Health and Social Care Bill

Public Bill Committee, 17 February 2011.

Clause 2

Liz Kendall (Labour, Leicester West)

I beg to move amendment 36, in clause 2, page 2, line 23, leave out

‘with a view to securing’

and insert ‘to secure’.

Christopher Chope (Conservative, Christchurch)

With this it will be convenient to discuss the following: amendment 37, in clause 2, page 2, line 29, leave out

‘with a view to securing’

and insert ‘to secure’.

Amendment 39, in clause 2, page 2, line 38, leave out ‘have regard to’ and insert ‘seek to deliver’.

Liz Kendall (Labour, Leicester West)

It is a great pleasure to serve under your chairmanship, Mr Hood.

Christopher Chope (Conservative, Christchurch)

Order. I have to tell the hon. Member for Stourbridge that we cannot have coffee in Public Bill Committees.

Liz Kendall (Labour, Leicester West)

This is my first Public Bill Committee, and the first time that I have moved an amendment. I am sure that we will conduct our debates in a spirit of co-operation, as we did on Tuesday.

First, I shall set out the context of clause 2, as it is important that the Committee should have a proper discussion about quality at the start of our debate. Improving quality in public health services and health care is vital, and that aim is supported by Members on both sides of the Committee and the House.

The investment and reforms of the previous Government helped to make significant drives forward in improving quality in the NHS. The National Institute for Health and Clinical Excellence was established, which helped to develop national quality guidelines in a range of areas of care, from dementia to stroke treatment. National service frameworks were put in place, which helped to make huge improvements—in cancer care, for example. The quality and outcomes framework, a new system of payment, was introduced.

A couple of years ago, Lord Ara Darzi’s “NHS Next Stage Review”, on high-quality care for all, looked to take that agenda forward. Among other things, it led to the establishment of a new National Quality Board, which had strong clinical representation, and a range of other changes have been made that focus services on quality, such as quality accounts in foundation trusts.

Those improvements made a difference. The 2008 Nuffield Trust report “The quest for quality” assessed the results of the changes, and found that

“Quality in the NHS in England has improved significantly since 1997. Increased funding and a dynamic reform programme have enhanced both the resources available and the impetus for quality improvement.”

However, far more can and must be done to improve quality; that will always be the case. Members of the Committee are well aware that care in some areas still falls short of what patients and the public rightly expect. That is why the clause is so important.

Earlier this week, the health ombudsman’s report on care for the elderly, which I am sure we have all read, raised significant questions about basic safety and quality care. We know that other areas of care need improvement—for example, care for those with learning disabilities has fallen short—and that there are serious problems in some parts of the system. The vast majority of care is good, but there are still problems, as the hon. Member for Stafford knows only too well. Our ageing population, changing health needs and new technologies mean that the NHS can never stand still. The Government are therefore right to say, as the previous Government did, that quality must be at the heart of the NHS and that it must improve continuously.

Clause 2 introduces the duty of continuously improving quality. According to the explanatory notes, the clause aims to place that duty first on the Secretary of State—on his or her public health functions and in relation to health services. Secondly, the duty will apply to the NHS commissioning board, assuming that it is established following our Committee’s discussions. It will apply also to commissioning consortia, although I am not clear whether it will apply to the providers to foundation trusts. I am sure that we will return to the duty in later debates on the national commissioning board and commissioning consortia. Thirdly, the duty seeks to improve the quality of particular outcomes, but we will go into that in more detail in our debate on amendment 38.

I do not argue that clause 2 alone will secure the delivery of high-quality care for all. Other factors are vital in improving quality. The first is NHS resources, which we all know are extremely tight. Indeed, after the money for social care is transferred to local councils and once real inflation is taken into account, the NHS will face cuts in its resources. It is not protected, as the Government promised it would be at the last election.

Simon Burns (Conservative, Chelmsford)

Yes it is.

Christopher Chope (Conservative, Christchurch)

Order. I will not have Front Benchers interrupting speeches.

Liz Kendall (Labour, Leicester West)

Thank you, Mr Hood. In fact, the NHS faces its tightest overall funding period since 1950.

Another thing that will help improve quality is capacity—the number of doctors, nurses and other clinicians. We are already hearing from organisations such as the Royal College of Nursing that staff numbers are being cut and posts are being frozen because of funding pressures. The training of health professionals is another vital factor, both pre and post-qualification. I do not want to stray beyond the clause, but I wonder where responsibility for training will lie once strategic health authorities are abolished, because the close association that deaneries have with SHAs has not been taken into account.

