new CHAI to be an authoritative, independent judge of quality and efficiency and to be a driving force for the continuous improvement of health care provided by all NHS bodies.

It is already obvious that the new CHAI will want to keep patients and the public informed of developments in the NHS and in independent health care provision. I am confident that CHAI will have patients and the public at the forefront of its considerations and that it will operate as openly as possible. CHAI will have ample opportunity to ensure that the public are informed about the provision of health care, and it is not necessary to state that explicitly in the Bill. I hope that the hon. Gentleman will withdraw his amendment.

Simon Burns (Conservative, West Chelmsford)

I am disappointed by the Under-Secretary's response, because, notwithstanding his remarks, the amendment would be a positive step towards increasing the transparency of the process and, as the hon. Member for Sutton and Cheam (Mr. Burstow) said, towards enabling us to have a judge and jury. I should like to stress on the record that this is a wasted opportunity. I shall not press the amendment to a Division, however. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I beg to move amendment No. 371, in

clause 43, page 15, line 7, after 'authority', insert

'and the Health Select Committee'.

Win Griffiths (Labour, Bridgend)

With this it will be convenient to discuss the following:

Amendment No. 347, in

clause 73, page 28, line 19, after 'State', insert

'and the Health Select Committee'.

Amendment No. 348, in

clause 135, page 57, line 20, at beginning insert—

'(1) If at any time after the passing of this Act—

(a) the name of the Health Select Committee is changed; or

(b) the functions discharged by the Committee at the passing of this Act, or functions substantially corresponding thereto, are discharged by a different Committee of the House of Commons,

reference in this Act to the Health Select Committee shall be construed as a reference to that Committee by its new name or, as the case may be, to the Committee for the time being discharging those functions.

(2) Any question arising under subsection (1) shall be determined by the Speaker of the House of Commons.

(3) .'.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

The amendments develop the theme introduced by the hon. Member for West Chelmsford (Mr. Burns) regarding transparency and greater openness in reporting. They seek to impose a requirement on CHAI and CSCI that the information that they produce should also be provided to the Select Committee on Health. Were that Committee's title to change, there is provision in the final amendment in the group for that to be dealt with in the usual way. There are provisions in

section 13 of the National Audit Act 1983 that deal with such matters in respect of the Public Accounts Committee, and this amendment seeks to cover the Health Committee in a similar way.

The amendments simply seek to ensure that there is a clear link between the work of the two commissions and the Health Committee. That Committee has an important job to do in scrutinising the health and social care activities of the Government, the public sector and others. They would be an additional and invaluable way of ensuring that members of that Committee—and, as a consequence, all Members of the House—could make sure that both commissions discharge their duties appropriately. I hope that the Minister will accept the amendments in the spirit in which they are moved.

Simon Burns (Conservative, West Chelmsford)

I declare an interest as a member of the Health Committee. The amendments of the hon. Member for Sutton and Cheam do not appeal to me. I understand the reasons form them, but they would not be practical. I do not part company with him in wanting more information and transparency. In that, we are in agreement. However well intentioned the proposal to ensure that the Health Committee gets information, his amendments are, up to a point, unnecessary and possibly misunderstand the role of the Health Committee.

The Committee usually carries out two major inquiries on health care subjects a year, in addition to a few mini-investigations on matters of health care and the provision of service. Apart from generating a great deal of effort and paper, what would be the benefit in ensuring that the Health Committee has, in effect, a statutory right to receive all the papers from CHAI?

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I am following the hon. Gentleman's argument closely. How does he expect the amendments to work, given that they propose to insert a requirement in the Bill that would presumably have placed the same obligation on CHAI to supply all that information to the public? How does he balance that?

Simon Burns (Conservative, West Chelmsford)

The public are entitled to receive that information or to have the opportunity to see it. The hon. Gentleman's amendments said that the information should be given as of right to the Health Committee. What would be the purpose of that? As I have explained, the Health Committee carries out investigations and inquiries into matters of health care and provision each year. It also calls Health Ministers to appear before it for a single sitting. However, they do not all appear at the same sitting.

Usually, the Secretary of State attends a sitting on his own, followed by the Ministers of State—[Interruption.] Of course, as the Under-Secretary has rightly just said from a sedentary position, the Health Committee had the privilege of questioning the hon. Gentleman only a few weeks ago. Sadly, it was a loss to both my education and my enjoyment that I was unable to attend because of a clash with my parliamentary duties on this Committee.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I am grateful to the hon. Gentleman and former Minister for giving way. I want to rehearse with him one of the reasons why such a requirement might be useful. I am grateful for his exposition of the role and purpose of Select Committees, particularly that of the Health Committee. The purpose of placing that requirement in the Bill is to ensure that members of the Health Committee, who have to determine the priorities for future inquiries, will benefit from information provided by the commissions when making those determinations. That helps to widen their vision and enables them to have a better understanding when determining the priorities of future work.

Simon Burns (Conservative, West Chelmsford)

I understand the hon. Gentleman's point, but I am not convinced by it. I see it as a skilful attempt to make the original point in a different way to add credence to his argument.

The other point is that the Health Committee can hold an inquiry into the operations of CHAI at any time. The Committee would receive all the information that it needed at the time to conduct such an inquiry and to monitor the activity of health care provision. Therefore the hon. Gentleman's amendments, however well intentioned, are misguided. In practice, they would add little to our knowledge and scrutiny of the operation of that area of health care, other than considerable paperwork and effort.

David Lammy (Labour, Tottenham)

The hon. Member for West Chelmsford makes many of my points for me and makes them with some flair and panache. I discovered that he is related to a famous rock star—David Bowie. Some similarities between the two are apparent this morning.

Steve Pound (Labour, Ealing North)

I am reluctant to intrude, but I think that David Bowie himself claims to be related to the hon. Member for West Chelmsford.

David Lammy (Labour, Tottenham)

I am grateful to my hon. Friend for putting me right on that point.

On the subject of the amendments, both Houses of Parliament have an established right to summon witnesses to appear before them to answer questions from Committees. They may summon any witness by virtue of the derogation of power. The Government fully support the principle that the commissions' work should support Parliament's scrutiny of policy in public services. That is why clauses 121 and 122 require the commissions to produce and lay before Parliament an annual report on their findings. Elsewhere in the Bill is the provision for the commissions to produce and make public reports as it undertakes studies throughout the year.

For those reasons I cannot support the amendments, and I hope that the hon. Member for Sutton and Cheam will feel able to withdraw them.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

Earlier, I inadvertently described the hon. Member for West Chelmsford—who speaks for the Opposition on the Committee—as the Minister. On this occasion, perhaps there was a sharing of the brief that is being used to rebut these amendments.

David Lammy (Labour, Tottenham)

I ought to put on record that I am related to Eddy Grant, the famous reggae star, and perhaps that is why there was some sharing of beliefs this morning.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I am grateful for the candour with which the Under-Secretary details his family tree. I do not plan to start discussing my family roots, because I would be out of order.

I have listened carefully to both hon. Gentlemen and their arguments for not accepting the amendment. It is undoubtedly an improvement to have an annual report by both commissions coming to this place; it will provide some comfort that their activities and findings can be scrutinised. CHAI would keep the appropriate authority informed on the provision of health care, but the clause does not stipulate that authorities will be deluged with tons of papers, bombarded by e-mails or in any other way completely inundated with material.

The clause enables CHAI to make a judgment about the information that it should be passing on at any given time. The improvement of the radar facilities of the Health Committee in determining the issues into which it may wish to conduct inquiries in future would be a useful addition to its many facilities. However, it is not worth pursuing the argument any further. We shall consider returning to it, having reflected on the arguments of both hon. Gentlemen. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Chris Grayling (Conservative, Epsom and Ewell)

I beg to move amendment No. 518, in

clause 43, page 15, line 7, after 'provision', insert 'and quality'.

Win Griffiths (Labour, Bridgend)

With this it will be convenient to discuss the following amendments: No. 515, in

clause 45, page 15, line 36, at end insert 'and healthcare outcomes'.

No. 519, in

clause 46, page 16, line 7, after 'provision', insert 'and quality'.

No. 520, in

clause 50, page 17, line 36, after 'provision', insert 'and quality'.

