Health Bill [Lords]

Public Bill Committee, 18 June 2009.

Edward O'Hara (Labour, Knowsley South)

Welcome back, members of the Committee, fit and ready for purpose.

Clause 8

Mike Penning (Conservative, Hemel Hempstead)

I beg to move amendment 87, in clause 8, page 5, line 6, after ‘containing’, insert ‘(but not limited to)’.

Edward O'Hara (Labour, Knowsley South)

With this it will be convenient to discuss the following: amendment 156, in clause 8, page 5, line 27, after ‘containing’, insert ‘(but not limited to)’.

Amendment 169, in clause 8, page 5, line 28, at end insert—

‘(3A) When required, bodies listed in subsection (2) must provide information for injury data collection on the causes of injuries for patients admitted.’.

Mike Penning (Conservative, Hemel Hempstead)

Thank you, Mr. O’Hara. It is a pleasure to discuss this part of the Bill. I am pleased that the amendments have been grouped together. We are minded, like a lot of stakeholders, to support quality accounts. The amendments are probing amendments to find out from the Government exactly what the quality accounts will look like. Sadly, a lot of the detail is likely to be covered in secondary legislation.

Stakeholders, such as the NHS Confederation, the King’s Fund, Help the Aged and others are concerned about the lack of detail. In fact, the King’s Fund believes that the publication will be relatively passive in its form and will not give the public the accountability of quality that we are looking for. Looking back to the Maidstone debacle and the shameful events that took place in Mid Staffordshire NHS Foundation Trust, the quality of the accounts that the public can see is important, as I am sure the Minister agrees. Amendments 87 and 156 would develop exactly who will be responsible for publishing quality accounts. The phrase “not limited to” is self-explanatory about where we are coming from.

I support Liberal Democrat amendment 169. It is important that data that could be used in other areas of public analysis are available. In recent years, we have not seen data on injuries within hospitals. For example, it is difficult for us, when tabling parliamentary questions, to find out from trusts the exact type of injuries dealt with by A and E departments. It is imperative that such information is available. I have tabled the amendment to urge the Minister to develop exactly who quality accounts will be limited to.

Sandra Gidley (Liberal Democrat, Romsey)

We, too, welcome the general idea of quality accounts but, to be useful, we must ensure that the information has a purpose and is not just another data collection exercise with no meaningful use. The accounts will have more credibility if the public can see that the information is put to good use. I welcome the Conservative amendments. They would widen the scope of quality accounts and make them more flexible in the future.

I want to discuss amendment 169. Before being approached by the Royal Society for the Prevention of Accidents, I had not realised that the United Kingdom used to be a world leader in injury surveillance. It had much useful data on how many people were hurt in accidents, what they were doing at the time and what products might have been involved. The data were used to analyse trends. Obviously if one is analysing trends, one should then take steps to ensure that there are no such accidents in the future.

Until 2002 the Department of Trade and Industry collected that data, but when the Department was reformed as the Department for Business, Enterprise and Regulatory Reform—there has obviously been another reorganisation since then—the data were no longer collected. The amendment is a probing amendment to see whether there is any facility to use the quality accounts, which might be collecting some of that data anyway, to reinstate injury data collection, so that once again the UK can be at the forefront of data collection, analysis and the prevention of accidents.

Mike O'Brien (Labour, North Warwickshire)

Essentially, what we have here is the collection of information and its publication for a particular purpose. That purpose is not only to inform people but to ensure a focus on quality. That arises out of the review by my noble Friend Lord Darzi into high quality care for all. He determined that quality relates to three “domains”—patient safety, effectiveness of care, and patient experience. I wish to set out what we mean by that and say something more generally about the quality accounts, so that hopefully people have a clear picture of our purpose and of why we are focusing on quality, and understand therefore why we cannot accept the amendments. I appreciate and am grateful for the indication from the official Opposition both that they support the concept of quality accounts and that the amendments are probing ones, designed to elicit more information about the nature of quality accounts.

We want to develop quality accounts to see whether the focus in the “High Quality Care for All” review is being used by organisations in the health service. That means that they are, for example, protecting patient safety by eradicating health care-acquired infections and avoidable accidents. It is about the effectiveness of care, from the clinical procedure that the patient receives to their quality of life after treatment, and it is about the patient’s entire experience of the NHS, ensuring that they are treated with compassion, dignity and respect in a clean, safe and well-managed environment.

Those are the three key areas that we want to focus on, and we intend quality accounts to contain a core of nationally determined quality indicators, so that comparisons can be made between providers. It is important that like can be compared with like, in respect of that core. The greater part of each quality account, however, will be determined locally, to ensure that providers can publish information that is relevant to the type of health care services that they provide, to the locally identified priorities for clinical improvement and to patients and other members of the public in their area.

Mike Penning (Conservative, Hemel Hempstead)

The key here is public confidence in the data that are being published. While I am a localist politician, I am concerned about public confidence, because if there are problems in a trust—we all know that that happens; the Mid Staffordshire trust was a great example—in the main, as the Minister has just indicated, it is up to the trust to decide who publishes what information about what.

Mike O'Brien (Labour, North Warwickshire)

One key thing we need to do is ensure that data that are published are not just left out there, unverified. It will be the responsibility of the Care Quality Commission to ensure that the data are looked at and conform to the data that it has about that hospital. If there are problems with the data in a report, correction within 21 days can be required. The hon. Gentleman is right. If we are to focus on quality, we need to assure the public—as far as we can ever rely on the expression of an opinion by an organisation—that it is as reliable as it reasonably can be. We are concerned that it should not focus just on the things that we have focused on in the past such as particular targets— 18 weeks and others. This is looking at something different—the quality, not the quantity, of the care that is provided. We also want to ensure that a quality account, which will be locally determined, puts quality care at the forefront. By high quality care, we mean care that is beyond the minimum set by the regulator.

This is not just about saying a particular target has been hit. In order to manage the NHS and get a return on the money going into it, we have sought to set basic standards with which everyone has to comply. We are now, with quality accounts, looking at something quite different. This is not about hitting minimum standards, although that will still be relevant, because if people are not doing so it will come out in other reports such as those by the CQC. We are now asking hospitals and other NHS institutions to look at what they do well. That involves two things: identifying who is performing at a very high quality level in particular areas and then comparing the best in different areas. It is not about minimums: it is about the best and how to keep the pressure on to push the best to be better; it is about making the reasonably good, good; and it is about making the good even better and excellent. It is also about testing those who are excellent to see whether they can push themselves further. They will have to say not only what they are good at but also what further improvements over time they want to see. We know that the medical teams that forge ahead and provide quality and excellence in the NHS are those that measure their performance, and the best are often well above minimum standards. They measure how well they are doing for their own purposes, but until now nobody has taken particular notice, because people think, “They are above the minimum. We need not worry.” But how do we make everyone perform to the highest level that they can? Quality accounts are part of that process.

Andrew Turner (Conservative, Isle of Wight)

I welcome the purpose of getting the maximum possible, but I am concerned about the minimum. I am concerned, for example, about elderly people who are in hospitals, who have nowhere to go, who cannot go home because they cannot look after themselves and who are not sent to less significant units. This happens right across the country, not just in my constituency. In most parts of the country there is something wrong every so often—not frequently, not all the time, but regularly. That fact is neglected, and I would like to hear more about how the minimum is achieved, before we get to the maximum.

Mike O'Brien (Labour, North Warwickshire)

I understand the hon. Gentleman’s point and he is right that the minimum is important. As the hon. Member for Hemel Hempstead has indicated, we saw the outcome of events at Mid Staffordshire NHS Foundation Trust, where various tests on the trust did not pick up the poor quality of treatment. Therefore, we need to ensure that we examine the minimum standards as well. An organisation that looks at minimum standards of care blew the whistle on what was happening at Mid Staffordshire. We have checks in place through the Care Quality Commission and, if the organisation in question is a foundation trust, through Monitor, to some extent. Such bodies need to ensure that the quality of basic standards is examined. The NHS Choices database is available to the public, who can look in detail at how hospitals and other NHS institutions are performing and at the quality of different teams to ensure that they are doing what they are obliged to do. Checks are there, and the minimum standards will be dealt by the CQC with its new enforcement powers, which start in April 2010 for acute trusts. A core CQC registration will form part of the quality accounts, so there are ways of doing it.

My point is that, as important as it is to ensure that minimum standards are hit and maintained, it is also important to go beyond that and recognise that the NHS is not about minimum standards. We—millions of us throughout the country—do not pay taxes for the NHS to get the minimum possible standards in a hospital; we expect those standards. We want hospitals that push to get the best and the highest quality, and where excellence is important. Across the NHS, there are people, medical teams and practitioners who are dedicated to excellence and who, until now, have not been measured and congratulated. Doing that will show that the NHS cares about excellence. The NHS talks a lot about excellence but does not measure it, which is what quality accounts are about.

The local part of those quality accounts enables local involvement networks to let the hospital or other institution know what they want the quality accounts to measure, providing it is about quality. That is what we want to focus on, and it is the agenda that we are pursuing. Providers will have the freedom and the responsibility to decide what goes into the local part of quality accounts. However, we need to stipulate that quality accounts are about quality, which is why clause 8 refers specifically to

“information relevant to the quality of...NHS services”.

For that reason, amendments 87 and 156 are not the way that we want to go.

Similarly, I understand the concerns raised by the hon. Member for Romsey, who is not in her place. I agree entirely that there needs to be a robust collection of data on the type of injuries that cause people to be admitted to hospital in the first place. However, such information is not within the scope of the quality account, because that information is, in effect, about quantity, and it measures something else. The information in the quality account must be relevant to the quality of a particular provider’s care. Data on the causes of admission, such as personal injuries, are available through other means. Information on accident and emergency attendance, for example, is collected as part of the hospital episodes statistics database, and it is already available on the information centre’s website.

Statistics show that there is a remarkable appetite for information about health issues. Figures for the NHS Choices website show that around 5 million people visit that site each month, with total visits occasionally reaching around 7 million a month. Given the number of people in this country, those figures are extraordinary, and I think that, when quality accounts are made available, we will see the public’s appetite to see the quality of provision available in their local hospital.

Andrew Turner (Conservative, Isle of Wight)

How many areas will be visited each year, and how many of those will be top rank? It would be helpful if we had some idea of what the Minister expects for this year or next. Also, how many of those visits will involve the whole of an NHS trust, and how many of them will involve operations, some of which may be less good, within an NHS trust?

Mike O'Brien (Labour, North Warwickshire)

We have an idea of the quality of some trusts through knowing about those that are hitting basic standards and through reports published in relation to inspections by CQC and its predecessor bodies, so we have some ability to assess the quality by which a trust performs its services. Information on individual medical teams and the extent to which components of trusts, which is what the hon. Gentleman has asked about, are performing to the highest standards, is less available, although there are some data in relation to that on the NHS Choices website.

I have no doubt that within the medical profession, a consultant knows whether another consultant at a hospital down the road is better and who is the best at a particular speciality in the country. Such information is available in the medical press, no doubt, but we want to provide accessible information to the public, so that they can see a relatively brief report reasonably easily. We have made it clear that we do not want lengthy, unreadable documents, because they are intended for members of the public, who will be able to see the quality delivered by, and the performance of, their local NHS organisation. More than that, we want the public to see the improvements that an organisation wants to make to the way in which it delivers quality during the coming year and in the future.

There will be a fair amount of freedom for the various organisations to say what they want to look at or whether they have a particular specialism. There might be a specialist team in orthopaedics, and it will be able to say, “We have got a medical team that is able to do something like this. It is not being done anywhere else in the country, we are at the forefront.” Such organisations will be able to advertise the areas in which they are the best, but they will also have to indicate areas where they are mediocre and state what they plan to do about it. An organisation might be above the minimum standard and pass tests by delivering what it needs to deliver, but it still might not match the best. It must say how it will improve over the coming years and what it is delivering in terms of patient quality. Patient quality is not a general concept; it has been set out my noble Friend Lord Darzi in his report, and we want to focus on it as something that the NHS will seek to deliver over the coming decade or more.

I will tell the story going back over the past 10 years. At the start of the decade, we recognised that there was a problem of underfunding and understaffing in the NHS—we had recognised that before, but we always had expenditure constraints. At that point, we started to put funding in, and we used the basic tool of targets in order to see what return we were getting. In the second tranche of change, we recognised that we had to go beyond merely putting in more money and setting targets for delivery and that there needed to be fundamental reforms in the NHS organisation.

Therefore, we went through a period of NHS reform. It was very painful and involved reconfiguration, the reorganisation of some NHS structures and trying out different ways of doing that until we felt that we had reached a system that could enable the delivery of better quality administration in the NHS. We think that we have broadly arrived at that, and we do not plan significant further administrative changes.

We now need to move to the next stage, which is where quality accounts will take us. The review by my noble Friend Lord Darzi focused on the issue of improved quality, so we have gone through a period of dealing with underfunding, understaffing and the necessary administrative changes, and we are now moving on to look at improving the quality of what the NHS does. It is a step-by-step improvement and in due course, as we fulfil the quality agenda, I hope that we will see an improvement in the quality of what we, as taxpayers and patients, get from the NHS.

Therefore, the issue of core accounts is at the centre of that vision for the future of the NHS and the next stage in improving it. I appreciate that the Opposition amendments are primarily probing amendments, and I hope that we will be able to acknowledge the importance of quality accounts and understand what they propose to do. I therefore hope that Opposition Members will not press their amendments.

John Horam (Conservative, Orpington)

May I probe the Minister a little further on how he will organise this? I understand that the thinking might not have got down to this level yet, but as I understand it, he is trying to elevate quality accounts to the same level as financial accounts. There would be financial accounts and equality accounts at an equal level, just as many organisations have elevated environmental accounts to the same level as financial accounts, and report on them in the same way.