We know from evidence, here and abroad, that there are many other levers to improve quality—payment incentives, the regulation of professionals and the system as a whole. However, those changes are not the sum total of what needs to be done to improve quality. Changing the culture between professions and organisations is important. Yes, it is influenced by legislation and structures, but it is also affected by a range of other factors, including the personal relationships between clinicians and patients, and between clinicians and managers. One of the most important findings of the health ombudsman’s report was that the failings in quality that had been identified were both personal and institutional. It is important to bear that in mind.

All those factors play an important role in improving quality, but the Bill seeks to introduce a duty to improve care continuously. That duty must be clear, specific, strong and coherent. Clause 2 falls far short of achieving those goals. The Committee will remember the evidence that we heard from witnesses—it was only last week, but it seems longer than that. They were concerned about how quality will be improved under the Bill and who will be responsible—I shall deal with that in a moment—but they were also most anxious that many aspects of the Bill could harm the quality of care.

Several witnesses said that the changes to be introduced under the Bill would constitute a huge distraction from the real challenge that faces the NHS, which is to continue raising standards of care with increasingly tight resources. My experience of organisational change in the NHS—I was involved in some of those changes in a previous incarnation—is that people take their eyes off the ball. That is true in any walk of life. Anyone who has worked in a business or charity knows that when big reorganisations are under way, people implementing the changes focus more on their jobs, or having to reapply for their jobs, than on the outcomes that the organisation wishes to achieve.

Sir David Nicholson, the chief executive of the NHS, has challenged the NHS—the Chair of the Health Committee called it the “Nicholson challenge”—to deliver £20 billion of efficiency savings over the next five years, which represents a 4.5% efficiency gain each year. No health care system in the world has achieved that for one year, let alone for five.

Simon Burns (Conservative, Chelmsford)

The hon. Lady is making an interesting point. Would she remind the Committee that what she describes as the “Nicholson challenge” was introduced last year by the Labour Government?

Liz Kendall (Labour, Leicester West)

Yes, I can easily confirm that, but we did not introduce a huge structural reorganisation that would take people’s eye off the ball. I shall give you an example.

Christopher Chope (Conservative, Christchurch)

Order. The hon. Lady should not be giving me an example.

Liz Kendall (Labour, Leicester West)

I am so sorry, Mr Hood; I sometimes forget that I am speaking through the Chair. Perhaps I can give you an example.

A colleague who works for one of the London primary care trusts is involved in commissioning important services for dementia care and care for children. She has spent the past six months trying to work out what will happen once the PCT is abolished. She has left the NHS and wonders whether she should reapply for her old job. The NHS will have to make these savings, but the question is whether the Bill will help or hinder the NHS as it does that. I respectfully contend that the Bill will hinder it. That is why members of the Health Committee and many witnesses said that it would be a huge risk to put the NHS through this massive structural change at the same time.

The second broad set of issues raised by witnesses was that it is unclear who will be responsible for driving up standards of care. The Care Quality Commission will be responsible for minimum standards, but not for a continuous improvement in quality. The national commissioning board will be responsible for producing a national outcomes framework and will work with commissioning consortia. The Government’s line of argument is that the commissioning consortia will drive improvements in care.

I draw the Committee’s attention to the fact that witnesses last week expressed real doubts about whether commissioning consortia would have the skills and capacity to drive improvements in care—perhaps not everywhere, but particularly in hospital care. Stephen Thornton of the Health Foundation told the Committee that the foundation’s research showed that in many of the initiatives in which GPs had been given responsibility for commissioning, there had been some effect on community and primary services—but that is to do with things that they already know. There is little evidence that they have had a real benefit in changing in-hospital care. It is important that the Committee should remember that.

The Government also say that patients and the public can help improve quality of care if they have more information and choice. I state clearly for the record that Opposition Members, myself included, have been long-standing champions of giving patients far more information and choice on the services that they receive. Indeed, that principle was enshrined in the NHS constitution, which was introduced by the previous Government. For me, it has always been a point of principle. It is our—by that I mean the public’s—health and our care, and it is our money that pays for it through the NHS. We, as patients and members of the public, must have a say. As an aside, may I say that it is difficult to argue that patients and the public should take more responsibility for their own health and care if they do not have a greater say in that care?

I know from my constituency that many patients want more choice and to get more involved in the NHS. That is central to delivering genuinely patient-centred care. However, as witnesses powerfully told the Committee, patient choice and public involvement should not be seen as a magic bullet or panacea for improving quality.