No. 521, in

clause 51, page 17, line 39, after 'provision', insert 'and quality'.

No. 522, in

clause 52, page 18, line 20, after 'provision', insert 'and quality'.

No. 523, in

clause 52, page 18, line 22, after 'provision', insert 'and quality'.

No. 524, in

clause 53, page 18, line 37, after 'provision', insert 'and quality'.

Chris Grayling (Conservative, Epsom and Ewell)

You will remember, Mr. Griffiths, that on one or two occasions I have spoken about the jigsaw puzzle and the pieces that we want to put in place to change the nature and tone of the inspection and regulatory system for health care in this country. I see these amendments as a significant part of that jigsaw.

The amendments are designed to change the balance of several important parts of the Bill. They add the words ''and quality'' after the word ''provision''. The word ''quality'' does not appear in

any of the clauses that deal with CHAI. In almost every case, it says ''provision.'' The problem is that provision is not quality. I could set up Dr. Harold Shipman in a surgery in a country village, and that would be a health care provision, but it may not guarantee quality of health care. That is a trite point, but it is a much more serious issue.

One of the key flaws of the target structure that the Government have established in the reference point that they will give to CHAI to assess the performance of the health service is that the focus is on the provision of health care. We do not ask whether the health service is making us better but whether it is treating us. There is a fundamental and important difference between the two. The Audit Commission's report referred to that difference this morning. We focus too much on whether we are treating people and much too little on how well we are treating them or on whether they are getting better.

The Government have set too many targets that do not examine health care outcomes. In fact, they actively distort health care outcomes by requiring clinicians to make decisions that are not necessarily in the best interests of their patients. Decisions are taken to enable the institutions of which they are part to meet the Government's targets, and the performance of those institutions will be judged against those targets. That is important because the benchmark that the Government wish to use to judge the quality and effectiveness of hospitals—the star-rating system—is not primarily about the quality of clinical work; it is about governance, management and provision.

CHAI uses 28 indicators to assess the effectiveness of a hospital in deciding whether it should be a zero-star, a one-star, a two-star or a three-star hospital. In fact, a hospital can lose a star rating due to provision and administration and not due to clinical governance. An NHS trust chief executive recently told me that he was afraid that he would lose a star this year due to financial, not clinical reasons. There was no reflection on the quality of health care carried out by that hospital. If his fears are confirmed, the rating that CHAI will place against that hospital will not be about quality of health care but about other issues.

A hospital can achieve three stars, as the 28 indicators are used to assess it against its peers to determine its star rating. The use of those indicators can mean that a hospital that does not perform well clinically can none the less get three stars if it delivers on provision and on the other factors. Therefore a hospital that does a stunning job in reducing waiting times, for example, can totally fail to treat patients effectively but still receive a high rating. The amendments seek to establish a duty, through the Bill, on CHAI to look not simply at provision but at the quality of health care being delivered.

A recent publication of a survey by the independent health care organisation, Dr. Foster, challenged the assumptions of the rating system and its effectiveness in delivering a true and proper assessment of the quality of health care achieved in hospitals. The figures demonstrated that many three-star hospitals were

doing less well clinically than hospitals with lower star ratings. Surely, we cannot tell those institutions that if they do a good job of making patients better, they will be rated by the inspection system, by their peers and by the environment in which they work less highly than those organisations that have delivered on management but not on health care. That is an anomaly that must not be perpetuated.

The amendments allow us an opportunity to write into the Bill that quality must be a fundamental part of the work of CHAI. The word ''provision'' does not allow that to happen. Provision is very much about waiting times, specific targets, capacity and recruitment of clinicians, all of which are important. The amendments do not seek to remove the word ''provision'' from the Bill; they seek to ensure, however, that when CHAI carries out its inspections it asks whether an institution is delivering quality health care; whether patients are getting better.

The part of the Bill about foundations hospitals tends to steer our discussions towards hospitals, but the issue is not purely and simply about hospitals. Ambulance trusts are judged, most significantly, on the length of time that their ambulances take to reach incidents, for which the Government have fixed a target of eight minutes. Accident and emergency departments also have targets for waiting times. The trust in Avon was recently given a hard time by CHI for its failure to tackle the waiting times in its accident and emergency departments. Much work is being done in that part of the world to resolve the issue.

However, targets do not give us a view on whether ambulance trusts save lives. Dealing with cardiac arrests is probably the most significant job that ambulance trusts do, because the length of time that it takes an ambulance to reach someone who has suffered a cardiac arrest will determine absolutely that person's chances of recovery. If he is treated quickly, he will have a fair chance of recovery. If not, he will probably die. Therefore the way that an ambulance trust performs with regard to heart attack victims is fundamental to whether those victims survive.

There is a huge disparity between ambulance trusts' recovery rates for cardiac arrest victims. In some areas, a significantly higher proportion of people are treated successfully and recover than in other areas. We should know the reason for that. We should examine what those ambulance trusts are doing and share best practice across the NHS. I am much more concerned about that than about whether a trust makes its eight-minute target across the board. What could be more important—

Adrian Bailey (Labour/Co-operative, West Bromwich West)

I am following the hon. Gentleman's comments with interest. I find it odd that if it is so important that an ambulance reaches someone who is in cardiac arrest quickly, it is not imperative that there be a target time in which it should do so. Frankly, the two elements of his argument do not fit together.

Chris Grayling (Conservative, Epsom and Ewell)

That is a fair point, so I will explain why it is not necessarily a matter of getting every ambulance to every incident within eight minutes. Let

us suppose that there are two incidents in the Committee Room. One occurs where the hon. Member for the City of Chester (Ms Christine Russell) is sitting.

Steve Pound (Labour, Ealing North)

One of them is certainly not me.

Chris Grayling (Conservative, Epsom and Ewell)

Since the hon. Gentleman wants to contribute, let us say that one of the incidents is where he is sitting, and the other is where the Chairman is sitting. Two ambulances are available. Let us suppose, God forbid, that the hon. Member for Ealing, North is a cardiac arrest victim. One of those ambulances can get to him more quickly than the other. However, if that ambulance goes, the other cannot get to Mr. Griffiths within eight minutes. If the ambulances are reversed, it may take longer to reach the cardiac arrest victim, but the trust will have met its target of having both ambulances reach their destinations within eight minutes. If one target were missed, however, an ambulance could reach the hon. Member for Ealing, North within two minutes.

The point is that, in pursuing a flat, numerical target, it may be that the wrong clinical decision is taken. It may be that if things were done differently, a life could be saved. I am not saying that it is wrong to have a target or an aspiration for the time within which ambulances should reach incidents. Equally, however, we should not constrain trusts by saying that that is their only driving force. Trusts should not be judged exclusively against that measure. If a trust demonstrates that by doing things differently it saves more lives, we should at least look at that and judge its performance against that criterion as well as the simple ability to reach an incident in the designated time.

Steve McCabe (Labour, Birmingham, Hall Green)

I am falling in love with the ingenuity of the hon. Gentleman's imagination. Can he give any examples of the wonderful description he has just given? Is there any documented evidence of the ambulance scenario he has just depicted, or is it purely a figment of his imagination?

Chris Grayling (Conservative, Epsom and Ewell)

I would never secure a documented example of that because no trust would ever give it to me. However, there are specific documented examples of trusts that perform much more effectively than others in dealing with cardiac arrest victims. They are not judged. The headline figures that the Government use relate to the provision of ambulance services—the provision of a service within eight minutes. Trusts are not judged on whether they save lives. My argument is not that the one is wrong but that both are necessary.

Going through the Bill, we see again and again the word ''provision'' but not the word ''quality''. Both are important. The omission of the word ''quality'' from the Bill is extremely important and should be rectified.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I support what the hon. Gentleman has just said, in two areas. He made a point similar to what I have been saying for five years about the danger of targets so distorting clinical priorities that patients suffer more. He used the example of the ambulance trust in that respect. What the hon. Gentleman did not point out—though he could have—is that the eight-minute target applies only to certain categories of calls.

There is no objective definition of those categories, and each trust can decide into which category a call comes.