In the case of financial accounts, there is a clear historic structure. There is a finance director to whom people report, and there is a clear, understandable procedure that is followed every year and is understood by everybody. In this case, we are in relatively untrodden territory, as the Minister has admitted to some extent. We are even dealing with questions that are not simply about target setting, check lists and waiting times, but that concern rather more intangible things such as the nature of care and the compassion that is shown, which are much more difficult to measure. Who will be responsible for that in any organisation, whether it is a primary care trust or hospital trust? Will that responsibility be put specifically on the clinical director’s shoulders, or will it lie with the operations director or the chief executive? In my experience, organisations and institutions do not work well unless there are specific, clear responsibilities. Obviously, quality goes right across the board. Everyone is concerned about quality in a hospital or primary care trust, but, none the less, someone will be collecting the information and pushing the agenda along. Has there been any thinking on that?

Mike O'Brien (Labour, North Warwickshire)

I agree with the key thrust of the hon. Gentleman’s points. We do not aim to create a new bureaucracy or a pile of information that needs to be collected to ensure that we can provide quality accounts. Much of the data that will be in quality accounts are available now. Currently, trusts provide the CQC with data about what they are doing, so that the CQC can look at the overall quality of what they are doing and can do its regular reports.

So, the data are provided to the CQC, rather than the public, and the CQC will periodically do a report based on some of those data. We want to make sure that those data are more readily accessible and available, as far as the core national data on quality are concerned, in a readable form for the public. Then, local NHS organisations will have particular data available to them, which they can measure themselves and can choose to put out there too. We hope that will lead to a focus on what they want to specialise in and where they can make a particular contribution to the NHS.

The hon. Gentleman asked who will be responsible, and that will vary through the NHS. In a hospital, the trust board will be responsible for the data that are out there. If they are medical data, the board will want to, and will be obliged to, consult the clinical director to make sure that the quality of those data are appropriate. In the end, the buck will stop with the board and with those who are legally responsible for the information that the trust puts out. That information will not just be out there unchecked. The CQC, which has much of that information anyway, will be able to say that some of it is not accurate. With local data, the CQC may say, “Let’s have a look at these data, because we want to find out the basis on which you have claimed that you’re producing at this level of quality.” If it found that the quality levels and the data backing them up were not sound enough, the trust or other organisation could be required to change them.

John Horam (Conservative, Orpington)

So, it will be up to the trust in question to decide which member of staff is responsible for collecting and monitoring that information and presenting it to the board. I agree that the board is ultimately responsible, but there must be someone inside the organisation, below the board, who collates all the information and presents it to the board, just as a finance director collects all the accounts and presents them to the board.

Mike O'Brien (Labour, North Warwickshire)

Clinical data are currently collected in any event, and I do not envisage that someone will get a new job on quality accounts. There will already be people who provide that information, and it will probably vary between the trusts who they decide should be responsible for delivering the text of a quality account. I am less concerned about that, and more concerned that, however they do it, we need to have quality accounts that the public can read and understand, and that are not too cumbersome or indigestible. They should be reliable and verifiable by outside organisations and they should give a clear picture of the quality of what is being delivered.

In the end, the people on the trust board, in the case of a hospital, for example, will be responsible. They will have procedures for making particular individuals responsible for particular aspects of the quality account. That will be a decision for them—we are not trying to top-down manage this. They will appoint clinical directors, there are good governance procedures which trusts are well aware of—some more than others. The governance procedures are out there and they are well known. So there will be ways in which the data will be collected and the appropriate people will be held responsible.

Mike Penning (Conservative, Hemel Hempstead)

I want to clarify a couple of points before the Minister comes to his conclusion. The Government already have powers under section 8 of the National Health Service Act 2006 to ask NHS bodies for quality accounts. As they already have such powers, will this legislation bring in other bodies, perhaps those supplying services to the NHS? If there are already powers, I cannot understand why we need the clause, unless we are bringing in other bodies.

If we are asking the public, understandably, to have confidence in the accounts, the accounts must be like for like. Two trusts next to each other must be offering similar things, and we must have a level playing field. We do not want a postcode lottery.

So who will audit the accounts? The British Medical Association is concerned about that, and I share its concerns. As this is prescribed information on the quality of the services, the manner in which they are published should, as I just said, be equal—in other words, there should be a level playing field. Who will audit the accounts, or will there not be an audit at all? If there is no form of audit, what is the logic of introducing the measure?

Mike O'Brien (Labour, North Warwickshire)

On bringing in other bodies, the hon. Gentleman is right. Quality accounts will apply not just to hospitals. They will apply to other NHS organisations and providers of NHS services. Even those in the private sector who provide NHS services will be required to look at the quality of what they do and report on it, and that information should be available to the public so that taxpayers are able to see the quality of what they get.

It is important that the quality accounts are verifiable. I have already indicated that CQC will be able to examine and check them. There will not be an outside auditor such as Ernst and Young brought in. That is not the approach that we are taking. We are saying that the trust or other organisation board, the partners in a practice and so on will be responsible for writing a basic quality account. There will be core national things that they must include and other things that they may choose to include. They will be responsible for ensuring the quality of the quality account. There will be a failsafe—a check—to ensure that what they have done is not in any way unsound. The CQC will be there to do that, but I suspect that once these things are made public, others who work in the NHS will start looking at them and asking questions about them. If people are making claims that cannot be substantiated, I suspect that they will be caught out fairly quickly.

Mike Penning (Conservative, Hemel Hempstead)

As I said at the outset, we are broadly in support, but there is very little detail in the Bill. I hope that the Minister will understand why we have introduced these probing amendments and discussions. With that in mind, I do not wish to press amendments 87 and 156.

John Pugh (Liberal Democrat, Southport)

I want to make a few comments on amendment 169. I believe the Minister alluded to the fact that, in the past, targets have been slightly distorting, and that assessing quality from time to time can become distorting. I wonder to what extent assessment by the public of quality accounts will differ from internal assessment by professionals. In the case of education assessments and establishments, people inside the education world and the general public often have different readings of information that is made public. However, I accept that assessing quality, albeit at a subtle distance, may at the end of the day improve the quality of services.

The Minister mentioned that the clause draws a distinction between quantity and quality. The amendment is about quantity, while the particular clause is about quality, though I accept that quantity and statistics are often a good indication of the quality of a service being delivered. The amendment makes an important point about the necessity of collecting injury statistics and presenting them in ways that would lead people to consider what the causes and the preventions are of such injuries. I want to put on the record that my hon. Friend the Member for Romsey has gone to the Health Committee and has not abnegated her duties here.

Mike Penning (Conservative, Hemel Hempstead)

I beg to ask leave to withdraw the amendment.

Mike Penning (Conservative, Hemel Hempstead)

I beg to move amendment 159, in clause 8, page 5, line 24, leave out paragraph (c).

The amendment would leave out the paragraph that stipulates that anyone who

“makes arrangements...for another person to provide NHS services”—

those who are pursuing a contract or making an arrangement

“for another person to provide or assist in providing”

such services—will need to publish a document. Even though the noble Lord Darzi attempted to address the situation in the other place, there is still a lack of clarity in the Bill regarding which organisations that supplies services to the NHS will be required to provide. A few moments ago, the Minister listed some. It would be useful, at least in correspondence, if the Minister could indicate exactly which bodies that supply services to the NHS will be required. That is important, as so much of the detail required will be left to the Minister or the Secretary of State to decide under secondary legislation.

The concern is that not everyone is going to be caught up in the quality accounts. The consultation that took place regarding which bodies should be there was—I am sorry to say—slightly flawed. Out of the whole of the NHS, only 299 people responded, of which 11 were GPs. That is not a real barometer on the field of the wonderful service the NHS provides to the nation. Further consultation took place between the Department, the donation trusts and other NHS organisations. Some 15 NHS trusts responded—not a huge amount—so did nine primary care trusts, one strategic health authority and the Foundation Trust Network. That is not a definitive list of respondents as to who will be caught up in the legislation.

The other thing, which I alluded to earlier, is the role of the CQC. The Minister responded that it will be the CQC’s responsibility to look at the accounts. When and how often are the obvious questions. What is the role of Monitor in routinely examining information for presenting the quality accounts for the foundation trusts? That could lead to quite a punitive effect if we are not careful. The Government’s assessments indicate that the accounts will be quite challenging for trusts. They may have to take on new and temporary staff. Exactly which organisations will be required to produce quality accounts must be definitive in the Bill, and it is disappointing that it is not.

Mike O'Brien (Labour, North Warwickshire)

There is not, as such, a definitive list, because the NHS varies across the country and NHS services are provided in different ways. There is obviously a list of the organisations that we want to include, but because the operation of the NHS is so variable and because services are delivered in so many different ways, we essentially want to be able to say that if an NHS service is being provided, by either the public or private sector, and if patients receive a service, we want it to be qualitatively examined. We are not interested in the delivery of paper to a trust; we are interested in what the trust and medical teams are doing to deliver services to patients. The sub-contractors who will be covered include many services offered by independent sector treatment centres. That would mean that patients will be able to see the quality of what is done when services are provided to the NHS. If a private sector centre provides NHS services and private sector services, the latter are separate, so the centre will have to look after them. However, where facilities are used to deliver NHS services to NHS patients, we want quality accounts.

Mike Penning (Conservative, Hemel Hempstead)

I think everybody would understand if phase 1, 2 or 3—if we get that far—ISTCs that were contracting had to do that, but what about other people that are contracting directly into the NHS such as dentists, the group of professionals about whom we were talking yesterday? They are self-employed and contracted to the PCT to deliver care from the primary sector directly to the public. Some practices—there are not so many of them now—in rural parts of the country might consist of a single dentist with two dental nurses and a perhaps a technician, but some practices are very large. Would dentists be required to provide quality accounts? I think they fall into the bracket that the Minister was just describing.

Mike O'Brien (Labour, North Warwickshire)

The straight answer to the question on dentists is yes, but not immediately. In the first year of quality accounts, acute hospital trusts will be required to provide a quality account, including ambulance and mental health trusts. In the second year, that will be extended to various community services, and in the third year, it will extend to primary care services such as GPs and dentists. We will work in detail with GPs to develop an approach that works for them. The national criteria for quality accounts that apply to acute hospitals will obviously not apply to a dentist, so we have to work with each of the stakeholders to ensure that we develop quality accounts that are suitable for that sector of the NHS.

Mike Penning (Conservative, Hemel Hempstead)

The Government’s impact assessment on quality accounts and the Bill in general said that there would be an impact, a cost and a burden on those who provide a quality account. Does the Minister realise that if we bring in small organisations such as dentists, chiropodists and physiotherapists who are contracted into the NHS, the burden on those businesses—especially dentists, who tell me that it is driving them away from the NHS—will be so onerous that we may well lose even more of them than we lose at the moment?

Mike O'Brien (Labour, North Warwickshire)

I thought the hon. Gentleman was supporting quality accounts. We will be looking at how quality accounts will have to be delivered by GPs and dentists. I assume that both of those types of organisations will want to measure the quality of what they do. I certainly hope that my dentist is concerned about the quality of his work. I hope that he wants to be sure that it is of a sufficiently high quality and that he checks the nature of the treatment delivered to patients. The difficulty is that, yes, there will be a need to write some of that down. Will it be an onerous or undue burden? In our view it will not. Will it enable the public to know what they get in return for the money that goes into NHS dentistry? It should provide them with more data and information. Will it enable them to have a better idea about what their GPs are doing, what their specialisms are and where they see the need for improvements in the coming year or two? Yes, it should; that is the sort of thing that we want GPs, dentists and others to do.

John Pugh (Liberal Democrat, Southport)

I am thinking about the public health agenda. A number of organisations are involved in partnership with the NHS in order to follow through on very important public health objectives. Many of them are quite small organisations working in fields such as alcohol awareness. Will they too be required to produce quality accounts?

Mike O'Brien (Labour, North Warwickshire)

It depends on the nature of the organisations. What we have is the ability to take a view that we will not require quality accounts from particular organisations, because of the nature of the services they provide. Those organisations may have some NHS funding, but quality accounts would not be something that they need to do. We are looking in particular at some smaller organisations—or small practitioners, or providers—and considering whether they need to provide quality accounts and, if so, the extent of the level of data they would need to provide. We have the ability in the Bill to exclude and take a view on those organisations. We are now in the process of consulting with various stakeholders about exactly how we can ensure that quality accounts will apply to their particular areas. There is the consultation, which will hopefully now proceed with broad support as the Bill goes through the House. In due course, because we are phasing this in over a number of years, we will want to consult with the various organisations to get this right and make sure the delivery of quality accounts does not produce an undue burden, not just for small practitioners, but also for the organisations described by the hon. Gentleman.

Mike Penning (Conservative, Hemel Hempstead)

I have listened carefully to the Minister. He is absolutely right in indicating that at the start of the Bill we were broadly in support of quality accounts. That does not mean that, after our probing amendments, we are not concerned about some of the comments that have been made in the debate this morning, not least because the Government’s own impact assessment said:

“There may be a lack of resource within organisations to prepare Quality Accounts - recruitment, on either a temporary or permanent basis may be required”.

How does that tie up with the comments made by the Minister a moment ago that he does not think that quality accounts will be onerous for such bodies?

Mike O'Brien (Labour, North Warwickshire)

Just to give the hon. Gentleman some estimate of the cost that we think that quality accounts might bring to an organisation, our impact assessment has calculated that it would cost around £3,000 per annum for the larger providers—an acute hospital trust, for example—to provide the data. That is the sort of calculation that we have put in it. As I indicated, we are open to exempting some of the smallest providers—those which may only see, for example, a handful of NHS patients in any one year.

Mike Penning (Conservative, Hemel Hempstead)

I have listened to what the Minister says. I do not think that dentists would fall into that bracket of “only a handful” and I can hear now, from a distance, the dentists being very concerned; they already are concerned about the provision of dentistry in the NHS.