There is Audit Commission evidence, and some whistle-blowing from trusts, to show that ambulance trusts put calls into categories depending on whether they think they will make it in eight minutes, or whatever the next category is. Since there is no objective measure—perhaps there cannot be one, because each call is different—it is open to distortion based on how it is measured.

The major problem is not that targets are met through the fiddling of their measurement—that is a problem in itself, but less of a problem than that of meeting targets while damaging patients. Even though both are wrong, it is better to save the patient and fiddle the figure than to meet the figure and let the patient suffer.

The way in which patients can suffer due to the meeting of these targets—or standards, because the Under-Secretary loves making that distinction—can be best seen using the example of the maximum waiting time for operations. I will give the hon. Member for Birmingham, Hall Green (Mr. McCabe) a specific example of how this damages people in the real world. I raised this in the last Health questions but one.

The target is to ensure that everyone has their operation within whatever the latest maximum waiting time is, say 12 months. CHAI will have to report on the provision, and it may well describe a trust as having met its target. Not only does that not report on whether the maximum benefit to patients is being achieved, but there is strong evidence that inevitably the imposition of that target—particularly where it is difficult to achieve because of capacity constraints—will damage patients. It will not just have a locus on quality, but will damage patients, because the patients who are usually left waiting at 12 months are, by definition, not urgent. Yet the patient who is in most urgent need in a trust is the one who is approaching his operation deadline.

What doctors and clinical teams tend to do is stratify patients according to the urgency of their operation. In the area of cardiology, for example, there are patients who are not emergencies but need urgent treatment. They may have unstable angina, critical left main stem disease or critical valve disease. They are not classed as emergency cases and may have had symptoms for a while, but every week that they wait poses a significant risk of a bad outcome, which in this case is dropping dead. I hope that that language is not too technical.

The problem is that in order to meet the target, waiting times for the other higher urgency patients have lengthened. People tell me that there are patients in my local trust areas who used to be seen within three days in order to reduce the risk of their dying while waiting who now have to wait for three weeks. Patients who used to be treated within three weeks, and who are often at home with unstable cardiac pain, are now treated within three months, which is well within the target, but poses significant risks for the patient. However, joy of joys, patients who used to wait for 14

months are now being treated after a 12-month wait, and for that group of patients there is a less significant risk.

No one wants patients to wait longer than they need to. Each patient, looking at the situation himself, and given that there are more in the low-risk category, will want to be treated quickly. However, the least urgent patients should not be the only priority in the system because of the maximum waiting time target. That would come at the expense of the overall quality of care for the most critical patients.

Steve McCabe (Labour, Birmingham, Hall Green)

I can see the general point that the hon. Gentleman is making. Manipulating targets in a way that disadvantages patients is not desirable. I am not sure where the massive difference is. Is it not the case that consultants have, for years, manipulated targets and priorities for varying interests, which have often nothing to do with the patients at all? The hon. Gentleman is objecting to a situation relating to Government targets for speeding up forms of treatment or waiting times. The same criticism about the way in which patients have been manipulated in the interests of consultants' priorities has been being made for years.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

It is not wrong of the hon. Gentleman to seek to defend a bad idea—the imposition of targets, particularly those that concentrate only on the least urgent patients, therefore damaging overall health care—by alleging concerns about another poor practice. If I accepted that there are some consultants who seek deliberately to lengthen waiting times for non-urgent patients who are thought to have some money so as to encourage them to go privately, which I think is what the hon. Gentleman is saying, I would condemn it. However, for the Government, as the hon. Gentleman implied, to do no more or no less than that is not a defence against the charge that I am making.

Chris Grayling (Conservative, Epsom and Ewell)

I am disappointed by the intervention that has just been made by the hon. Member for Birmingham, Hall Green, because it undermines the professional reputation of consultants in a totally unjust way. Has the hon. Gentleman spoken, as I have, to consultants in diabetic clinics who find that if they have an out-patient needing urgent admission to an in-patient bed, they have to telephone the accident and emergency department to ensure that no one has been waiting for more than four hours before they can get access to a bed?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I am not going to go down that path because it is another example of the sort of distortions that exist. However, the point that the hon. Member for Birmingham, Hall Green made may be valid in some cases. He will know from my amendments on private practice of the instances in which NHS beds are needed by a more clinically urgent patient. I am in congruence with his general thrust, but I am also grateful that he has at least conceded, I think, that the point I making is valid and that these targets can be damaging.

The problem is that a trust is measured on whether it meets the maximum waiting time target. It is not measured, in this performance rating system, on the outcomes, taking into account the level of patient sickness. It is not just that trusts fail to measure true clinical patient outcomes, but the imposition of something else makes it worse. I agree with the hon. Member for Epsom and Ewell on this point. Indeed, I would go even further. It is not a surprise that trusts that are not measured as performing as well as other trusts in the Government's performance tables might do better than trusts that are performing well in those tables. Sometimes it is because they do not do as well, because they are not prepared to distort clinical priorities, that they are actually performing better in terms of hard clinical outcomes.

I want to reinforce what the hon. Member for Epsom and Ewell said about the problem of Dr. Foster and the performance star-rating system. It is the problem of the man with two watches. The man with two watches will never know what exactly the right time is.

Simon Burns (Conservative, West Chelmsford)

Why not?

Win Griffiths (Labour, Bridgend)

Order. That is not a point for debate.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I wish to explain, because it is extremely relevant. Two watches will often show slightly different times.

Simon Burns (Conservative, West Chelmsford)

Only to a Liberal.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Of the two clocks in the Room, one reads 10.46 am and the other reads 10.47 am. Who knows which one is right? The Chairman regards the time on the annunciator as being right. Generally speaking, except perhaps in the ordered world of the hon. Gentleman, watches often show slightly different times.

The Secretary of State is like a man with three watches. He has Dr. Foster, which the Department of Health co-operates with by providing data; he has the Commission for Health Improvement reports; and he has star-rating systems. They often say different things. The most appropriate rating system at the moment is a CHI report, because it is not forced to measure performance on star ratings, and it is able to look at the overall picture of a trust.

The next most appropriate and most effective measure of performance is Dr. Foster, which looks at some characteristics of the patient base that a unit, team, or even a commission eventually, is dealing with. It also looks at proper clinical outcomes, such as the number of deaths within 30 days of surgery, which is a meaningful clinical outcome. Dr. Foster fails because the Government have not yet sold it all the confidential patient data, and therefore it cannot yet grasp the level of health of the patients on an individual basis. Consequently, that can distort the outcomes.

The better units, which treat the more difficult cases, will have worse outcomes. Nevertheless, they are better, and it is because they are better that they have worse outcomes. Dr. Foster cannot yet grasp that. The

star-rating system does not even come near to considering whether a unit is taking more difficult patients because it is a better unit.

In this group of clauses, the Government propose to force CHAI, whose predecessor is the best measure of hospital performance, to adopt the star-rating system. That is why the amendment is so important. Multi-star trusts have had stars knocked off on several occasions following a CHI report. That shows that the Government accept that, compared with in-depth CHI reports, the star-rating system is a joke when it comes to measuring quality and proper clinical outcomes.

The combination of the imposition of the star-rating system on CHAI and the failure to put the onus on CHAI to look at quality, rather than just provision as the Government define it, is what is so worrying about the Bill and why this group of amendments is important and worthy of support.

George Young (Conservative, North West Hampshire)

I very much hope that when the Minister replies to the debate he will reflect seriously on the two speeches that he has just heard. They have included some very powerful points.

We have recently agreed clause 40, which sets out what the NHS bodies are meant to be doing. The word ''quality'' is used. Clause 40(1) states:

''It is the duty of each NHS body to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care provided by and for that body.''

Clause 43 deals with the functions of CHAI, which is the authority that will monitor the NHS bodies. Clause 43(1), to which the amendment refers, does not mention quality; it simply mentions provision.

If there is to be some consistency between the responsibilities of CHAI and the jobs that CHAI is meant to be supervising, the word ''quality'' should appear in clause 43. I agree with the point that has just been made: if all that CHAI does is look at the provision of health care, that will be a partial discharge of its responsibilities. One wants to know more than what services were provided; one wants to know whether they worked and were successful. There is something unilateral about simply measuring the provision—these are the services that were provided. I hope that CHAI will go beyond that and look at the outcomes.

Amendment No. 515 relates to clause 45, which deals with NHS foundation trusts. Clause 45(1) states:

''The CHAI is to keep the regulator informed about the provision of health care''.

The one thing that the regulator already knows is what the foundation trusts are providing, because under clause 4 they have to tell him. However, he may not know if the outcomes were any good. Amendment No. 515 inserts after ''provision'' the key words ''and healthcare outcomes'', which will give the regulator some useful information that he does not stand to have at the moment.

Within this group of amendments are amendments relating to clause 46, which deals with annual reviews of NHS foundation trusts. These annual reviews

should not be just about the provision of health care; they should be about quality. I agree with my hon. Friend the Member for Epsom and Ewell that the amendment relating to clause 46 is powerful.

Clause 51 deals with annual reviews. Clause 51(1) refers to ''performance rating''. If we are to go into the business of rating performance, quality is an essential input. We should not measure only the provision of services, but also the quality. CHAI will have to deal with failings, and we will discuss that when we come to clause 54. If we are to make a judgment about whether a body is failing, we must look beyond the services provided and see how effective they are.

Let us say that we had the equivalent of CHAI to audit and inspect Members of Parliament. It would not look simply at the provision of services by Members of Parliament and at how many advice bureaux they held; it would go beyond that and look at the quality of the advice. I see surprise and astonishment on the faces of Committee members. However, if we are to have a body that does its job well, it must look beyond the numerical measurement of services and try to come to some judgment about the quality. I hope that the Minister will either accept these amendments or come up with some amendments of his own.

Gary Streeter (Conservative, South West Devon)

Mr. right hon. Friend is making a very important speech. Is it not now commonplace for the Department for Education and Skills to measure added value and outcomes in schools? If that can be done in schools, is it beyond the wit of man to come up with a similar proposal for health care?

George Young (Conservative, North West Hampshire)

I award the highest possible quality mark to my hon. Friend for his intervention. It is indeed the case that in other Departments quality and value added are measured. Look at Ofsted, for example. I hope that when the Under-Secretary replies he will take on board the thrust of the argument and points made in interventions, and say either that CHAI will do that or that he will amend the Bill to ensure that its responsibilities go beyond the simple measurement of provision and require it to come to some judgement about the quality of services provided.

David Lammy (Labour, Tottenham)

The amendments seek to ensure that CHAI comments on the quality of health care provided by and through NHS bodies, and on other health care outcomes, when discharging its functions to provide information and advice, carry out reviews and publish national performance data.

It is the Government's intention that CHAI be established as an authoritative, independent judge of quality and efficiency and that it will be a driving force for continuous improvement across all NHS bodies. The right hon. Member for North-West Hampshire (Sir George Young) mentioned the use of the provision in clause 43. I want to reassure him that clause 43 is a general expression, covering different aspects of the service, including quality.

Chris Grayling (Conservative, Epsom and Ewell)

No, it would not.

David Lammy (Labour, Tottenham)

Let me go on.

In a sense, that clause and this amendment should be read in the light of clause 49(2)(b), which places CHAI under a clear duty of quality. Clause 40 puts a duty of quality on the NHS, and CHAI will be expected to inspect against that. Therefore, much that has been said on the issue of quality is provided for in the context of that clear duty under clause 49(2)(b).

I want to reassure the Committee that that is the Government's intention. We feel that as we have empowered CHAI with such functions, it will want to concern itself with the quality of health care provision and assessment of health care outcomes.

George Young (Conservative, North West Hampshire)

The Under-Secretary makes a good point, but why does clause 49 not apply to the earlier clauses? Why does it apply only to clauses 50 to 54 and not to clauses 43 to 48?

David Lammy (Labour, Tottenham)

The right hon. Gentleman makes a good point. I will need to take advice and come back to him. It is my understanding, on the face of it, that there is a general duty that obliges CHAI to provide a duty of quality across the board, and that that duty of quality is implicit throughout the Bill.

Chris Grayling (Conservative, Epsom and Ewell)

This is an important point. Is the Under-Secretary's understanding of it the same as mine? It is my understanding that any statutory body established in primary legislation does not have a duty to do something unless that duty is enshrined in the legislation.

David Lammy (Labour, Tottenham)

What I said was that the duty of quality is pervasive. It is set out in clause 49(2)(b), and that duty of quality is implicit. The right hon. Member for North-West Hampshire pointed out, rightly, that the proposal is specific to clauses 50 to 54. My advice is that the duty is implicit and pertains to the functions of CHAI. However, I will seek further advice on that technical point and come back to the Committee in due course.

Patsy Calton (Liberal Democrat, Cheadle)

When the Under-Secretary comes back with advice on clauses 50 to 54, will he also reflect on clause 49? That clause refers to quality, but does not require that quality be reported on. If the Under-Secretary looks at the amendments, he will see that they are asking for quality to be reported on and not just examined, as clause 49 requires.

David Lammy (Labour, Tottenham)

The hon. Lady's point flows from the points that were made by the right hon. Member for North-West Hampshire. I want to undertake to examine this matter again, and this is the purpose of the Committee. It is my intention that there should be a general duty of quality. I want to ensure that that quality is pervasive and that CHAI must have that in mind.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Will Government amendment No. 284, which inserts ''subsection (1) and'' before sections 50 to 54, provide answers to some of the issues raised by the right hon. Member for North-West Hampshire, because clause 49(1) appears to be a general duty on CHAI?

David Lammy (Labour, Tottenham)

That may well form part of the further deliberations that the Government wish to have. I repeat my wish to come back to Committee on that important point.

Chris Grayling (Conservative, Epsom and Ewell)

We have had an important debate. I think and hope that the Under-Secretary has understood the strength of feeling in the Committee about the issue. I am slightly disappointed that he is not sufficiently up to speed on the issues to be able to respond immediately. That said, I am grateful for his assurances that he will look at the issue again, and on that basis I am happy to beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 43 ordered to stand part of the Bill.

Amendment proposed: No. 274,

That Clause 43 be transferred to the end of line 14 on page 20.—[Mr. Lammy]

Win Griffiths (Labour, Bridgend)

With this it will be convenient to discuss the following:

Government amendments Nos. 275 to 278.

Amendment No. 514, in

clause 46, page 16, line 9, leave out from 'trust' to end of line 9.

Amendment No. 513, in

clause 46, page 16, line 11, leave out from 'it' to 'and' in line 12.

Amendment No. 517, in

clause 47, page 16, line 30, leave out paragraph (b).

Amendment No. 516, in

clause 47, page 16, line 24, leave out paragraph (a).

Amendment No. 512, in

clause 47, page 16, line 41, leave out 'if regulations so provide'.

Amendment No. 480, in

clause 47, page 17, line 4, at end add—

'(9) In exercising its functions under this section in relation to any health care the CHAI must take into account the standards set out in statements published under section 41.'.

Government amendments Nos. 282 and 283.

Amendment No. 481, in

clause 49, page 17, line 23, leave out 'other than' and insert 'including'.

Amendment No. 397, in

clause 49, page 17, line 24, after 'sections', insert '45 and'.

Government amendment No. 173.

Government amendment No. 287.

Government amendments Nos. 289 to 291.

Government amendments Nos. 294 to 297.

Government amendment No. 30.

Government amendment No. 298.

Government amendment No. 300.

Government amendment No. 303.

Government amendment No. 452.

Government amendments Nos. 306 and 307.

Chris Grayling (Conservative, Epsom and Ewell)

I am interested that the Under-Secretary does not want to explain his own

amendments because, as far as we can see, they represent a significant change to the Bill.

The amendments appear to change the whole nature of the division of responsibility that CHAI will have over foundation and non-foundation trusts. The deletion of clause 46 would remove one of the most significant clauses in the Bill. I should like the Under-Secretary to give a much clearer explanation of what is happening. Given the context, the star-rating system, which would be perpetuated by clause 46(1), is a cornerstone of the process by which foundation trusts are established. There have been some significant question marks against that cornerstone. Initially, the Government's stated intention was that only three-star hospitals would be eligible to become foundation trusts in the first wave. Indeed, all the initial applicants and those on the shortlist are three-star trusts.