Mike O'Brien (Labour, North Warwickshire)

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

Mike Penning (Conservative, Hemel Hempstead)

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

Mike Penning (Conservative, Hemel Hempstead)

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

Edward O'Hara (Labour, Knowsley South)

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

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

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

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

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

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

(a) to publish electronically and in paper form;

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

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

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

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

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

Mike Penning (Conservative, Hemel Hempstead)

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

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

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

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

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

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

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

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

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

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

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

Mike Penning (Conservative, Hemel Hempstead)

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

Mike Penning (Conservative, Hemel Hempstead)

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

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

Edward O'Hara (Labour, Knowsley South)

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

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

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

Mike Penning (Conservative, Hemel Hempstead)

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

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

“believe that providers are falling short on quality”.

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

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

Stephen O'Brien (Conservative, Eddisbury)

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

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

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

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

Stephen O'Brien (Conservative, Eddisbury)

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

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

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

Stephen O'Brien (Conservative, Eddisbury)

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

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

John Horam (Conservative, Orpington)

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

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

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

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

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

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

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

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

Stephen O'Brien (Conservative, Eddisbury)

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

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

Andrew Turner (Conservative, Isle of Wight)

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

Mike O'Brien (Labour, North Warwickshire)

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

Sandra Gidley (Liberal Democrat, Romsey)

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

Mike O'Brien (Labour, North Warwickshire)

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

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

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

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

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

Stephen O'Brien (Conservative, Eddisbury)

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

Stephen O'Brien (Conservative, Eddisbury)

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

Mike Penning (Conservative, Hemel Hempstead)

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

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

Mike Penning (Conservative, Hemel Hempstead)

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

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

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

Mike Penning (Conservative, Hemel Hempstead)

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

I accept fully what the Minister said—he has been very open and honest about the amount of consultation he intends to undertake—and I beg to ask leave to withdraw the amendment.

Sandra Gidley (Liberal Democrat, Romsey)

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

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

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

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

That is fine. Then it says:

“This part will focus on key Departmental priorities.”

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

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

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

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

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

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

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

Mike O'Brien (Labour, North Warwickshire)

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

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

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

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

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

Clause 9

Mike Penning (Conservative, Hemel Hempstead)

I beg to move amendment 92, in clause 9, page 6, line 4, after first ‘State’, insert

‘and simultaneously laid before Parliament’.

The amendment provides for greater parliamentary scrutiny of quality accounts by ensuring that they are laid before Parliament at the same time as they are submitted to the Secretary of State. That is an important principle for all parliamentarians, and one to which the Minister should give consideration. It is clear that if quality accounts are to be successful, widespread engagement with them is needed, including by parliamentarians, especially if we are to represent our constituencies correctly.

Mike O'Brien (Labour, North Warwickshire)

The amendment would place a responsibility on the Department of Health to lay copies of quality accounts before Parliament. That is clearly not for the purpose of public accountability, as copies will be publicly available locally from the provider, and nationally when we publish them on the NHS Choices website. Public accountability is there. It is open to any Member of the House to access any of the documents that are on the NHS Choices website, so Members will be able to find out what is in the quality accounts.

I cannot emphasise enough the production process that we envisage. Our testing and engagement process has shown that the NHS wants to ensure that quality accounts are a success. The final version of quality accounts has already been subject to local scrutiny by patients and the public. What will be sent to the Secretary of State will therefore be the best account that can be given.

It is certainly open to any Member of Parliament to request that a particular quality account be placed in the Library of the House. I am not sure that having large numbers of quality accounts from, in due course, every dentist, doctor and health organisation in the country piled up on the table in the Chamber is what is needed. If anyone wants access to a document, it will be easily accessible to Members of Parliament and members of the public, so the level of accountability is actually considerably greater than almost anything else that is available to MPs.

I do not think that it is necessary for the accounts to be laid formally before the House. There will be so many of them that I do not think that that would be the appropriate way to proceed.

Stephen O'Brien (Conservative, Eddisbury)

In support of my hon. Friend the Member for Hemel Hempstead, the amendment is probably informed by the fact that those of us who share the privilege of being shadow Health Ministers find that much of the difficulty of furnishing ourselves, as would be expected, with the information that helps us to scrutinise and hold the Government to account arises from the fact that so much information is held not at ministerial level or even departmental level, but at SHA and trust level. Very often, we have found that asking written parliamentary questions has not enabled us to elicit that information, particularly on all the various accounts that relate to the wide panoply of trusts. As a result, freedom of information requests have tended to be the methodology used and, as the Minister is well aware, that is a very time-consuming and burdensome operation. What lies behind the amendment is the desire to short-circuit some of the hard slog that is needed just to make the information available, as any proper Opposition should be doing to hold any Government to account.

Mike O'Brien (Labour, North Warwickshire)

I am hurt by the suggestion that asking parliamentary questions does not elicit all the information required.

Stephen O'Brien (Conservative, Eddisbury)

Not always. It is unreliable.

Mike O'Brien (Labour, North Warwickshire)

I am also aware that it is in everybody’s interests that Opposition Members, particularly shadow Health spokesmen, are able to do their work. Certainly, we want to ensure that that is the case in future.

Stephen O'Brien (Conservative, Eddisbury)

I am glad I raised the subject.

Mike O'Brien (Labour, North Warwickshire)

Let me take the point on board and consider, with the Secretary of State, whether we can talk to the Library and see whether it would be prepared to take all the documents. They have the information in the sense that it is on the internet, so they have easy access to it. I am sure that the Library would be able to print off from the internet any document and any quality account that is required.

Mike Penning (Conservative, Hemel Hempstead)

It might not be suitable for the Library to be doing that. The Vote Office, which has publishing facilities and capacity in the House to print off the relevant forms should a Member require that, is probably the logical way forward.

Mike O'Brien (Labour, North Warwickshire)

The Secretary of State will have a copy of the quality accounts and we will look at ways to ensure that Members have easy enough access to them. I think that there is easy enough access anyway through NHS Choices. I doubt that there is a need to publish or print them internally in the House, given that they are so easily available, but I will consider what the hon. Gentleman has said.

Sandra Gidley (Liberal Democrat, Romsey)

Is the Minister saying that all of the information will be in one place on NHS Choices? That is fine, because the problem now is that it is held in all the different trusts and collating information is usually very difficult.

Mike O'Brien (Labour, North Warwickshire)

NHS Choices will need to have all the reports and make them all available. They will be accessible via the website, so if the hon. Lady wants a report on a trust, the website is the route that I envisage her using. I am not sure whether that deals with her point, but the information should be easily accessible on NHS Choices.

Sandra Gidley (Liberal Democrat, Romsey)

The point is that all the quality accounts information should be in one finite place, rather than listed separately under each trust, which makes it far more difficult to collate and compare.

Mike O'Brien (Labour, North Warwickshire)

That is a fair point, and I will take it back to the Department. The hon. Lady seems to be suggesting that not only should the reports be available in relation to other data on particular trusts and other organisations, but that they should be identified separately on the website, so that it is possible to access just quality accounts. That is a reasonable suggestion, and I will talk to NHS Choices about whether that can be arranged.

Mike Penning (Conservative, Hemel Hempstead)

I thank the Minister for listening to the arguments. The purpose of the amendment was to extrapolate what we have extrapolated. It is crucial to have accessibility to documents in one place, whether in the Library or on NHS Choices, so that we can cross-assess trusts. I beg to ask leave to withdraw the amendment.

Mike Penning (Conservative, Hemel Hempstead)

I beg to move amendment 158, in clause 9, page 6, line 6, at end insert—

‘( ) A document (whether in whole or in part and whether alone or jointly with others) made available to the public by the Secretary of State must be accompanied by such information as may be recommended to the Secretary of State by the National Institute for Health and Clinical Excellence with a view to enabling the public to assess the document’s contents by reference to relevant and meaningful standards of comparison.’.

For the first time in the two days that I have sat on this Committee, an amendment refers to NICE and its role in providing better information. The amendment, which was tabled in the other place by my noble Friend Earl Howe, makes a simple proposal. If NICE has relevant information that would be suitable, necessary and perhaps informative to individual trust users, it should be placed in or alongside the quality accounts, so that the quality improvement focus that NICE may want to recommend would allow the public to understand better the facilities that they receive.

Mike O'Brien (Labour, North Warwickshire)

Amendment 158 would impose on NICE a role in helping people to understand providers’ quality accounts by providing further information to allow a comparison between accounts and to oblige the Secretary of State to publish NICE’s guidance. Our view is that NICE is not best placed to provide the comparability tool. That is not its role. NICE provides standards. It does not measure against them subsequently. It sets them.

Having said that, we are looking closely at how to facilitate comparison in other ways. We have given a commitment that quality accounts should be published on the NHS Choices website specifically to allow for informed and meaningful comparisons to be made. We are also considering providing more explanatory material to the public and a toolkit for publishers of quality accounts to draw on to ensure that their documents are reader friendly and to enable comparability by the public. We intend to do that by guidance rather than prescriptive regulation.

One factor in the production process for the toolkit is evaluation of the current quality accounts testing process being led by NHS East of England and Monitor. We expect to have the final report within the next eight weeks. That will help us to identify any problems, and thus solutions, in aiding public understanding of the meaning and import of the information used in quality accounts. That will then inform our consultation on draft regulations and guidance later in the year. We believe that the role proposed in the amendment would not be welcomed by NICE and would not fit easily with its current role in the NHS.

Mike Penning (Conservative, Hemel Hempstead)

I have listened carefully to the Minister, and although he will not accept the amendment in its present form, it sounds as though work is being done on what NICE could do to help to inform NHS users. With that in mind, I beg to ask leave to withdraw the amendment.

Mike Penning (Conservative, Hemel Hempstead)

I beg to move amendment 163, in clause 9, page 6, line 6, at end insert—

‘(4A) A document (whether in whole or in part and whether alone or jointly with others) made available to the public by the Secretary of State shall contain information about the choice of services available to patients.’.

This amendment gives additional provisions for quality accounts and would put the principle of patient choice on the face of the Bill. This is mentioned in the impact assessment, but is not explicit in the Bill due to the emphasis on powers by regulation.

I am sure that the Minister has had time to read the work that the King’s Fund has done on the Bill. They have put forward four suggestions to help us address the points raised in the impact assessment. These are, first, patients and carers should make choices based on better information; secondly, providers and commissioners should determine priorities for improvement; thirdly, the boards of NHS trusts and non-NHS equivalents should place quality at the heart of their procedures for planning and delivery; and, fourthly, clinicians and clinical teams should evaluate and compare their performance.

Eminent authorities and think-tanks, such as the King’s Fund, would like to see such processes on the face of the Bill. The impact assessment indicated that they would be there, but they are not. Could the Minister assure me that such processes will be addressed even if they are not on the face of the Bill.

Mike O'Brien (Labour, North Warwickshire)

Patient choice is important and we want to ensure that it is at the heart of a number of the initiatives that we are taking. The NHS Choices website is the core way in which that data is made available to members of the public. The website has information well in excess of what will be provided in quality accounts. When making a choice of where to have an operation or what medical service to use, NHS Choices is the source for that information. Quality accounts would only be a fraction, a part, a component of the wider information that is provided by NHS Choices. They can look at quality accounts on the NHS Choices website, but we do not envisage that that would be the basis on which all choices would be made.

We need to make clear the limitations of quality accounts as well as their purpose. Quality accounts will help to shape services on offer from each provider and make each provider account for the quality of those services. That is linked to patient choice, but choice is just one of the ways in which providers will be held to account. There has to be broader support for quality accounts coming from our engagement and I am concerned that using them for a purpose for which, of themselves, they were not intended could detract from the objective of improving quality in the NHS. Choice is important, but there are other ways of delivering it. Quality accounts will be a component of the choice equation, but only a part of it.

Mike Penning (Conservative, Hemel Hempstead)

Perhaps I could clarify a point that I raised in my earlier remarks. I indicated that the four points were from the King’s Fund. I misread it, they actually came from the impact assessment. Even though the Minister seems to disagree with his own impact assessment, I should clarify that point. The King’s Fund was concerned about the passive and limited method for increasing public accountability within the publication. I have listened to what the Minister has said and with that in mind I beg to ask leave to withdraw the amendment.

Stephen O'Brien (Conservative, Eddisbury)

I beg to move amendment 119, in clause 9, page 6, line 10, at end insert—

‘(aa) as to the information technology that trusts will require to measure and report on quality in the quality accounts;’.

We all know that the Government’s national programme for IT is now four years behind schedule and there is little to show for its £12 billion budget. The Lorenzo patient administration system is in use by only three trusts and the Cerner Millennium system is live in four trusts, three of which are using only the first phase of the software. If 96 per cent. of acute trusts are without a patient administration system, arguably the most fundamental of the national programme for IT projects, one questions how many trusts possess the IT capacity to provide an accurate portrait of the quality of their services. Without the ability to track a patient’s progress through various NHS services and record the outcome of their treatment, trusts will not be able to present accurate information on the overall quality of the services that they provide.

The impact assessment for quality accounts stated that

“any data mandated for inclusion in the accounts is likely already to be collected for other purposes, so no further data collection costs are anticipated.”

However, given the woeful inadequacy of IT provision in the NHS and the recent report from the Audit Commission on the lack of quality in NHS data sets—the report noted an error rate in NHS data of up to 52 per cent.—I wonder if the Government are overestimating the capacity for trusts to measure quality from existing data systems. I am also concerned that the Government’s estimate that there will be no extra costs is, frankly, a little optimistic. Either the integrity of the quality accounts will be—

Sandra Gidley (Liberal Democrat, Romsey)

The hon. Gentleman makes an interesting point and I share his concern. In some fields, it is being made fairly clear that a lack of a consistent data sets means that it becomes almost impossible to compare trusts. Although we had reassurances earlier from the Minister that there will be some flexibility about the way that trusts collate data, any comparison will be meaningless if the data sets are not similar. So there is a bit of a conflict here with what we are doing, which the hon. Gentleman has rightly highlighted.