After that statement was made, it became clear that the situation was not that clear. The reason is very simple; the Government's aspiration, unless something has changed, remains that all hospitals should be able to become foundation trusts within a few years. We have expressed strong disagreement with that approach. We believe that all trusts should become foundation trusts immediately. If that does not happen, we will see what has been described by my hon. Friend the Member for Woodspring (Dr. Fox) as a dog-eat-dog culture in the national health service.

Nonetheless, the Government have told us that it is their aspiration to achieve foundation trust status right across the national health service within a few years. For that to happen, the linkage between the star-rating system and foundation trust applications becomes much less clear. Initially, the Government's stated intention was that as each hospital rose up the star-rating league and achieved three-star status, it would be eligible to become a foundation trust. That cannot be the case.

The star-rating system is proportional to the total number of hospitals. The three-star status is intended to represent only a certain percentage of hospitals. The system does not provide for every hospital to become a three-star hospital. It would be impossible for that to happen and for every hospital to achieve foundation status. If all the hospitals that are currently at the top of the league retain their position, it will be possible for a hospital that currently has no stars to achieve foundation status only if foundation status can be achieved by hospitals with two, one or even no stars.

Before the Minister tears up CHAI's role in assessing the star ratings of foundation trusts, it is extremely important that he now explains exactly how the star-rating system will work. He should explain what the difference will be, if any, between the way an assessment takes place on a three-star hospital with or without foundation status and how, if at all, foundation hospitals will be judged differently.

It surely cannot be the case that a non-foundation trust hospital can be judged in precisely the same way as a foundation trust hospital, because it is operating with different systems of governance and has additional freedoms. The whole point about

foundation hospitals is that they are supposed to be different. If they are different, how can we have a common rating system, and how will we compare the rating systems of foundation and non-foundation hospitals? By throwing out clause 46, the Government appear to be saying that we will no longer have separate performance ratings for foundation trusts and that we will no longer judge them differently. Frankly, I am a bit confused about what will happen.

It is particularly extraordinary that the Under-Secretary simply stood up to move these amendments formally. He did not consider a major change of this respect to be worthy of explanation to the Committee. That does him discredit. I am astonished that that is the case. I very much hope that when I have finished speaking and he has been able to gather his thoughts—

David Lammy (Labour, Tottenham)

May I put on record that I received bad advice from my Parliamentary Private Secretary? There was no other intention. Mistakes happen in all walks of life.

Chris Grayling (Conservative, Epsom and Ewell)

That is an enlightening statement. I would not wish to cast the same aspersions on the hon. Member for Weaver Vale (Mr. Mike Hall), whom I know.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

In the light of that revelation, and to speed things up, would the hon. Gentleman consider inviting the Under-Secretary to speak next to explain the amendments, particularly in the absence of any explanatory notes? I realise that the hon. Gentleman and the hon. Member for West Chelmsford have already raised that matter. We could make quicker progress that way, rather than doing things in reverse order.

Chris Grayling (Conservative, Epsom and Ewell)

That is a sensible point. I will happily give way to the Under-Secretary, and I might then seek to catch your eye, Mr. Griffiths. Before I sit down, I should like to ask the Under-Secretary three questions that he can address when he speaks. First, what are the reasons behind the change of heart? Secondly, how will CHAI's reviews reflect the terms of the foundation trusts' authorisation? Thirdly, how will CHAI work with the regulator to ensure that its review reflects the demands set out in the regulator's authorisation?

David Lammy (Labour, Tottenham)

The Government amendments seek to ensure that the same regime effectively applies to NHS foundation trusts as to other bodies. The Bill, as currently drafted, seeks to make a distinction between the inspection regime that applies to NHS foundation trusts, by linking inspections and reviews to the terms of authorisation and contracts with primary care trusts, and the inspection and review that applies to other NHS bodies. In practice, there is likely to be very little distinction between the reviews and inspection of NHS foundation trusts and those of other NHS bodies. Everything will be reviewed against the duty of quality, as in clause 40. For the sake of clarity, we are tabling these amendments to make it explicitly clear that a common inspection regime applies to both NHS foundation trusts and other NHS bodies.

Some minor differences result from the roles of the independent regulator and the Secretary of State in

relation to foundation trusts and other bodies. In some cases, clarification is achieved by making the clause apply to all NHS bodies by removing the exclusions that apply to foundation trusts.

Simon Burns (Conservative, West Chelmsford)

The Under-Secretary has made an important speech, and I have listened carefully to it. What are the differences that he mentioned?

David Lammy (Labour, Tottenham)

If I may continue, the hon. Gentleman will get the clarity that he is seeking. In some cases, clarification is achieved by making the clause apply to all NHS bodies by removing the exclusions that apply to foundation trusts. Fourteen amendments fall into that category—Nos. 30, 173, 283, 287, 289, 290, 291, 294–97, 306, 307 and 452—and all have that effect.

Amendment No. 276 is a drafting amendment recommended by parliamentary counsel to ensure consistency with other parts of the Bill. Counsel has also suggested that CHAI's function of encouraging and improving the provision of health care is technically a general function. Amendment No. 282, therefore, seeks to make that clear.

Amendment No. 277 places a duty of co-operation upon the independent regulator and the CHAI when carrying out their respective functions under part 1, chapter 3 of the Bill. It will ensure that CHAI and the independent regulator work together efficiently in the discharge of their respective functions.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I have been following the Bill, and, indeed, this group of amendments, closely. The Under-Secretary is not speaking particularly quickly. However, in the absence of a written explanation, it is quite hard to prepare one's response to the point that he is making and the explanation that he is giving. Why was it not possible for an explanation to be given of the group as a whole, and of the distinctions made between the various amendments, in order to help Opposition Members? In a positive spirit, would it be possible for that to be provided by this afternoon's sitting? I understand that we are to finish in 10 minutes. I suspect that the Under-Secretary will not have finished within the next 10 minutes. Could that explanation be arranged, so that we can have a more constructive debate?

David Lammy (Labour, Tottenham)

I undertake to have something prepared by this afternoon, which I hope will provide the clarity that hon. Members seek.

I was saying that the provision would ensure that CHAI and the independent regulator worked together efficiently in the discharge of their respective functions. It would also avoid duplication and ensure that opportunities to rationalise information requirements from NHS trusts are taken. CHAI will still be able to provide advice and information to foundation trusts if they request it under clause 49(1), which encourages improvement. Other amendments have clarified the position of CHAI in respect of NHS foundation trusts. In doing so, clause 48, which places a duty on CHAI to report significant failures to the independent regulator with regard to the provision of health care by or for an NHS foundation trust, will be removed.

Simon Burns (Conservative, West Chelmsford)

We are extremely grateful for the Under-Secretary's assurance about a briefing. However, does he agree that, given the problems that were raised by the hon. Member for Oxford, West and Abingdon, it might be sensible to adjourn the Committee now, so that we can resume this afternoon, when we will have had the briefing and will be able to understand better the context of what he is talking about?

Steve Pound (Labour, Ealing North)

On a point of order, Mr.Griffiths. Is it in order for my hon. Friend the Member for Rossendale and Darwen (Janet Anderson) to flourish a bottle of champagne in the Committee Room, or is it permissible only on those occasions when we wish to celebrate the recent wedding of my hon. Friend the Member for Poplar and Canning Town (Jim Fitzpatrick)?

Win Griffiths (Labour, Bridgend)

I thank the hon. Gentleman for raising that point of order. It is not strictly in order, but—[Laughter]. I ask the Under-Secretary to give us a sentence to complete his speech, and we can then move to the Adjournment.

David Lammy (Labour, Tottenham)

I hope that I have been able to reassure the Committee that we will be able to provide further advice on the issue. However, as I stated originally, the group of amendments will simply bring matters in line and make clear that foundation trusts should be subject to the CHAI regime, as are other NHS bodies.

Debate adjourned.—[Jim Fitzpatrick.]

Adjourned accordingly at eighteen minutes past Eleven o'clock till this day at half-past Two o'clock.

Standing Committee E

Health and Social Care (Community Health and Standards) Bill

Peter Atkinson (Conservative, Hexham)

I understand that a document has not yet arrived, so I propose a 10-minute suspension of the Committee until we sort that out.