Stephen O'Brien (Conservative, Eddisbury)

I am grateful to the hon. Lady, because she raises the horizontal comparison, which is very important. To some degree, what I am about to say slightly goes against my own instinct to have a top-down approach and I dare say that the Minister was revving up to make that rather easy point. However, regarding the horizontal comparison there is a question, as is the case with all IT implementation, notwithstanding our criticism of the current Government project on IT and indeed our own views on how that project can be improved, which will be made public later in the year. One must recognise that there are great advantages in having some standard setting and some protocols, because it is too easy to argue that it is purely a case of rubbish in, rubbish out. That is the vertical comparison.

However, with the horizontal comparison, we are going to need really useful data sets that will drive this process. The Government use the words about this issue occasionally, but I regard it as being fundamentally more central to improving patient healthcare outcomes. That is to use much more of an upward-spiralling motivating benchmark process, which is owned by the internal clinicians. That would be very helpful, but it absolutely requires a fundamentally well-applied, locally-owned IT approach, while at the same time having protocols across certain standards, so that we can get the horizontal data. So the hon. Lady makes a valid point in complimenting the approach that I was trying to raise with the Government.

As I was saying, either the integrity of the quality accounts will be undermined by a lack of reliable data, or the cost of the accounts will far exceed the cost that is outlined in the impact assessment. Hopefully the Minister will take the opportunity to clarify which one of those rather tense scenarios is closest to the truth.

I shall move on to outcomes, which, as I indicated, are surely the most objective indicator of quality. Again, we return to the issue of costs. In March, I asked the Secretary of State for information on the outcomes that are being measured for surgical operations. The Secretary of State for Culture, Media and Sport, who was then a Health Minister, replied that the clinical audit outcomes data for surgery was “limited” and was collected for only six types of cancer surgery and for heart disease. When information on outcomes is so sparse and the technology to collect it is barely present, I fail to see how quality accounts can play a role in improving the quality of NHS patient care without there being further investment in systems to measure outcomes.

The Government have failed to create a framework of technology and data collection that will support trusts in the measurement of quality. Trusts are expected to produce annual quality accounts without having been given the technological and statistical toolkit to do so. It is important that it is a toolkit; it is not an imposition, but a question of making available the right tools to be able to deliver on the job. That situation will lead only to what the impact assessment calls “perverse incentives” to publish an unreliable or misleading document to meet the annual deadline.

I noted in an earlier intervention that the publication date of the quality accounts of April next year raises questions about the trusts’ preparedness for the initiative, not least because they should already be collecting data from 1 April this year, before the Bill has been considered fully and before trusts can assume that they have to. The Minister said on the last amendment group that people tend engage once they know that the law is coming into effect, so they may not be engaging and therefore not preparing for what is already the year of account. I am concerned that this measure is jumping the gun, which the Minister accused me of on Tuesday on the NHS boards. There is a certain reciprocity of argument.

I hope that the Secretary of State will clarify the baseline data from which trusts are expected to analyse the quality of their services for the first year of the scheme. For instance, if trusts are using mortality as an indicator of quality, they will need to compare the mortality rates this year with those of another, as yet unspecified, period. It is unclear how trusts will go about benchmarking services in terms of quality in 2010 when the terms by which the Government define quality were not available to trusts in previous years to benchmark against. It makes sense to delay the publication date of the first round of quality accounts until 2011 when the trusts can compare data from two successive years.

I hope that those points have been heard and that there is recognition that the Government are behind the curve in making the means by which they want to achieve their aspirations come about.

Mike O'Brien (Labour, North Warwickshire)

Let us be clear about what is being proposed: regulations should be made to make provision

“as to the information technology that trusts will require to measure and report on quality in the quality accounts”.

If that is not top-down micro-management, I do not know what is. The Opposition have constantly said that they want to give trusts and NHS organisations greater freedom. They are not even in Government yet—if they ever will be—so should not try to get Whitehall and this House to dictate the information technology that trusts require to report quality accounts. They will use various kinds of information technology.

We need to ensure the good quality of the data provided. I agree with some points made by hon. Member for Eddisbury. The CQC will need to ensure that it can use its data for assessing the quality of what particular trusts provide. The hon. Gentleman says that some trusts are not providing the data now, but we have clearly said that we will use the data that are already provided by trusts to the CQC. Trusts are preparing for quality accounts, as they are already providing data to CQC, which is of precisely the kind that we envisage being used for the first set of quality accounts.

In a sense, we are not behind the curve, but well ahead of it. Therefore, there does not need to be any delay in the way in which quality accounts will develop in the course of the coming year. The data are broadly available. We know what we want to do, but we want to consult on the detail of how we will present it, how we will set out the regulations and the extent to which we want core data to be provided to the CQC and in quality accounts. That core data is one of the key issues—how much is core and how much is local? It is important that we get the balance right. I hope that the hon. Gentleman will accept that there is no need for that level of top-down micro-management, as proposed by the Conservative party. I am somewhat surprised that it has gone down that route. I did not expect it to, and I very much hope that, on reflection, it can think again about its top-down micro-management.

Stephen O'Brien (Conservative, Eddisbury)

As I anticipated, when we reached the substance of the Minister’s remarks, putting to one side the well-rehearsed attempt at a little political banter, he said that he broadly agreed with what I was seeking to do, and I am grateful to him for that. Even the Bill states:

“Regulations under subsection (1) or (3) of section 8 may”—

not “must”—

“in particular make provision”.

The Government have a fundamental misunderstanding of how IT projects work. Simply stating an aspiration and then seeking to impose it in a “one size fits all”, does not make happen, as the NHS IT programme has demonstrated. Far from our seeking to dictate anything, as the Minister said, somewhat pejoratively, on the contrary we recognise that IT is a tool that helps to facilitate and enable processes that improve patient health care and social care outcomes.

Indeed, as highlighted by the hon. Member for Romsey, part of what is required, even when going down the quality route of IT applications, is to make available the information and the expectation required so that people can procure the right type of IT to make sure that it is interoperable with all the other aspects of communication channels necessary to build data sets to interrogate and collate and, thus, be useful in policy and, above all, quality audit. There is also the motivational and quality enhancement process that comes through sensibly applied benchmarking, the horizontal reference to which hon. Lady referred.

I saw that work extraordinarily well in my pre-political career in the manufacturing industry for more than a decade. Through good benchmarking techniques and the provision of sensible IT standardisation without imposing from the top down, quality can really be spiralled up and people engaged in such a process can be motivated rather than achieving that result by means of imposition, in my case from head office, or in this case from Government. I strongly urge them to consider matters with genuine seriousness and make little less of an attempt to deal with such matters on a political point scoring basis.

The matter will be more broadly in context with a number of things. I shall not press the amendment to a Division. That would just be a gesture. More importantly, I have put my argument and I hope that the Government will think more about it. If they really want to make sure that we get some quality accounts, our point must be taken somewhat seriously. I hope that we can revisit the matter, but now I beg to ask leave to withdraw the amendment.

Edward O'Hara (Labour, Knowsley South)

With this it will be convenient to discuss the following: new clause 2—Report to parliament on impact of quality accounts—

‘(1) The Secretary of State shall report to Parliament no later than 4 years after the coming into force of Part 1 on the impact of quality accounts.

(2) The report shall examine the methods and technologies employed by trusts to measure the quality of services and collect data for inclusion in their quality accounts.’.

New clause 5—Notification to Parliament of the impact of quality accounts—

‘(1) The Secretary of State shall make a statement to Parliament no later than 3 years after the coming into force of this Part regarding the impact of quality accounts.

(2) This statement shall address the demand for quality accounts from patients and members of the public, the improvements that quality accounts have brought about as provider organisations focus on quality improvement, and the way that quality accounts reflect the healthcare needs of patients served by the bodies listed in Clause 8, subsections (2) and (3).’.

New clause 7—Evaluation of quality accounts—

‘(1) The Secretary of State shall make a statement to Parliament no later than 4 years after the coming into force of this Part regarding the impact of quality accounts.

(2) This statement shall examine the way quality accounts reflect the demographic, social, economic and geographical areas served by the bodies listed in Clause 8, subsections (2) and (3).’.

Stephen O'Brien (Conservative, Eddisbury)

I shall deal with new clause 2, and my hon. Friend the Member for Hemel Hempstead will deal with the other two new clauses. New clause 2 would make the Secretary of State accountable for the consequences of quality accounts four years after their introduction. At present, there is no mechanism for accountability to Parliament under the Bill, which means that the Government could launch a significant initiative on trusts without any intention of reviewing its impact on Parliament later down the line. If quality accounts descend into the realm of bureaucracy, trusts need to have an assurance from the Government that they will intervene to tackle the problem. However, if, as the Minister is promising, they will have a substantial effect on raising the quality of services, I am sure that the Government would welcome the opportunity to report on that success to the House.

The second part of the new clause would ensure that the Government’s report to Parliament would examine the information technology needs of trusts producing quality accounts, which is very much linked the point that we discovered in respect of the forgoing amendment. My concern lies once again with the capacity for acute trusts to measure outcomes when they do not yet have a patient administration system to allow them to track the progress of each patient through different NHS services.

The Government have produced a prototype for quality accounts as a template on which trusts can base their quality accounts. As we all know, it is rather charmingly called, “The Sunnyview University Hospital Trust quality report 2008-09”. Unfortunately, I fear that if trusts were to follow this document as an example of measuring quality with any kind of sincerity, their hopes of driving up quality would be as utopian and unrealistic as the name “Sunnyview”.

If we turn to priority 1 in the document—I am sure that other members of the Committee have seen it, as it is part of the documentation behind the Bill—which deals with the reduction of stroke mortality rates, we begin to see some of the problems posed by the measurement of quality. Mortality is not a nuanced measure of quality if the circumstances leading up to the death of each patient are not examined. Strokes are caused by a variety of circumstances and conditions, and each stroke patient’s medical history will differ. By setting clinicians a target of reducing stroke mortality without examination of the care pathway of each patient, the trust will not obtain an accurate indication of quality.

I realise that the Sunnyview document is not intended to be replicated to the last word by trusts, and that trusts are expected to ascertain their own priorities for measurement. However, I can easily envisage a tired and stressed chief executive cutting and pasting information into a document in order hastily to meet the annual quality accounts deadline. What precautions has the Minister taken to ensure that that does not become a prevalent practice among trusts?

My worry is that quality accounts will descend into a rebranded version of targets and will detract from the care of individual patients. If trusts were given the IT capacity to measure patient care from start to finish and to record the circumstances surrounding their condition, and if quality were deduced from that and not from amorphous mortality or infection rates, real progress could be made.

Somewhat harking back to the amendment that we have just discussed, which I tabled, if the Government’s national programme for IT had delivered the systems it promised, acute trusts would already have significant capacity to track electronically a patient’s pathway through services and to measure the outcome of their treatment right the way from their first GP consultation to their final discharge from hospital. However, the programme is four years overdue, and the information and data that trusts possess on outcomes is patchy and limited to individual specialisms or procedures.

We support a strengthened emphasis on quality in the NHS, but we also recognise that trusts will not be able to measure quality accurately if they cannot track the care of patients along the care pathway. Information systems are a key facilitator—that is an important word—in this, which is why I propose to place a duty on the Government to review IT capacity in trusts after four years.

I hope that the Minister listened carefully to the previous conversation. The fact is that this is not intended to impose IT, which he sought as a defence for not accepting the previous amendment, but to recognise that for any kind of information system that is supported by IT, there needs to be analysis of the standardisation. The intention is not to limit the offering of products, but to ensure that there is at least a quality assurance within the IT systems and an interoperability analysis so that the data classes and the measures which will enable these things to happen will be in place.

With that, I beg leave to move new clause 2.

Edward O'Hara (Labour, Knowsley South)

It is not a question of moving new clause 2. If it were to be moved, it would be at a later stage. You will see from the selection list that the debate takes place now. The debate is on clause stand part, and new clause 2 is considered as part of that debate.

Mike Penning (Conservative, Hemel Hempstead)

On a point of order, Mr. O’Hara. I was intending to speak on new clause 5, not new clause 2.

Edward O'Hara (Labour, Knowsley South)

The hon. Member for Eddisbury spoke to new clause 2. I was explaining that he was not moving it but simply speaking to it. You may now speak to new clause 5.

Mike Penning (Conservative, Hemel Hempstead)

Thank you, Mr. O’Hara.

New clause 5 would give notification to Parliament of the impact of quality accounts on the NHS. It would give Parliament an opportunity to scrutinise the implementation of quality accounts within three years of their coming into force. The Secretary of State would be required to make a statement, written or oral, to the House or to the excellent Health Committee, on the demand for quality accounts from patients. He will need to make it clear what improvements have taken place in NHS bodies in those three years and what impact the policy objectives of the quality accounts set out in the impact assessment, which has already been published, has had on the NHS. Finally, the Secretary of State will need to show how these documents reflect the health care needs of patients served by these bodies and the NHS.

Mike O'Brien (Labour, North Warwickshire)

I am concerned that the hon. Member for Eddisbury was worried about tired chief executives cutting and pasting things. Let me assure him that there will be no dodgy cut-and-paste dossiers from this Government—[Interruption.] I thought I would get that in before another Committee member did.

New clauses 2, 5 and 7 would oblige the Secretary of State to carry out an impact assessment of quality accounts and make a report to Parliament, covering the manner of publication, impact on services and demographic, social, economic and geographical factors. That is a worthy objective, but we do not need primary legislation to obtain it. It is worth emphasising that the quality of the care offered to patients is fundamental to the delivery of health care. High-quality care is better for patients and offers better value for money for the taxpayer. Despite that, historically the quality of health care has not been as high on the agenda as the discussion of the performance and operational efficiency of the NHS. That brings me back to the narrative that I gave of the development of the NHS, moving from dealing with underfunding, the need to get targets in, to the need to restructure it and now the need to move on to a new, higher agenda that is basically about bringing quality into the NHS as the focus of its activities.

Where elements of quality have received significant attention—for example, in respect of health care-acquired infections or reduced waiting times—we have seen significant improvements. Quality accounts enable quality improvement by promoting local accountability and transparency. They should enable clinical teams to open up dialogue with their community, which means that a large element of the quality accounts will be for local determination. That is why I am a little bit concerned about the requirement for overall reviews that would be brought in under the amendment.

The legislation as drafted provides a broad framework with broad principles, with the details to be determined later and set out in regulations and guidance. The current engagement in the testing processes is shaping these products. We will consult on our regulatory proposals later this year. It is clear at this point that the data required for a quality account are simply the existing service quality data that providers already report to Department of Health commissioners or the regulators. The legislation therefore sets out minimum requirements. There is no added burden on the NHS beyond the cost of preparing the document; all other work is or should be happening already.

The ambition is to make quality accounts a vehicle for quality improvement. That is why we are working closely with stakeholders in designing the format. More than 1,000 stakeholders have been consulted so far, including NHS managers, clinicians and patients. We will, of course, be implementing and developing ideas through secondary legislation. The process obliges us to present evidence of the real-world impacts resulting from our policies. So the sorts of data and information that the Opposition are currently seeking will need to be provided to Parliament, in any event, during the course of developing the detail of our policies on the quality accounts agenda.

The current testing process is the key to what we want to achieve. We have already started evaluating it. The first report will be available in the next eight weeks and will enable us to move to the detailed design phase. Thus, by autumn we will have firm proposals, strong evidence of their likely impact and an engaged and informed provider community waiting to implement them.

The consultation process—design, testing, implementation, evaluation and revision—will continue. One by-product of that process will be an annual impact assessment over the next three to five years, dealing with the impact of the policy against the wider criteria set out in the provisions tabled by the hon. Member for Eddisbury. That will become apparent when we publish our evaluation later this summer. However, I am happy to give a commitment now that I will ensure that we consider all the criteria in our impact assessments. He need not worry about that. We have taken on board some of the concerns that he has raised; indeed, they are concerns that we had before. Some of the information he requires will therefore come forward, and it is our intention to make an annual impact assessment over the next three to five years in any event. I hope that, on that basis, he feels able to withdraw his new clauses.

Edward O'Hara (Labour, Knowsley South)

It is not a matter of withdrawing them as they were not moved. To be clear, should the Opposition wish to press the new clauses, they would be moved formally later, as they have been debated.

Clause 10

Stephen O'Brien (Conservative, Eddisbury)

I beg to move amendment 122, in clause 10, page 6, line 34, leave out ‘annulment’ and insert ‘approval’.

Thank you, Mr. O’Hara. We move to clause 10, which deals with more regulations under clause 8. The premise of amendment 122 is simple: the House should be given the opportunity to debate the regulations proposed in clause 8 regarding the form and content of the quality accounts. Presently, the regulations will be introduced into the Bill by way of a statutory instrument that the House will have the opportunity to annul. If we were given the chance to debate the regulations through approval of the secondary legislation rather than annulment, the Government could benefit from the views of the House on the scope and content of their regulations.

Without sight of the regulations, it is impossible to ascertain whether quality accounts will be rigorous and objective enough to paint an accurate picture of a trust’s services, or indeed the quality of those services. Although we endorse the notion and principle of quality accounts, we have not yet been given the opportunity to scrutinise the detail of the proposal. The regulations would raise a number of issues for debate, such as the circumstances in which the Secretary of State might exempt a trust from producing a quality account and the extent to which the regulations provide for an objective account of quality based on outcomes. In previous debates, we have certainly touched on the former, and the Minister, in responding to a previous proposed amendment, stated that the Secretary of State would have the power to exempt a trust from producing a quality account.

I think that the Government have in mind very small suppliers of NHS services who might find that producing quality accounts is neither proportionate nor particularly relevant to the service supplied. We must be extraordinarily careful that that cannot be used to exempt from producing quality accounts pioneer technological suppliers or those at the riskier end of providing services to the NHS, as more innovative suppliers can often be. If quality accounts are not produced, there would at least have to be no expectation that quality assurance—or the requirement for patient safety, of course—would be lessened by the granting of the exemption. It is easy enough to imagine a small operation for which it would be disproportionate or a terribly minor part of an overall service given, but we need some reassurance that the measure is not a potential way to get out of the obligation to produce quality accounts.

As with so much of the Bill, we do not have the draft secondary legislation or the proposed detail of the quality accounts. We have some examples, but the Minister rightly observed that that is not what is expected in the final iteration and analysis. The amendment would therefore be helpful in giving the Government, and indeed the House, the opportunity to take a view on whether the approach is working well, rather than simply using the process of annulment.

Mike O'Brien (Labour, North Warwickshire)

Our original proposal was to use the affirmative route on the first occasion and the negative route thereafter. We amended the Bill in the other place to address recommendations by the Select Committee on Delegated Powers and Regulatory Reform that the negative route would suffice in this case. We have responded to that by taking our present position. Of course, we will want to engage extensively with external stakeholders on the design of the rules for quality accounts. We have already heard the views of more than 1,000 interested parties, and we want further consultation when appropriate before bringing things forward.

I do not see that much would be added by using the affirmative route for approving these often detailed regulations and procedures. We need to ensure that the various stakeholders are engaged; if they have concerns, they will doubtless bring them not only to our notice but to that of Opposition Members. The stakeholders will therefore be able to ensure that appropriate discussions are held should regulations prove controversial. However, we envisage that the development of the regulations would not usually be a matter of considerable controversy.

The hon. Gentleman said that we must not create a process under which various organisations can get out of providing quality accounts, and I agree with him. We need to be careful how the exceptions are used. That is why we want to consult on their detail, and when we should use them and when not. We do not want to impose unnecessary burdens on small organisations or small providers of limited services; but we want to be sure that if there is an issue about the quality of service that a patient may receive, there is an opportunity to consider whether quality accounts ought to be delivered. That may well be the outcome of the consultation on the particular providers of equipment that the hon. Gentleman mentioned.

I hope that the hon. Gentleman understands why we took the route that we did in our approach to statutory instruments, which was in response to the suggestions by the Select Committee on Delegated Powers and Regulatory Reform in the other place. We have taken that view on board and responded to it. To some extent, I believe that we deserve credit for having done so.

Stephen O'Brien (Conservative, Eddisbury)

I recognise how the position reached in the Bill came about, but it was necessary to probe to obtain that confirmation. The intent is clear and I agree with it. The main thing is to ensure that there is no opportunity for misunderstanding. That exchange, in itself, should suffice. I beg to ask leave to withdraw the amendment.

Clause 11

Stephen O'Brien (Conservative, Eddisbury)

I beg to move amendment 186, in clause 11, page 7, line 7, leave out

‘securing the provision to a patient of’

and insert

‘enabling a patient to secure’.

We are forging rapidly through the amendments, and we have reached clause 11. The Minister will recognise that we are likely to find ourselves engaged for a while, as we have reached the subject of direct payments. It is known across the House to be an extremely important development in health policy. However, it raises a number of concerns because it relates sensitively to some of the most vulnerable people in our society—be they the elderly in need of care, or those with long-term conditions who need the confidence of knowing that their care packages will be sustained and that they will receive them in a quality way.

The amendment addresses the heart of the principle behind direct payments. The substantive question is whether the Secretary of State is still in charge, or whether patients are truly empowered to commission their own care. We would argue that the Government have come somewhat late to the party on direct payments; we have been calling for them since 2004. The Government rejected them as recently as 2006, when we debated the White Paper entitled “Our health, our care our say”. The then Secretary of State for Health—there have been several—the right hon. Member for Leicester, West (Ms Hewitt), called them a

“revival of the patient’s passport”.—[ Official Report, 30 January 2006; Vol. 442, c. 29.]

She could think of nothing ruder. Can the Minister explain his party’s change of heart?

In fairness to the Minister, the Government are going only as far as piloting direct payments. I think that that is a way of saying that they are the right thing to have, but I also think that they have been concerned about a number of issues that have been raised with them, not least by those on the Government Benches and some people outside the House who represent groups of interests.

Given that we know where the two major parties stand on the issue, it will be useful, in the course of this process, to have equal clarity from the Liberal Democrats. I know that there are a number of amendments to the clause that the Liberal Democrat spokesman will be leading on. I have been concerned that perhaps we have not been completely as one in our approach to direct payments, which has always struck me as being absolutely in the line of Hobbes and Hume. I would be very surprised if the Liberal Democrats did not support this, but we shall see as the debate proceeds.

The point is about enabling the patient—the person who needs the care—to be empowered and, as the expert in their own care, to be in charge of the care with which they are provided. In addition, we should not forget that often the family and friends who are their carers are equally expert.

It is interesting to note that the former Health Minister, Lord Warner, said in Committee in the House of Lords:

“I have often thought that the NHS, which, as a Minister, I sometimes found a somewhat inward-looking organisation, is rather slow to learn from local government, which has often been much more innovative”.—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC212.]

I hope that the Minister will agree with his noble Friend’s assessment of our NHS, that we can now move rapidly to much greater clarity and expansion of the principle of making direct payments, and that that will become much more central to Government policy. As we shall develop the point through succeeding amendments, I shall not take up the time now, but we need to ensure, in relation to the patient being in charge, that we have the ability to make direct payments effective and move beyond the current pilot stage to something more full-blown.

Mike O'Brien (Labour, North Warwickshire)

We want to develop a more personalised style of care from the NHS, and last year my noble Friend Lord Darzi announced a pilot programme to explore the potential of personal health budgets in his document “High Quality Care For All”. We are all aware of the success that has come from the Government’s initiative in relation to community care direct payments. We want to ensure that these direct payments will enable people to benefit to some extent in the same way that they have in community care from controlling a greater degree of their health care.

We are approaching the matter with caution. We think that it is worth exploring in a series of pilots. Giving people who have particular conditions the ability to manage their own health needs through control of the budget will, we think, appeal to a limited number of people who want to exercise the level of control over their care that is needed. We see that happening in the following way.

A patient would go to their provider—probably their GP initially—say that they want to have a health care package that does a particular set of things and then negotiate the budget with the health care provider. There may be more than one provider. The person could then ensure that that was delivered. It will not involve the handing over of money. It is about a budget being made available to meet the needs of a particular individual. Those needs may be unique; perhaps the person has a long-term disability or a particular condition. They could have control over their own lives and be able to make decisions about how and when they want particular services delivered. That must be done in negotiation with their health provider; we see that being done primarily through their GP probably, although it will not always be their GP. They will agree that process, the health care will be delivered and we shall be able to evaluate whether it has been successful. There should be about 70 pilot projects, to see how it would operate, and then we shall evaluate whether any expansion is the right way forward.

I know that the Conservative Opposition take the view that direct payments are a way, effectively, of giving some sort of private ability to control money—spend it—whichever way the person wants to. I am not sure how far the Conservatives would go with that, but I want to be clear how far the Government propose to go, and that has its limits. Where appropriate, where negotiated with health providers and where there is agreement about what will be delivered in a way that suits the personal needs of a patient with a particular condition, we want to run some pilots to see how direct payments will operate. Then we shall evaluate the outcome of those pilots before deciding either to continue with such payments or that the system had not operated correctly and that we needed to look at it again. This is a bit more than an experiment; it is a pilot that we hope will enable us better to ensure that personalised health care is delivered to those individuals who particularly need it.

Stephen O'Brien (Conservative, Eddisbury)

I am glad that the Minister has said that it is more than an experiment, because his immediate predecessors in the Health Department made it clear that it was very much more than an experiment; that it was very much the direction of travel. To pick up on a couple of his phrases, the expressions that his predecessors used were a touch less cautious and perhaps emphasised less that the system applied to such a limited number of people. It is important—not least because it appears in the legislation—and is very much seen as one of the central bricks in the wall of the future of care .

As we move through the amendments, we need to be clear that we are talking about what is written in the Bill—direct payments—and put that in the context of what the Minister calls personal health budgets, which were originally described by us as individual budgets. The nomenclature is neither here nor there, but the point is that within the budgetary process there will arise the question of who makes the payment and handles the cash. The Minister strayed perilously close to making an unnecessarily contentious point, but there is no one—across the House—saying that this is anything to do with enabling a private approach. His own side has been very conscious of not wanting it branded as some form of voucher scheme. Interestingly, a consensus has developed across the House that the right forward direction should not be impeded and hindered by the prejudice of a number of people—again across the House—who are fearful of the implications of anything that could be equated to a voucher scheme. We are very much at one with that careful approach.

I hope therefore that we shall not find, as we proceed with the clause, that our discussion is itself impeded by such a mental map on the Minister’s part. I am prepared, of course, to withdraw amendment 186, because we shall find plenty of opportunity to explore how this works. As we proceed, it is vital that we ensure that patients feel in control of their destiny when it comes to their care and that they can command the quality in accessing that care. Everything we can do to enhance the provisions in this chapter will be vital in ensuring that what is intended to be delivered can be delivered. As I have said, we have urged the Government to introduce these measures for years, so I hope that they realise that they have our support. I beg to ask leave to withdraw the amendment.

Stephen O'Brien (Conservative, Eddisbury)

I beg to move amendment 106, in clause 11, page 7, line 28, at end insert—

‘(7) Health care provided in accordance with this section constitutes a function of a public nature for the purposes of section 6 of the Human Rights Act 1998.’.

I am sure that hon. Members are aware that we touched on human rights when considering the Health and Social Care Act 2008. A number of colleagues of the hon. Member for Hendon (Mr. Dismore) from the Joint Committee on Human Rights were members of that Public Bill Committee and they put forward ideas that had arisen in the Select Committee. To some degree, those issues read across to these provisions. We should bear it in mind that we are trying to empower patients. The quality of the care of the elderly should be the benchmark test for this legislation.