Chris Grayling (Conservative, Epsom and Ewell)

On a point of order, Mr. Atkinson. You were not here this morning to witness the chaos over the set of amendments. The Minister has clearly not been prepared for them. Opposition Members have not had a chance to see the documentation that was due to be prepared. Frankly, it should have been here this morning; has not been delivered for the afternoon sitting, so I should like to propose that the Committee adjourn until Tuesday to give the Minister time to get his act together, and Opposition Members a chance to see the documentation from the Department.

Peter Atkinson (Conservative, Hexham)

I hear what the hon. Gentleman says, but I have said that I am prepared to suspend the Committee for 10 minutes, and that is what I intend to do at the moment.

Sitting suspended.

On resuming—

Peter Atkinson (Conservative, Hexham)

It has been requested that the Committee remain suspended for a further five minutes to allow hon. Members to read the documents.

Sitting suspended.

On resuming—

Peter Atkinson (Conservative, Hexham)

Again at the request of the Committee, I suspend the sitting for a further 15 minutes.

Sitting suspended.

On resuming—

George Young (Conservative, North West Hampshire)

On a point of order, Mr. Atkinson. Might I might make a suggestion that would enable the Committee to catch up on some of the time that it has lost. The group of Government amendments that we are debating deals with the relationship between the regime for foundation trusts and other NHS bodies, as confirmed by the document helpfully provided by the Department of Health. Nearly all the amendments apply the clause to foundation trusts. The section of the Bill on

foundation trusts was dealt with almost exclusively by the Minister of State, who is now with us. Would it enable us to make faster progress if he were to handle this group of amendments?

Peter Atkinson (Conservative, Hexham)

Order. Which Minister deals with which clauses is a matter for the Ministers and not for the Chair.

Simon Burns (Conservative, West Chelmsford)

On a point of order, Mr. Atkinson. Are you are aware, the Government rightly place on any Standing Committee Parliamentary Private Secretaries from the Department responsible for the business. They are, by tradition, non-speaking members of Committees on the subject for which they are Parliamentary Private Secretaries. You were not here this morning, but part of our problem has been that the Minister moved formally a group of highly important Government amendments. When the Committee expressed its surprise and concern, the Minister made a statement that I hope, on reflection, he would consider to have been unfair, in that he said that he had made a mistake in moving them formally and that he had received bad advice from his Parliamentary Private Secretary. The Parliamentary Private Secretary is unable to defend himself in Committee. It seems unfair for him to be put in that awkward position. Can the Minister, through the Chair, withdraw that—

Mike Hall (Labour, Weaver Vale)

Further to that point of order, Mr. Atkinson. What the hon. Gentleman has said is correct. I gave my hon. Friend the Under-Secretary bad advice and I acknowledge that. No apology is necessary.

Peter Atkinson (Conservative, Hexham)

Order. Once again, that is not an issue for the Chair. The Committee has heard what has been said on both sides.

Andrew Lansley (Conservative, South Cambridgeshire)

On a point of order, Mr. Atkinson.

Peter Atkinson (Conservative, Hexham)

Can there be another point of order?

Andrew Lansley (Conservative, South Cambridgeshire)

Yes, indeed, there is a separate point of order that might be a matter for you, Mr. Atkinson. We have lost some 40 minutes from the intended allocation of time for the discussion of these matters between now and Tuesday evening. In protecting the ability of the Committee to discuss matters fully and fairly, can you advise how we might recover that time?

Peter Atkinson (Conservative, Hexham)

I hear what the hon. Gentleman says. I am reluctant to advise him because, as he knows, the Committee is open ended and can sit for as long as it likes tonight, although I was hoping that it would not.

Dame Cheryl Gillan (Conservative, Chesham and Amersham)

On a point of order, Mr. Atkinson. I put on record my thanks for the way in which the Chair has granted us time to study the documentation. Opposition Members—I hope that I speak for the Liberal Democrats as well—are grateful for the amount of time for which you suspended the Committee while we considered the three-page document that was produced at 2.32 this afternoon for the Committee to peruse. I would also like to place on record that, while not unprecedented, it is unusual and fairly shambolic

for 23 Government amendments to be clarified at such a late stage in the Committee's proceedings. The Government have told us that this is a piece of flagship legislation that has been well thought through, yet we are already privy to Government amendments that run into the hundreds.

Peter Atkinson (Conservative, Hexham)

Order. The hon. Lady is making a speech, not a point of order. That is not a matter for the Chair. What Ministers bring to the Committee and when they bring it is a matter for Ministers. No doubt, the Ministers have heard what the hon. Lady has said.

Dame Cheryl Gillan (Conservative, Chesham and Amersham)

Further to that point of order, Mr. Atkinson, can you advise me whether you would be willing to grant further suspensions should the situation arise again, and would you express an opinion as to whether the Government should conduct the business of the Committee in that fashion? Is it not fair that we should have time to consider such important and fundamental changes to the Bill?

Peter Atkinson (Conservative, Hexham)

Order. I take the hon. Lady's point. As Chairman, I want to ensure that all hon. Members have an opportunity to read all documents, and I shall continue to do that. Once again, when and how documents are produced is a matter for Ministers.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Further to that point of order, Mr. Atkinson, I associate myself with the thanks of the hon. Member for Chesham and Amersham (Mrs. Gillan) for the suspension. It gave us time to read the documents that arrived at such short notice.

Peter Atkinson (Conservative, Hexham)

Perhaps we can now get on with the business of the Committee. As I was, fortunately, not here this morning, I understand that we are dealing with clause 43.

Amendment proposed [this day]: No. 274,

That Clause 43 be transferred to the end of line 14 on page 20.—[Mr. Lammy.]

Question again proposed, That the amendment be made.

Peter Atkinson (Conservative, Hexham)

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

Government amendments Nos. 275 to 278.

Amendment No. 514, in

clause 46, page 16, line 9, leave out from 'trust' to end of line 9.

Amendment No. 513, in

clause 46, page 16, line 11, leave out from 'it' to 'and' in line 12.

Amendment No. 517, in

clause 47, page 16, line 30, leave out paragraph (b).

Amendment No. 516, in

clause 47, page 16, line 24, leave out paragraph (a).

Amendment No. 512, in

clause 47, page 16, line 41, leave out 'if regulations so provide'.

Amendment No. 480, in

clause 47, page 17, line 4, at end add—

'(9) In exercising its functions under this section in relation to any health care the CHAI must take into account the standards set out in statements published under section 41.'.

Government amendments Nos. 282 and 283.

Amendment No. 481, in

clause 49, page 17, line 23, leave out 'other than' and insert 'including'.

Amendment No. 397, in

clause 49, page 17, line 24, after 'sections', insert '45 and'.

Government amendments Nos. 173, 287, 289 to 291, 294 to 297, 30, 298, 300, 303, 452, 306 and 307.

David Lammy (Labour, Tottenham)

You have heard much of what happened this morning, Mr. Atkinson. In providing the Committee with an explanatory note, I was seeking to be as helpful as possible with what I accept is a complex group of amendments. However, I should put on record that nearly all the amendments in the group were tabled on 21 May, according to parliamentary counsel, so they were available to members of the Committee a fortnight ago.

Dame Cheryl Gillan (Conservative, Chesham and Amersham)

Could the Under-Secretary tell the Committee when the explanatory note was prepared?

David Lammy (Labour, Tottenham)

As this morning's Hansard will show, the explanatory note was prepared at lunchtime to assist the Committee in its deliberations. However, the amendments have been available for two weeks.

As I said this morning, each of the Government amendments is designed to ensure that CHAI should be able to consider the quality of services in foundation trusts as in other NHS bodies. I assure hon. Members that the changes that we are making are designed simply for that purpose. There is no hidden side to what we are doing. To make the legislation simpler and clearer, we have to make several technical amendments, to which I began speaking this morning.

Chris Grayling (Conservative, Epsom and Ewell)

The Minister refers to technical amendments. May I take issue with him on whether they are technical and ask him a question? Clause 54 as it will be reconstituted permits CHAI to investigate the financial side of any NHS trust. We know that the star-rating system in part reflects the ability of a trust management to maintain or pay off a deficit, yet the explanatory note states:

''Nor would we expect CHAI to routinely inspect or review NHS Foundation Trusts against requirements in its terms of authorisation'',

and uses the example of compliance with the prudential borrowing code. Why would a deficit be treated differently from the prudential borrowing code, and why is the code excluded?