Lord Dubs raised this issue in another place and questioned whether, in light of YL v. Birmingham city council—which admittedly is a social case—the provider of services commissioned and/or paid for through a direct payment constitutes a public authority under the Human Rights Act 1998, an Act with which the Minister is very familiar. Lord Darzi argued in response that the Government consider that all independent providers of health care that provide services to the Secretary of State in fulfilment of his duty to provide health care are carrying out a public function. They are therefore all public authorities for the purposes of section 6 of the 1998 Act. He argued that because the patient would sit in the same legal position as the Secretary of State, independent providers commissioned through a direct payment would similarly be covered by the 1998 Act.

That argument, of course, has not been tested in the courts in the manner of YL v. Birmingham city council. Lord Dubs remained less sure than Lord Darzi that the Law Lords would agree if pushed to a decision. That debate is on the record, and I will not trouble the Committee with references to it. I would be grateful for the Minister’s views on that.

More interesting are cases in which a patient commissions a type of care that the Secretary of State would not normally commission, or care from a type of provider that he would not normally commission from or is prevented from commissioning from. Under the large tranche of amendments that we are about to discuss, we will debate the different forms that direct payments might take. If the patient is left totally free within his agreed care plan, can the Minister guarantee that anybody he commissions from will come within the ambit of the Human Rights Act 1998, simply as a result of the act of commissioning? I am sure that he is as aware as I am of the consequences that will flow from his answer. That issue was at the heart of much of the consideration of the Joint Committee on Human Rights when trying to protect the rights of the elderly and those most in need of care in particular.

Hon. Members from all parties are genuinely deeply concerned about many campaigns on these issues, such as “Action on Elder Abuse”. If there is one function that we must all fulfil as MPs, it is to give a voice and effective action to people so that some of the greatest abuses do not take place.

I hope that the Minister sees that this point is seriously made and that he assures the Committee that the human rights aspect of the legislation will be in place.

Sandra Gidley (Liberal Democrat, Romsey)

I shall be brief. I support the amendment. It is important and well intended. I welcome the Conservative party’s support for the Human Rights Act 1998, which is not always forthcoming from its Benches.

Mike O'Brien (Labour, North Warwickshire)

I share the hon. Lady’s welcome for the repenters; it is always nice to hear. The hon. Member for Eddisbury is broadly right in the sense that it is our view that the Secretary of State’s duty to provide a comprehensive and free health service under the National Health Service Act 2006 is a core public function. The Government consider that, when providing services in fulfilment of that duty, independent providers of NHS-funded health care are carrying out public functions. They are there for public authorities for the purposes of section 6 of the Human Rights Act 1998.

The Government do not consider that any distinction can be drawn between the situation where the Secretary of State directly enters into a contract with an independent provider of health care services—as permitted by section 12 of the NHS Act 2006—and the current situation, where the patient enters into a contract with an independent provider of health care services under the proposed legislation.

The Government know that services provided under the proposed direct payment arrangements will ultimately be met by public funds. They note that there would be a strong public interest in ensuring that services are properly provided. They believe that stating explicitly that providers of health care procured by direct payments are carrying out public functions for the purposes of the Human Rights Act would cast doubt on whether independent providers of health care services acting under other relevant sections of the NHS Act 2006 were exercising functions of a public nature. We would rather it were not stated here, because it seems clear that the Government are aware of concerns on the matter raised by the Joint Committee on Human Rights, and they remain committed to consulting on the scope of the Human Rights Act in due course.

As I have indicated, providing services in the fulfilment of the Secretary of State’s duty under the 2006 Act, the Government consider that independent providers of health care are carrying out public functions—if they take the queen’s shilling they have a duty, which includes ensuring that the Human Rights Act is complied with. I hope that provides reassurance. I do not think, for the reasons that I have given, it would call into question other provisions where we believe the Human Rights Act would apply. We do not want to call into question those provisions, so it is better not to put the provision in the Bill as if it needs to be stated; we think that it is clear that it applies.

Stephen O'Brien (Conservative, Eddisbury)

I have listened to the Minister and I think he has taken the point seriously. However, I am not sure whether I buy the argument that if the amendment were added it might imply that other provisions were not included within the overall approach of the NHS Act 2006. That is not the most powerful argument that the Minister has advanced in the course of our proceedings. I think that that area is engaging us to such a degree that it makes considerable sense to put it to the test, and I will therefore press the matter to a vote.

Stephen O'Brien (Conservative, Eddisbury)

I beg to move amendment 187, in clause 11, page 7, line 31, at end insert—

‘(a) as to the balance of risk between the patient’s autonomy to use the direct payment and the Secretary of State’s accountability for the appropriate use of public funds.’.

Edward O'Hara (Labour, Knowsley South)

With this it will be convenient to discuss the following: amendment 170, in clause 11, page 7, line 34, at end insert—

‘(aa) as to whether a patient wishes to use direct payments as a means of obtaining health care;’.

Amendment 15, in clause 11, page 8, line 5, at end insert—

‘(fa) as to circumstances in which the patient might pay a carer with a direct payment,’.

Amendment 188, in clause 11, page 8, line 7, after ‘payments’, insert ‘and the notice period required’.

Amendment 123, in clause 11, page 8, line 18, at end insert—

‘(l) as to arrangements to be made where the patient exercises a direct payment alongside a top-up.’.

Amendment 189, in clause 11, page 8, line 18, at end insert—

‘(l) as regards the procurement of maternity services.’.

Amendment 124, in clause 11, page 8, line 18, at end insert—

‘(l) as to the retention of savings made as a result of a direct payment by the Primary Care Trust;

(m) as to the granting of money for direct payments to the Primary Care Trust by the Secretary of State.’.

Amendment 125, in clause 11, page 8, line 18, at end insert—

‘(l) as to the commissioning of emergency, urgent and intensive care with a direct payment.’.

Amendment 126, in clause 11, page 8, line 18, at end insert—

‘(l) as to the commissioning of palliative care with a direct payment.’.

Amendment 127, in clause 11, page 8, line 18, at end insert—

‘(l) as to the responsibilities of the patient as an employer.’.

Amendment 128, in clause 11, page 8, line 18, at end insert—

‘(l) as to the purchase of community services at tariff prices.’.

Amendment 129, in clause 11, page 8, line 18, at end insert—

‘(l) as to the use of direct payments by prisoners.’.

Amendment 130, in clause 11, page 8, line 18, at end insert—

‘(l) as to the use of direct payments to fund complementary therapies.’.

Amendment 131, in clause 11, page 8, line 18, at end insert—

‘(l) as to the use of direct payments to purchase care in from another health system—

(a) in the United Kingdom;

(b) in the European Union’.

Stephen O'Brien (Conservative, Eddisbury)

I think that in reading that out, Mr. O’Hara, it is the first time that you have had to make a speech in this Committee.

This is a large bunch of amendments, and it will obviously detain us for a while. They try to press on a number of points to get complete clarity, and to explore the nature of the pilots of direct payments. There is a general question why it is necessary to frame the legislation in pilot terms. We have heard the Minister pray for a degree of caution, but that might need to be contrasted with the phrases that have been used by his former ministerial colleagues.

Section 7 of the regulatory impact assessment notes:

“Some benefits of increased contestability may arise during piloting; however, the full benefits are unlikely to arise unless the policy is introduced nationally.”

It will be neater to make the legislation underpin the provision of direct payments, with the Secretary of State retaining powers of guidance over when those powers might be used for, say, the first three years. Removing such legislation from the statute book would be no greater palaver than removing this, if Parliament rejects direct payments after piloting. If direct payments were accepted, no legislative changes would be made. As I think that I have already indicated, it may be of some interest, or even comfort, that the official Opposition are committed to the direct payments anyway.

The question of timelines might be something in people’s minds, in giving the options for the future. A couple of questions arise from the impact assessment regarding that. The first is a quick aside as to which Minister signed the RIA. For the first time, none of us can work out which signature has been used. It is an odd RIA, because words rather than figures predominate next to the pound signs. Will the Minister explain how the net benefit of pilots is higher than the net benefit of straight introduction, and how the cost of straight introduction can be uncertain when the costs of pilots is established as a rather precise £23 million? I am interested that the RIA also mentions a notional health budget, which is currently legal. The patient would not have the money—we have almost discussed that already—but would be able to see the pot, rather like the indicative budgets in practice-based commissioning. The Committee may be aware that, when he was a Health Minister, the Secretary of State for Health proposed giving people an indicative bill at the end of their NHS treatment. I am therefore interested to find out whether that is something the Minister would support, because it is patently relevant to the process of pilots and the particular arrangements on direct payments.

Before we debate the amendments, it is appropriate to remind the Committee that, under the Bill as currently drafted, regulations made under this section will be introduced according to the negative resolution procedure. That means that the House will not have the chance to debate the substance of the pilots. It is unlikely that we would want to vote down the regulations supporting the pilots, but it is likely that we would want to amend them, depending on whether the Government act on the debates we are about to have.

The Committee will be aware of amendment 140, the purpose of which is to bring the regulations under the affirmative resolution. These debates will, no doubt, condition our approach and treatment of that. I would also be interested if the Minister could explain the Executive provenance of this section of the Bill. Lord Warner told the Committee that he thought

“the regulations about direct payments in new Section 12B were drafted by the Treasury.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC212.]

Lord Darzi said that the PowerPoint presentations that he was using came from the policy strategy unit. I hope that the Minister will confirm whether the No. 10 strategy unit is calling the shots or whether the measure originated in his Department, although that might be a moot question.

Amendment 187 goes to the heart of the issue that we, as politicians, face in this and similar policy areas—the balance of risk. The amendment would ensure that regulations are published on the balance of risk that is acceptable to the Government after consultation. I submit that broadly, as a class, politicians are not the best and most practised at handling risk. I inevitably speak from personal experience, but that is partly because it is not usual for politicians to have had hard-line commercial experience, which is obviously almost completely predicated on the calculation of risk, and partly because the single event can be catastrophic for politicians in media terms when, in fact, it may mark only a small deviation from the norm.

The two major risks with direct payments are that the patient commissions the wrong care and suffers as a result, or that the patient commissions, to put it pejoratively, a holiday in Spain. There is also the more subtle risk that the patient commissions something that delivers a better health outcome for them, but that it is seen as a holiday-in-Spain option by the media. Obviously such risks will be mitigated by the presence of an agreed care plan. I argue that the patient should be constrained as little as possible, but—I put this in estimated terms—it is right that, in this day and age, we should seek to legislate not for the 2 per cent. who will do the wrong thing, but for the 98 per cent. who are the experts in their care and will do the right thing.

If we get the understanding of risk right, we are more likely to get the pilots and the direct payments right. What is clear is that every possible permutation should be piloted. Baroness Barker, who speaks for the Liberal Democrats in the other place, said:

“one of the great benefits of direct payments is that they enable people to take risks if they choose to do so.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC228-229.]

Individual budget pilots have shown that it is the empowerment that comes from being allowed to take the risk almost as much as the care that is commissioned that contributes to the individual’s health and improving well-being. That ties in strongly with another common agenda across the House: that the sense of dignity of independence should be an overwhelming driver of well-being and, indeed, community and family-based care.

That covers amendment 187. I will reserve my position on amendment 170 until the hon. Member for Romsey has made her case. I shall move straight on to amendment 15. On 13 January 2008, the Government trialled something called a carer’s wage, which was mentioned in the newspapers. It was reported in The Sunday Times under the headline, “Cash reward plan for forgotten army of carers”, and in the Daily Mail on 14 January under, “Brown promises a decent wage for family carers”. Reports said the proposal was at an early stage and that it could form a key element of the carers strategy. Needless to say, there was nothing to that effect at all in the carers strategy when it was published. I hope that the Minister will therefore take the opportunity to clarify whether a patient will be able to pay their carer with money from a direct payment, and if not, will he state whether the Government will deliver on the promise of a carers wage?

The amendment also touches on the question of budget pooling. In the other place, Lord Warner expressed the hope that

“we will not get into a situation where this innovative change that the Minister and the Government are introducing is stymied by very restrictive regulations in the inevitably blurred boundary area between health and social services.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. 213.]

I dare say that that is something with which we are all familiar from countless constituency cases. Budget pooling, meaning a single direct payment funded by NHS and social care, which the Opposition support and have argued for, while fully recognising that it carries with it some complexities and complications, would enable the patient to negotiate that blurred boundary and close the gap between the two. It would also prevent direct payments from being chipped away by PCTs keen to cost-shunt their responsibilities on to local authorities. I am therefore keen to hear what plans the Minister has to pilot pooled budgets. Will the legislation allow pooled budgets to be piloted under this Government or, indeed, a future Government?

Amendment 288 can be dispatched quickly, as I am just looking for an assurance from the Minister that patients with direct payments will not find them stopped suddenly for PCT budgetary reasons, and particularly not without notice. What circumstances is that section intended to cover, and what is the notice period likely to be?

Amendment 123 allows us to explore the relationship between direct payments and top-ups. Will the Government be piloting direct payments in cancer care, which can be almost akin to a long-term condition in some cancers? In addition, would a patient be allowed to top up their direct payment privately in order to get services not available on the NHS. That, as I am sure the Minister recognises, was part of the process under discussion in the report that the previous Secretary of State commissioned and on which he then made a statement to the House. Will the Minister be looking to pilot that process?

As the old joke goes, all of us have been touched by a midwife at some stage in our lives, and amendment 189 is looking for the assurance from the Minister that midwifery services can being procured through direct payments. In the other place, Lord Darzi said:

“I would certainly be very interested in proposals for maternity services”.—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. 222.]

That gives the Minister the opening. However, how does he propose to cater for unpredictability, such as the need to transfer from a home birth to a consultant-led obstetric unit in the event of unforeseen difficulties?