David Lammy (Labour, Tottenham)

The hon. Gentleman knows the answer, because my right hon. Friend the Minister of State has discussed it at length during the eight or 10 sittings of the Committee so far. There is a very clear demarcation between the role of CHAI and the role of the independent regulator. Indeed, that is partly what the group of amendments is about.

Andrew Lansley (Conservative, South Cambridgeshire)

Perhaps I might explain why I believe that there is a real problem with the Under-Secretary's explanation. The intention of the group of amendments is to make CHAI's activities in respect of NHS foundation trusts much the same as for other NHS bodies, leaving aside certain regulatory activities.

The difficulty is that until now I had thought that the exclusion

''other than NHS foundation trusts''

in clause 49, which will be removed by the group of amendments, meant that none of CHAI's activities would apply to NHS foundation trusts, other than expressly provided for, but now NHS foundation trusts are being brought in as if they were all one thing.

Clause 99 transfers the functions of the old National Care Standards Commission in respect of independent hospitals to CHAI. I hope that you will forgive me, Mr. Atkinson, for a rather long intervention, but this is an important point. I have not really worked this out. On the one hand, there are NHS foundation trusts, and, on the other hand, there are independent hospitals, but there are actually three bodies. There are NHS foundation trusts that are also independent hospitals. By virtue of clause 99, they will be brought under CHAI for the purposes of registration. How will the Under-Secretary be able to manage them in exactly the same way as other foundation trusts, if he goes down that path?

David Lammy (Labour, Tottenham)

The hon. Gentleman is confused. He is talking about independent trusts, but I do not see what relationship they have with NHS foundations trusts.

Andrew Lansley (Conservative, South Cambridgeshire)

If I might—

Peter Atkinson (Conservative, Hexham)

Order. The hon. Gentleman has already made a long intervention. What he wishes to say may be better put in a contribution to the debate than an intervention.

David Lammy (Labour, Tottenham)

As I said, independent hospitals are not NHS foundation trusts. The hon. Gentleman is confused.

Andrew Lansley (Conservative, South Cambridgeshire)

On a point of order, Mr. Atkinson. I seek your protection. If I have to wait to make a further contribution, the Minister might at least wait to hear it before attempting inaccurately to refute it.

Peter Atkinson (Conservative, Hexham)

That is not a point of order for the Chair.

David Lammy (Labour, Tottenham)

As I was saying, CHAI should be able to consider the quality of services in NHS foundation trusts as it does in other bodies. There is no hidden side to the amendments. That is what they seek to achieve.

The hon. Member for Epsom and Ewell (Chris Grayling) raised some specific issues this morning. He asked whether CHAI will relate to the terms of authorisation. It does not. As my right hon. Friend explained previously, that is the job of the independent regulator, who sets the terms and judges whether they continue to be met. However, as the hon. Gentleman would expect, the regulator will use information—

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I seek clarification about the relationship between a foundation hospital is to be regulated by CHAI and a co-located private hospital. Who will register the private hospital? If services are being purchased by the foundation trust, will CHAI be doing two different things? I want to understand how the relationship works between the private hospital that provides

services to a foundation trust; I presume that the services will be accredited and then audited by CHAI.

The provisions seem still in some ways to give CHAI separate responsibility for foundation trusts, but there seems to be quite a confusion, which I hope the Under-Secretary can clarify, between its registration and auditing responsibilities when NHS money is being used to purchase services from the private sector.

David Lammy (Labour, Tottenham)

I am happy to clarify that. The independent hospital now has a relationship with CHAI for the purposes of inspection and registration. I am also trying to explain that CHAI will be inspecting foundation trusts. However, another important proximate relationship to foundations trusts, as pertains to their authorisation and finances, is with the independent regulator; it has been discussed at length, and I am surprised that the hon. Gentleman is still confused. There is no confusion between the relationship that the regulator has with the independent hospital trust and that with foundation trusts or other NHS bodies. CHAI is the organisation that we have charged with the job of inspecting the NHS, and the Bill allows us the chance to include another group of institutions within that arrangement.

Chris Grayling (Conservative, Epsom and Ewell)

The Under-Secretary will be aware that the original explanatory notes said that CHAI had separate functions because it is to review them against the terms of its authorisation in relation to foundation trusts. If CHAI is assessing the range and quality of services provided by a hospital, and if its conclusions could have a material impact on the authorisation, can he explain the process that CHAI would go through with the regulator to change that authorisation?

David Lammy (Labour, Tottenham)

No, I cannot. Under the Bill, CHAI, as an independent body, and the regulator, being independent of Government, have a duty to work together and co-ordinate. The independent regulator will take an interest in what CHAI has to say about specific hospitals. That must be plain. However, it cannot be for me to prescribe here the nature, definition and detail of that arrangement. The relationship is clearly important as regards the terms of authorisation.

Chris Grayling (Conservative, Epsom and Ewell)

Let us suppose that a CHAI review says that a hospital's maternity department is no longer viable and should close—a perfectly reasonable scenario, given the pressures and changes in the maternity arena. Let us suppose also that the regulator's authorisation says that that hospital must provide maternity services. What process does the Minister envisage for a resolution of those conflicting aspirations?

David Lammy (Labour, Tottenham)

There will not be conflicting aspirations. I think that the hon. Gentleman misunderstands the terms of authorisation. The independent regulator will use information from CHAI reviews and inspections in deciding how it might take action if the terms of authorisation are being failed. That is where it becomes important in relation to the amendments.

Chris Grayling (Conservative, Epsom and Ewell)

The explanatory notes to the Bill state:

''CHAI has separate functions in relation to these bodies because it is to review them against the terms of their authorisation''.

That is exactly what the Minister has just said. However, the changes to the Bill mean that CHAI will no longer assess foundation hospitals against the terms of their authorisation, so how can that happen?

David Lammy (Labour, Tottenham)

CHAI was never intended to assess the terms of authorisation. That was always in the domain of the independent regulator. But clearly CHAI is aware of the terms of authorisation. That is why it has a relationship with the independent regulator.

Chris Grayling (Conservative, Epsom and Ewell)

On a point of order, Mr. Atkinson. I wonder, if the Minister does not have a spare copy of the notes to hand, whether the Badge Messengers can give him a copy so that he can take a look at the text that appears on page 21, of which he appears to be unaware.

Peter Atkinson (Conservative, Hexham)

That is a debating point, not a point of order.

David Lammy (Labour, Tottenham)

I see no dichotomy or difference. The hon. Gentleman may be deliberately getting into semantics. I have explained the position clearly and I think that he knows the position. It is clearly not for CHAI to decide whether a maternity unit is an NHS trust or an NHS foundation trust, and how that pertains to it being open or whatever. He knows that that is the case. Changes such as the closure of a maternity ward would have to undergo the usual processes of consultation, oversight, scrutiny and so on. I know, because I have discussed this with the hon. Gentleman before, the arrangements for merger, closure or change in the nature of NHS functions relating to, for instance, a maternity unit.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The statement is not just on page 21 of the explanatory notes. The hon. Member for Epsom and Ewell will be aware that page 23 also states that, under clause 47,

''CHAI may carry out reviews . . . on the extent to which an NHS foundation trust complies with the terms of its authorisation''.

That is restated there. Is it not a change of policy by the Government, which they have denied in their note and in words this morning, to have only the regulator dealing with authorisation and the terms of and compliance with authorisation? I am not saying that that is necessarily a bad thing, but the Minister should concede that it is a change of policy, because it may well be welcomed on the Opposition Benches.

David Lammy (Labour, Tottenham)

I want to clarify that that is not a change of policy; that was never the intention. We do not expect CHAI routinely to inspect or review NHS foundation trusts against requirements in the terms of authorisation that CHAI would not normally address in inspection or review of other health care bodies.

Simon Burns (Conservative, West Chelmsford)

I am getting rather confused by the Minister's responses. Will he explain the statement in paragraph 158 on page 23 of the explanatory notes?