That also bears on the question of independent midwives. Will the patient be able to commission an independent midwife, particularly where a local service is not available from the NHS? On that, Lord Darzi said:

“There is plenty of evidence, not only in this country but elsewhere, where we have seen independent midwives working very well, such as in New Zealand and certain parts of England where such a service exists.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. 222.]

Will there be a requirement that patients must buy an indemnity for that, or indeed for any service that they buy? I hope that the Minister will be able to give us a view on the question of indemnity.

Amendment 124 is framed to reassure PCTs that they will, with regard to subsection (1), not face a clawback of any savings that they make through piloting direct payments. Under proposed new paragraph (m), they will be able to supplement their budgets if they lose money at that stage. I do not for one second underestimate the complexity of that area. The amendments might seen rather counterintuitive in a sense, as surely either the Department should keep the savings and sub the deficit, or the PCTs should do so. However, such a system would create perverse incentives in the pilot phase, and I dare say that the Minster and his officials have been thinking about that.

Will the Minister clarify whether PCTs will be able to keep any savings and whether they will be subsidised for any loss? That is linked to a point made in the other place by Lord Darzi, who said that

“where PCTs do not wish or are unable to apply to be pilot sites, I do not want to force them to do so. We are looking to harness existing enthusiasm in the NHS for personalisation, rather than to impose pilots on PCTs by selection by the Department of Health.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC247.]

I admire the commitment to local choice, but I would be very concerned if direct payments were limited to PCTs with effective visionary leadership. Is there a case for pilots to assess how unenthusiastic bureaucrats—let us not pretend that there are not some—can also be encouraged to roll this out? Western Cheshire PCT in my constituency is set to pilot a range of continuing and end-of-life care services, but I note—perhaps it has moved on rapidly since I last checked—that the Minister’s PCT in Warwickshire is yet to do so. We need to compare and contrast areas to find out why there are such differences.

On amendment 125, will the Minister explain why he is not piloting the commissioning of urgent care with a direct payment? On amendment 126, what sort of end-of-life and palliative care commissioning pilots will he be running? As I am sure he is aware, that question has been asked by many outside this place who take a grave and well-informed interest in such things.

On amendment 127, Lord Darzi said:

“Will patients be employers? The answer is yes; they could become employers, as I said earlier, with all the employment regulation that comes with that.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC239.]

The Government should set out clearly the nature of this employment status. Administering direct payments can be very difficult for patients or their delegates. Baroness Barker recounted the comments of someone who said that the direct payment

“is brilliant, because it enables me to go on working...However,”

the local authority

“doesn’t tell you anything about insurance or national insurance. It doesn’t tell you anything about what to do if it does not work out with the person whom you’re working with. It doesn’t tell you whether it’s up to you as the employer to deal with it and, if you are, how you do that. There was an organisation that helped us a lot, but unfortunately it’s packed in and there’s nothing now.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC204.]

I can also report—this is the reason for the amendment—that we had an hour at the end of the health debate at the last Conservative party conference on caring for our elderly population, which I accept the Minister did not attend. I am told that that is the first such debate at any party conference. We were privileged that Sir Terry Pratchett came to make one of his first big speeches about the early onset of Alzheimer’s.

During the course of a conversation, which a former newscaster mediated, a wonderful woman called Marianne Talbot gave testimony from her experience. She is known for her punchy contributions to Saga blog and is also a lecturer at Oxford university. She has looked after her father and, most recently, her mother, who have gone through dementia and Alzheimer’s respectively. She looked after her mother, who only recently went into a home, as her carer for two years. With all her intelligence and capabilities, she said that she hit the brick wall when one of the package of six carers wanted to go on maternity leave. She felt that she did not have the capacity, knowledge, expertise or confidence to deal with that.

If we are going to make the direct payments really work, we have to recognise that support and advice services have to continue to be provided and ensure that such services are still available and operating properly. That is what the amendment deals with. Local authorities are immediately in the frame to support such a service. By doing that, one can expect to see direct payments come through better.

On amendment 128, the 2008 Budget announced the extension of the tariff to community services in mental health. When will that work be done and how much is it predicted to save? The Minister may choose to write to us about that. Will direct payments be extended to community services as they are currently? If not, will they be extended to direct payments when the tariff is introduced?

Amendment 129 raises the question of direct payments and prisoners. The Government have completely failed to get to grips with prison health—we have had quite a lot of contentious discussion on that—and they have let down our prison population as a result. We might have liked to have a debate on that today, but I suspect that that is not quite appropriate. If public and mental health issues were addressed in relation to prisoners, that would go a long way towards reducing reoffending rates. There is a lot of common ground across the House, particularly among those who are concerned that many prisoners might, had they had mental health and drug treatment as a priority, not have found themselves so much on the wrong side of the criminal justice system.

In the other place, Baroness Masham of Ilton asked:

“Will drug and alcohol services be included in direct payments? So many people are sitting in prison now and not getting the right treatment, because it comes from another budget and health or social services simply do not want to pay for it.” —[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC219.]

The noble Lord Darzi, somewhat unusually, failed to give an answer on that point, so I hope that the Minister will take the opportunity to do so.

With amendment 130, I wish to probe the Minister as to whether direct payments will be used to fund complementary therapies. There was some discussion about this in the other place, and not necessarily because many of their lordships are of a different generation. Lord Darzi confirmed:

“Any intervention that will improve the health and well-being of the patient that is signed off by the care manager within the care plan would be implemented.” —[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC223.]

The big “if” in that statement is that it will be allowed if it is signed off by the care manager—so it is not whether the therapy will improve the health and well-being of the patient, but whether it will do so in the opinion of the care manager. Lord Campbell-Savours said:

“I can imagine circumstances in which the patient might say, ‘I want a £200 mattress’. The manager might say, ‘It is in your care package, but we think you should have this mattress’,” —[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC231.]

not that one. Whom does the Minister’s team envisage will be the care manager? Will it be the GP or a PCT worker? What are the perverse incentives of having budget holders signing off care plans? Will the care manager be someone open-minded who supports the patient’s choice, and will they be constructive?

Baroness Cumberlege made the helpful point:

“I remember when we had GP fund-holding. It was very interesting to see the enormous difference that that made to complementary therapies and the number of people who went to their GP. We should remember that it was the last time that patients really had some power over their care. The GPs wanted to respond to patient choice because it affected their income. A number of people—the figures are quite startling—chose to have complementary therapies, and, so far as I know, no damage was done. As soon as GP fund-holding was done away with, those figures fell.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC216.]

As the Minister is aware, we certainly pledge to return to real budgets for GPs.

Some complementary therapies, such as acupuncture and hydrotherapy, have brought benefits to many people, whereas most of us would regard some other therapies as being a touch more wacky. Even if some of them are regarded as being a bit off-norm, if they deliver improvements in health and well-being, and in doing so make a saving to the NHS, the question will arise whether they are likely to be included in a care package. Any clarification that the Minister can give on that would be helpful.

To some degree, this issue ties in with the long-running campaign, with which many Members have been strongly engaged, about supplements as a matter of patient choice, particularly because it seems that what appears to be the norm across the rest of Europe could damage access to supplements and in certain concentrations in this country.

Amendment 131 addresses the purchase of care across national borders. I shall not take long over this, but I want to make sure that it is not overlooked as the last amendment in this group. This issue is particularly relevant to those of us who have constituencies that abut a national border, as I do with Wales, which is a completely different nation for health purposes. Many issues are daily of great stress to the Countess of Chester hospital, which receives lots of blue-light admissions from Wales, partly because it is in the interests of those people to benefit from the shorter waiting times. Many of my constituents who live in Farndon wish to cross the River Dee by the old Roman bridge to get to a pharmacy in Wales to get free prescriptions, but it is not quite as simple as that because the GP with whom one is registered has an effect. Those issues are causing considerable worry, and we are worried, particularly in relation to this clause, that the Government are dragging their feet over putting in place guidance on health care at the European level. Presumably, individuals could request that their PCT commissions care from within the EU through the direct payment. I am talking about care that, if commissioned abroad, could be topped up. Will anything prevent them from commissioning care outside the UK? That will probably be a tough question for the Minister to answer off the top of his head, but perhaps he has the answer to hand.

I conclude my remarks on a very long group of amendments covering a very broad range of necessary questions, although I have not touched on the Liberal Democrat amendments.

Sandra Gidley (Liberal Democrat, Romsey)

This is a useful string of amendments that tries to tease out some of the detail behind direct payments. Liberal Democrats have always supported direct payments in social care, and we very much welcome them in health care. However, a number of complexities need to be addressed. Before I turn to the Conservative amendments, it might be appropriate to direct my comments slightly more widely, but I promise not to speak during the stand part debate.

I shall turn to amendment 170. We are very much in favour of direct payments in health because they provide patients with autonomy. Social care departments have been very enthusiastic about direct payments, but on occasions people have been put under pressure to go down that route, which clearly is not right either. In some ways, therefore, the amendment is an attempt to predict the future, which is always difficult—and we attempt it at our peril. However, for argument’s sake, let us say that the pilots for direct payments are successful and a trust decides that a particular form of health care is best delivered by a direct payment.

The amendment would establish the right of a patient to say, “Actually, no, I don’t want to go down that route.” Some slight confusion has arisen over this already. In response to an amendment tabled in the Lords Grand Committee to define the right to refuse direct payments, the noble Lord Darzi stated that

“the NHS Constitution makes clear that patients have the legal right to accept or refuse treatment that is offered to them and not to be subjected to any physical examination or treatment unless they have given valid consent.”—[Official Report, House of Lords, 2 March 2009; Vol. 708, c. GC242.]

That misses the point. Payment is not the same as treatment.

Mike O'Brien (Labour, North Warwickshire)

I think that I can short-circuit this: it is not intended that anyone should be obliged to take a personal health budget.

Sandra Gidley (Liberal Democrat, Romsey)

I am grateful for that remark, because it has cut short my comments. When the Minister sums up, perhaps he would like to clarify why he feels that it is not necessary to put that in the Bill. On occasion, it has been a problem in social care.

I shall deal more generally with the Conservative amendments, many of which are worthwhile, because they provoke a very useful debate. Given the complexities in health care, it is right to pilot these direct payments and not rush headlong into something that has not been thought through. Health care is not quite the same as social care. People react to treatments and medicines in different ways. There is no one-size-fits-all solution. Also, some people do not respond well to best-practice guidelines from the National Institute for Health and Clinical Excellence. They might just not work for them. At the heart of this, we must think about what works for individual patients.

One of my concerns about the GP having to sign all that off is that we are not giving patients as much autonomy as we could, and there is a question to be asked about that. Most of us have a GP we are fairly happy with. However, I have come across cases of a patient being unhappy with a GP because they are either too into alternative medicine or too against it—there is a whole host of reasons. A number of people make decisions to access other forms of health advice, and it seems that the GP as the gatekeeper could still be a barrier to patient autonomy.

Amendment 187 is important. The hon. Member for Eddisbury said, I think, that we should not get too obsessed about the 2 per cent. of patients who get it wrong, and that we should think about the 98 per cent. of patients who get it right. A few minutes later in another context he went on to mention the Daily Mail. I wonder if this is the Daily Mail fear test for any Government who seek to introduce this. There are 98 per cent. of people doing it right, but we all know that the Daily Mail will hone in on those examples of someone who has had a holiday in Spain or bought the wrong sort of mattress. Understandably, the Government want to avoid that, and I am not unsympathetic to that. I would like some reassurance on that point, as I think that amendment 187 gets to the heart of the matter if we are truly interested in giving autonomy to patients.

I also have problems with the tariff and how it will be priced. It is not always easy to price a bog-standard course of health care because personal variations are involved. Some people will cost more and some less. Some people will have other co-morbidities that complicate their situation.

From my time on the Health Committee it is also clear that in the past, trusts— PCTs in particular—have not been good at working out the cost of care. One has only to compare the costs of treatment of different illnesses across a range of trusts, to realise what widely differing budgets are available for what should ostensibly be the same sort of care.

I think that there is now much better financial management in the NHS, and some of those differences have been ironed out. However, it worries me slightly that a patient in one part of the country might not have as much money available to them as a patient in another part of the country. It is not a north-south thing; there are sometimes widely differing variations between trusts that sit side by side.

It occurred to me—particularly in light of coming financial pressures, which we all acknowledge—that direct payments could be used by some trusts as rationing by the back door. The cost of a certain type of care might escalate, but the cost over a period of time might be increased only by inflation. Those two things can be widely differing. Therefore, I seek assurances that there will be not just an annual uplift but reviews of the budget.

The hon. Member for Eddisbury raised queries about money or savings running out, and it is useful to clarify what will happen if, for very good reasons, the budget comes to an end. I am not clear how that will be tracked or how the patient will know how much they have left. Who will monitor that? I gather that in some parts of the country, there have been experiments in social care with a card that allows people a monthly budget that they can use. I do not think that we have the technology for that, but it is an interesting idea. Will it be a yearly budget? What happens if it runs out after six months? Will it be divided into monthly sections?

I was pleased to see amendment 189 on maternity. I raised the issue of maternity services on Second Reading. I think that the ministerial response at that stage was, “I don’t really understand that. We have choice, anyway.” I can assure the Minister that women do not have choice in all parts of the country. In some areas women are still denied a home birth. Obstacles are put in their way. A lot of community maternity units have closed down or consolidated in recent years, and increasingly people might be looking to the independent midwifery sector. It creates an interesting precedent, but one that is worthy of discussion. I would not want this to be seen as a wholehearted rush towards embracing the private sector, but in maternity specifically there are quite broad issues around the use of independent midwives.

Amendment 127 is useful. The hon. Member for Eddisbury mentioned Baroness Barker’s comment that she was not told about insurance or whatever. My experience with social care shows that it is the big barrier to the adoption of direct payments. Direct payments work brilliantly where you have people who are confident about what they are doing and it is fairly simple. They work brilliantly for people who have clear ideas about what they want to do and want to take absolute control. They work less well, unfortunately, in people who might be a little older or frailer, or might for many reasons have difficulties in understanding a complex situation.