It reads:

''Clause 47 provides that the CHAI may carry out reviews and publish reports on the extent to which an NHS foundation trust complies with the terms of its authorisation''.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

That is what I just said.

Simon Burns (Conservative, West Chelmsford)

Yes, I am trying to get a reply.

David Lammy (Labour, Tottenham)

As I said, we expect CHAI to have a key relationship with the independent regulator, and there is a duty to co-ordinate. The reference to

''the extent to which an NHS foundation trust complies with the terms of its authorisation''

is not incompatible with the fact that the terms of the authorisation rest firmly with the independent regulator. There is a relationship, and CHAI will clearly be aware of those terms. I want to help the Committee, however, and to make it clear that that is not a change in policy—it is simply a matter of the way in which things are expressed in the explanatory notes.

Chris Grayling (Conservative, Epsom and Ewell)

Will the Under-Secretary explain the difference between the original background notes and the new notes? The original notes say:

''CHAI has separate functions in relation to these bodies because it is to review them against the terms of their authorisation''.

Today's notes say:

''Nor would we expect CHAI to routinely inspect or review an NHS Foundation Trust against requirements in its terms of authorisation''.

They are clearly different, and the simple question is why.

David Lammy (Labour, Tottenham)

Let me answer that very simply—they are explanatory notes. What we are really concerned with is the Bill. The hon. Gentleman knows that we could spend a lot of time talking about the semantics of explanatory notes.

Andrew Lansley (Conservative, South Cambridgeshire)

Let us get off the explanatory notes for a minute and examine what is going on. Perhaps I can help the Under-Secretary. Clause 47, which has gone, gave CHAI the power to undertake reviews of foundation trusts in relation to their terms of authorisation, in pursuance of the regulator's power in clause 23 to consider whether a trust is failing in any respect. Does amendment No. 298 not recreate exactly that power? It states:

''CHAI must also make a report to the regulator where it''—

that is CHAI in this case, so things are not being done at the regulator's behest—

''is of the view that . . . there are significant failings in relation to the provision of health care by or for an NHS foundation trust''.

On its own initiative, therefore, CHAI will look into the activities of foundation trusts.

David Lammy (Labour, Tottenham)

CHAI's functions—

Andrew Lansley (Conservative, South Cambridgeshire)

I am trying to be helpful.

David Lammy (Labour, Tottenham)

I am grateful if the hon. Gentleman is, indeed, trying to be helpful. As I have said, CHAI's functions relate to health care inspection and review, not to the wider issues there may be in the terms of authorisation. The hon. Member for Epsom and Ewell gave the example of the closure of maternity services, and I told him that that would be a subject for overview, scrutiny and consultation. CHCs would look into it under the present arrangements, while patient forums would do so under the new arrangements. Of course, a whole range of issues will be important as regards a foundation trust's terms of

authorisation, and one would expect CHAI to have a relationship.

Let us not, however, stray from the purpose of the amendments, which is to clarify and simplify the position. It is interesting that hon. Members have largely referred to explanatory notes that they had in the past—at least, the hon. Member for Epsom and Ewell did so. I am seeking to make progress and to indicate the direction of travel.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

As it happens, I agree with the shift of emphasis in the amendments and with the direction of travel—it is correct to treat hospitals in the same way. To move off the point, however, the Under-Secretary must accept that there has been a change of policy and/or that the information in the explanatory notes was wrong and misleading. It is important that he does that from his seat, because if this is challenged, what he says from that seat can be taken into account in the absence of any other clear direction under the Pepper v. Hart ruling. I invite him to say that the Government have changed the policy and that they were wrong in relation to current policy. We would welcome that change, and move on.

David Lammy (Labour, Tottenham)

As I said, I do not want to be misunderstood. The purpose of the amendments is to clarify the situation. As I said this morning, the terms of reference in clause 46 were too wide and we are seeking to clarify them. The independent regulator must be responsible for the terms of authorisation.

I now want to move on. It remains the case that CHAI and the independent regulator have distinct roles. CHAI is responsible for reviews and investigations of NHS care, including that provided by NHS foundation trusts. The independent regulator is responsible for granting authorisation to applicants for NHS foundation trust status and for setting the terms of the authorisation under which they will operate. The regulator is also responsible for monitoring NHS foundation trusts' compliance with their operating conditions, with powers to intervene where necessary to bring an NHS foundation trust that is failing to meet its obligations back into line. CHAI and the independent regulator will need to work closely together without duplication or over-regulation, which is why the Bill places a duty of co-operation on them.

There is one area in which we have made a change, which I hope hon. Members will welcome. We are making it clear that CHAI's general duty of improvement in clause 49 applies to NHS foundation trusts. The amendments make the relationship between CHAI and NHS foundation trusts clearer. I went through the amendments this morning, but shall continue where I left off.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The Under-Secretary did not get very far through them at speed without the explanatory notes. It may be helpful if he starts again on that section, because it was brief; he may repeat part of the notes that he has now given. That would enable us to make interventions on the relevant parts, which would help the debate. Some questions that are relatively

minor are best asked on intervention rather than in speeches.

David Lammy (Labour, Tottenham)

As I said, amendment No. 283 applies to the provisions of clause 49. The explanatory note would say that. Amendment No. 173 applies to the provision of clause 50. Amendments Nos. 287 and 289 apply to the provisions of clause 51. Amendments Nos. 290, 291 and 294 apply to the provisions of clause 52. Amendments Nos. 30, 295 and 297 apply to the provisions of clause 53. Amendments Nos. 306 and 307 apply to the provisions of clause 66. These are a series of technical amendments that establish in a clear section in the Bill the relationship between CHAI and foundation trusts.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

This is a useful point at which to intervene to ask a general question. In our discussions this morning, the Under-Secretary was asked why clause 49(2) apparently applied only to sections 50 to 54 on exercising the function of encouraging improvement and being concerned with a list of things. To help the Committee, he said that he would clarify what CHAI should have regard to.

David Lammy (Labour, Tottenham)

I shall make it clear to the hon. Gentleman; I have served on several Committees with him and know that he takes these things very seriously. As I said, this is a series of technical amendments, and I have provided an explanatory note for them. I shall take advice if he raises technical issues of that nature, and I may be able to answer him during the course of the debate. However, I shall have to write to the Committee if hon. Members choose to unpick in detail some of those issues. I am seeking to assist the Committee.

Simon Burns (Conservative, West Chelmsford)

Can I assist the Under-Secretary? I understand what he says, but I would be surprised if he did not know that the whole point of the Committee is to examine the legislation line by line. The point made this morning by my right hon. Friend the Member for North-West Hampshire (Sir George Young)—referred to just now by the hon. Member for Oxford, West and Abingdon—is not a technical issue in the narrow terms that the Under-Secretary uses. It is an important part of our study of the Bill.

David Lammy (Labour, Tottenham)

We have now been sitting for a number of hours, so I am aware of the Committee's purpose; or have the last 12 hours been a dream? [Hon. Members: ''A nightmare.''] Or a nightmare. I shall go far as I can, but I think that we all accept that it is important for me to give our reasons for making these technical amendments and to provide the context.

Patsy Calton (Liberal Democrat, Cheadle)

I think this is a technical point, and I would be happy to accept a written note. When clauses 43, 45 and 45 are moved one at a time to line 14, page 20, the provisions will be in reverse order. Will the Under-Secretary reassure the Committee that that will have no effect on the meaning of those provisions; or is it the intention that they should remain in the same order as now?

David Lammy (Labour, Tottenham)

I wish to clarify the position with regard to the duty of quality. Am I right about what the hon. Lady wants to know?

Patsy Calton (Liberal Democrat, Cheadle)

I am simply asking a technical question. All that I want to know—it will be helpful to the Committee—is whether, when clauses 43, 44 and 45 are moved one at a time to the same point, they will be in reverse order? If they are reversed, I wonder whether the headings will move with them. On page 15, above clause 45, the following words appear in italics:

''Functions relating to NHS foundation trusts''.

The amendments do not mention that title. Does it move with clause 45, or is left behind, hanging in the air? It would be helpful to know where those various headings will be found, so that we shall know in what order to read it.

David Lammy (Labour, Tottenham)

I am advised that the simple answer is no.

The rest of the debate is in Hansard.