Quite serious issues can arise if someone suddenly becomes an employer. It is sometimes quite difficult for Members of Parliament to understand the vagaries around employment law, if one has staffing problems. So direct payments will only really work if advice and support is clearly available to people.

Finally, it was pertinent to raise the problem of prisoners, and particularly drug and alcohol treatment. There is an opportunity here for people with alcohol problems who might not be in prison and who have trouble accessing services, because many services rely on drug money and it is more difficult to access services if the problem is purely to do with alcohol. If people were given a budget to manage their condition, it would save the NHS a lot of money in the long term, because a lot of evidence shows that some interventions do work in a good proportion of people, and if people have budgets available, services that are currently lacking in many areas of the country might be developed.

Direct payments are a fascinating proposal. We need to retain enough flexibility so that if pilots go in the wrong direction, we do not stop completely. Also, the analysis of the pilots—what went wrong and what went right—has to be open to wide public scrutiny. An underlying concern is that it looks good on paper but does not give patients as much autonomy as some of us might wish.

Mike O'Brien (Labour, North Warwickshire)

I remember once I was asked to arrange a meeting between a senior social worker and a fundholder who had his own care budget. He had in effect a surplus on that budget and wanted to deploy it to further care. The social worker took the view that the money had to be returned. The person, who had considerable disabilities, took apart the social worker’s arguments and clearly established that it was his budget, which he would continue to run. He was doing so perfectly competently, which everyone conceded, and the budget provided him with the liberty and the capacity to make decisions about himself and his disabilities, which was very important to him. Both the social worker and I learned that, in the appropriate circumstances, individual budgets can provide freedom and enhancement for individuals. So I very much favour the piloting of such budgets to see how we can extend them into health and whether they can provide that same freedom.

However, as the hon. Lady said, it depends on the circumstances of each individual. We certainly must not get into a position where we give a budget to people who do not want one. We will not oblige people to have a budget. Also, if people have particular infirmities or disabilities that make it inappropriate for them to have a budget but they still make a request for one, an evaluation will have to be made to establish if it is appropriate for them. Furthermore, it may well be that a carer of an individual requests a health budget for that individual’s care. Again, an evaluation would have to be made to establish whether that carer was the appropriate person either to hold a budget or to deliver it.

The budget will be supervised and people will have access to advice. Furthermore, there will be someone who has to supervise the way in which that individual budget is used. There will be a care plan—in effect, a health plan—that will set out the parameters for the use of public money. If the money is deployed appropriately and there is a surplus, it is envisaged that the individual will be able to identify, within the terms of the care plan, ways in which that surplus could be deployed. However, if that individual found that there was a deficit in their care plan, an evaluation would again have to be made. Was that deficit the result of an inappropriate pricing of the plan, or was it the result of the inability of the individual, their carer or whoever was managing that budget to manage it properly? At that point, a review would have to take place about the way in which the health budget was going to progress.

A number of questions have been raised by the hon. Member for Eddisbury. First, he asked who signed the regulatory impact assessment. It was my noble friend, Lord Darzi, the Under-Secretary of State. I will pass on to him the concern that was expressed—that his signature needs to become a bit more legible—but he is, after all, a doctor so we have to make allowances.

I was asked a number of other questions. I was asked whether any difficulties in the budgets for PCTs might lead to individuals in one area finding that they did not receive the appropriate budget while individuals in another area did. The individual circumstances of a PCT should not determine an individual patient’s budget; it is the health care needs of that individual patient that should determine that budget. Therefore, the area where an individual lives should not determine whether they are able to get a certain amount of money.

It will be up to PCTs to determine the number of pilots that they conduct. They will have to make that judgment and they will have to conduct the pilots within their budgets. It has been indicated to us that a number of PCTs are very interested in taking this process forward. So we are very encouraged by the interest that has been shown.

I was also asked who had made some of the rules and in particular whether it was the Treasury. In fact, the rules were made by the Government, who have collective responsibility. In practice, however, most of the work was done by the Department of Health policy and strategy unit. So that is the answer to that question.

Some pilots are specifically investigating the idea of pooling social care budgets and health budgets. If we can get the handling of the issue right, there is an opportunity for pooling budgets. However, the handling is the key and the devil is in the detail. We must work out how pooling can be done. Ideally, individuals with quite complex care and health needs must be able to ensure that they have a single budget for them, and we want to pilot how that might be delivered.

I am conscious of the time, so I shall go through the amendments briskly. First, amendment 187 is about

“the balance of risk between the patient’s autonomy to use the direct payments”

and attaining proper spending accountability. We aim to put the power into the hands of patients and to give them the support they need to exercise it. Essentially, we want an agreement about how the patient will spend the money, supervision and negotiation of that agreement and then allocation of a budget. I am not talking about a bunch of fivers in the hand but about access to a budget so that health care can be purchased appropriately. I hope that deals with amendment 187.

Amendment 170 relates to what the hon. Member for Romsey said about ensuring that a patient has to give consent, and I hope I have dealt with that matter. We do not want such a provision in the Bill because we want to see how things develop in the pilot. The amendment relates both to the individual and to those who have the ability and the right to make decisions on their behalf. Some individuals may have disabilities, but it may none the less be appropriate for them to have individual budgets because of the complexity of their care needs. It is essential that the decision should be arrived at by them. I cannot envisage a situation in which people who do not want a budget are somehow obliged to manage it, because they clearly would not do it. There has to be consent and, more than that, there has to be a seriously informed level of consent behind the administration of the budget.

Moving to amendment 15 and whether a direct payment can be used to pay a carer. The answer is yes, but we are concerned about situations in which resident family members are living with someone and in control of the budget. We need to exercise a certain degree of care. Except in exceptional circumstances, regulations on social care direct payments do not allow carers to be paid through direct payment if they are spouses or other relatives who live in the same house. Social care direct payments may be used for some family carers if they are non-resident. We intend to follow that example with health care direct payment.

We are concerned about evidence from social care that suggests that resident family members can become dependent on direct payment as a significant source of their household income. The effect of that is to limit people’s independence and choice, as they feel obliged to continue to employ a resident family carer even if that is not the best way to meet their personal needs. We need to exercise a high degree of caution in that area.

Sandra Gidley (Liberal Democrat, Romsey)

I understand the need for some caution, but I should like to mention a particular constituency case. A mother has a son with health and social care needs who is in a wheelchair. The mother is a nurse and would like to provide the nursing care and use some of the money to get other help around the house. She is not allowed to do that. She has to employ a nurse and do other work herself. I know that not many families are in that position, nevertheless, the mother has been deprived of a choice that would not make her financially dependent. The same amount of money is coming into the family, but there is a lack of flexibility over who delivers a particular type of care. As a mother, she is quite clear that she would like to do it herself, and she seems to be deprived of it under the present rules, which seems a shame.

Mike O'Brien (Labour, North Warwickshire)

The hon. Lady raises a valid point. There are always exceptions to a rule, but it is there because we must avoid unpleasant things happening to individuals who may be vulnerable. The rule that protects vulnerable people may also fail to give them the higher level of care that may be provided by a close relative. I accept that her constituent would seem to be such a case. However, it is necessary to balance the risks. At the moment, we believe that caution is needed. A mother’s care may be greater, given the nature and the extent of her qualifications, but we intend to exercise care about that in the pilots. It does not mean that rules might not be developed at some stage in future should the proposal become a long-term project that would allow a more detailed evaluation of the balance of risk.

Stephen O'Brien (Conservative, Eddisbury)

I appreciate that we are pressed for time, but the Minister will be aware that I asked whether there was any sign of a carer’s wage. I pointed out that the Government’s promise had created some expectation.

Mike O'Brien (Labour, North Warwickshire)

We are pressed for time, and I want to ensure that we get through some of the issues briskly. Perhaps the hon. Gentleman will forgive me if I return to him on that question.

Amendment 188 would set a notice period. We do not envisage any direct payment being stopped because of a PCT’s budgetary problems, and certainly not as part of the pilot schemes. We do not envisage that any PCT would be so crass that an individual budget would make a great difference to its overall circumstances. The straight answer is that we do not foresee that happening.

On amendment 123 and whether people may top up their direct payments, our view is that that should not happen. Patients may not top up their personal health budgets from their own resources, given the health plan that has been put in place. If they want to buy something additional, such as health care outside the budget plan, that is a matter for them and they will, in effect, be paying privately for additional health care. However, if they have a health budget that they manage, it should be done within the terms of the funding provided by the public. The NHS is not there to subsidise private medicine. NHS money should be used to provide necessary NHS care, not to provide the wealthy with a way of obtaining a little additional money from taxpayers for something that they would otherwise pay for privately.

On maternity services, we want to give women more choice in maternity care, and the matter was discussed at length in another place. We are very interested in the principle and we are pleased that one of our provisional pilot sites at Eastern and Coastal Kent PCT has included maternity services as part of its proposal for exploring personal health budgets. However, we have said that PCTs must decide locally where personal health budgets might bring the greatest benefits for patients.

On whether we are prepared to consider private sector maternity providers, we will consider the details of particular circumstances and see how the pilots operate. A private maternity programme may be developed in the future and benefit some women, but it is not in place at present. Let us see how things develop and what the circumstances are. We do not have a closed mind. We are willing to look at how that develops.

I was asked whether people would need to buy an indemnity. That is a problem. If people are producing an entirely privately funded provision, they would have to consider the implications. An additional budget will not be provided from outside to ensure that something the NHS would not otherwise have to provide will be provided because someone has decided to get a service from the private sector. People will have to bear that in mind. On amendment 124, the benefits of any cost savings would be deployed in the personal budgets.

I was asked whether we would pilot in areas that are unenthusiastic. We are not planning the pilots in those terms. We want to see whether the scheme can be a success. It is not just about testing in enthusiastic areas. If it can be successful in some areas, it may then need to be tested in less enthusiastic ones. We will see how that works. It will be a matter of working out how we engender enthusiasm in those areas.

On amendment 125, we do not envisage that the scheme could be used to commission emergency and intensive care, because it would be difficult to set a meaningful budget. In many cases, there could be a lack of clinically appropriate treatment choices for people to make. Our personal health budgets are unlikely to add any significant benefit in that area at present and could even introduce some complexities, so we are not envisaging that being part of the pilots.

With regard to palliative care, we could see some significant progress in terms of individual budgets. Personal budgets could give patients greater choice and control in designing support to give them the best possible quality of life. Several of our provisional sites propose to explore aspects of palliative care, especially end-of-life care, and supporting people with long-term conditions. We are keen to explore that further. However, we are also aware that people may not wish to manage a budget during what can be a stressful, difficult period. No one should be forced to take more control of their care than they feel comfortable with. It is vital that we get the balance right.

Rather than just saying, “Here’s a budget plan, now get on and do it,” which we might do with some people, we would not exercise such a hands-off approach in that area. There needs to be a level of support for people, particularly in end-of-life care, that may go beyond that available in some other areas. It is about ensuring that we get the level of support right in such circumstances, but the personal budgets really could provide a significant advantage and could improve the circumstances of individuals.

Amendment 127 relates to individuals who become employers. People who receive direct payments will need to understand and fulfil their obligations as employers. Primary care trusts involved in the pilots will need to ensure that patients and carers have the information and support they need to act as responsible employers. We know from recent research that care workers employed using social care direct payments may not receive sufficient training opportunities. However, other people receiving direct payments to employ care workers are keen to ensure that their staff have not only good, appropriate terms and conditions, but access to training. There are issues that we will need to explore through the pilots, but, yes, there are obligations on employers and, if people decide to employ others, as part of their budget they are taking on the things that go with that.

Amendment 128 relates to the use of community services tariffs when using a direct payment to purchase care. Where local tariffs exist for community purposes—we are encouraging their development—they may provide the pilot sites with a useful basis for calculating a direct payment or other type of personal budget.

Amendment 129 relates to prisoners. I do not envisage that direct payments would become available to prisoners. I appreciate what the hon. Member for Eddisbury said about prisoners having mental health problems, but the NHS and the services within the Prison Service are a better way of dealing with that, rather than giving the prisoner a budget with which he then buys his own care. That is not an area in which I envisage direct payments being appropriate, although I hear what he says.

Amendment 130 relates to complementary therapies. We do not intend to rule out the use of direct payments to purchase such therapies. Many people find complementary therapies useful as part of a wider package of care—for example, using acupuncture as part of a package of pain relief that includes drugs and traditional physiotherapy. The whole aim of personal health care budgets is to allow a flexible and personalised approach, not to draw up a national list of eligible treatments in some kind of regulation. However, any therapies would have to be agreed as part of the health plan as likely to meet the person’s health care needs. No money would be spent on services that are not in the agreed health plan.

Amendment 131 relates to the purchase of health care from devolved Administrations or from other countries in the EU. The hon. Member for Eddisbury referred to his personal circumstances and his constituency having a proximity to another country. We do not intend to introduce any specific restrictions at this stage. In principle, a direct payment or other personal health budget could be used to purchase care from providers elsewhere—in other countries in the UK or in the European economic area—in the same way as a traditionally commissioned service. Any use of overseas providers would have to be agreed with a PCT as part of the health care plan. Direct payments should not be a way to get access to treatments that other patients in the UK would not be entitled to receive. We would need to look carefully at all these issues.

I hope that I have covered most of the many questions raised and I hope that, on that basis, the amendment will be withdrawn.

Stephen O'Brien (Conservative, Eddisbury)

The Minister has done his best to tackle all the issues that were raised. I am sure that he recognises that it took us some time to put them together to make sure that they were properly explored. The devil will be in the detail—he used that phrase in relation to pooling, which is interesting—and that is why it has been important to look through the provisions. It is also why there is justification for pilots and there will be concern to make sure that they can convert into a roll-out once lessons are well learnt. On that basis, we have had a useful exercise, which is the purpose of the Committee, so I beg to ask leave to withdraw the amendment.