The Government suggest that patients dissatisfied with the quality of care commissioned by their consortium could simply move elsewhere. It is right for people to have a choice about their GP, but to suggest that people could move to a different consortium that may be many miles away is, to put it politely, to suggest a false choice. It is clear from evidence to the Committee that many patients, particularly those with rare or life-threatening conditions, do not have the time, inclination or capacity to get involved in advising commissioning consortia.

I am sure that many of us were moved by the evidence we received from the patient suffering with ovarian cancer. She said that she will be focusing on staying alive, not on giving advice to GPs. People such as Jennifer Dixon from the Nuffield Trust pointed out that evidence from this country and America—if I am allowed to bring that country into the discussions—suggested that quality of health care is often driven by the culture within services and the nature of the relationship between clinicians, which is often called peer-to-peer review. That does not mean that we should not give patients more information and choice, but that is not a panacea to improving quality.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

The hon. Lady makes her argument well. She is talking about the fact that clinicians commissioning services is important, but apparently that cannot happen because managers make the decisions, not the clinicians. Patients have decisions about their care run through managers. The partnership that she wants to create is between clinicians and GPs, and between GPs and GPs, but at the moment, the structures in place stop that from happening.

Liz Kendall (Labour, Leicester West)

I thank the hon. Gentleman for that useful intervention. There may well be places where clinicians feel that they are not involved, but from all my experience of the NHS, including my time as director of the Ambulance Service Network, it is not true to say that clinicians do not come together because managers are in the way. I am sure the hon. Gentleman wishes to ensure that all clinicians—hospital doctors, nurses and others—are involved in commissioning, not just GPs. We will come to that point later.

Jeremy Lefroy (Conservative, Stafford)

Does the hon. Lady remember the evidence from the president of the Royal College of Physicians? His members felt disempowered by the current situation. What does she suggest might improve that?

Liz Kendall (Labour, Leicester West)

As I said, I think that some clinicians have felt disempowered in the past. I am a champion of greater clinical involvement in commissioning decisions— that point was made clear by the previous Government through Lord Ara Darzi’s review. Rather than throwing all the pieces of the jigsaw up in the air, changes could, or should, have been made to primary care trusts. I am sure we will come back to that issue when we discuss the clauses on the commissioning consortia.

Witnesses spoke about another area concerning quality. I am going through these points because the amendment seeks to strengthen the duty of quality. That is important because the concern is that improvements to quality may not necessarily happen as a result of the Bill. Some witnesses pointed out that the Bill says virtually nothing about improving quality in certain key aspects of care, and the point I am about to make will be important in later discussions. Nine out of 10 patient contacts with the NHS are in primary care.

Maintaining the quality of those services is vital, particularly for patients with long-term chronic conditions, which are the biggest health challenge facing this country. None the less, Dr Jennifer Dixon from the Nuffield Trust said that

“the Bill is silent on how else the quality of care may be improved”.–[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 24, Q51.]

If we have a duty to improve quality, it is vital that it should cover all aspects of care.

Finally, the witnesses were clear that some provisions in the Bill will actively harm the quality of care. I am sure that I shall get some interventions on this point. I am aware that I must not stray beyond the scope of the amendments, but it is important to ensure that we listen to the points raised by witnesses about the Bill’s likely effect on quality. [Interruption.] I see that the hon. Member for Preseli Pembrokeshire is raising questions about what I am about to say before I have said it. If this duty seeks continuously to improve quality, it must be strong and clear, particularly if we are worried that other aspects of the Bill may harm quality.

Witnesses said that turning Monitor into an economic regulator with a primary duty to promote competition, introducing EU and UK competition law in relation to the NHS into primary legislation for the first time, and abolishing the structures—PCTs and strategic health authorities—that currently manage the consequences of choice and competition could harm the co-ordination of services, which is so vital to improving the quality of care.

Many witnesses said that there was a real risk that the Bill would lead to a further fragmentation of services. I point here to the “handover” points—I think that an ugly term—between ambulances and hospitals, and hospitals and social care.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

May I draw the hon. Lady’s attention to proposed new section 14M of the National Health Service Act 2006, which outlines the duty in relation to quality of primary medical services? The hon. Lady suggested that there is no duty on consortia to deal with issues of quality, so I just wanted to ensure that she had not missed that particular clause.

Liz Kendall (Labour, Leicester West)

With the greatest respect to the Minister, I did not suggest that there was no duty on GP commissioning consortia. I said that Dr Jennifer Dixon, an eminent researcher, said that there is virtually nothing in the Bill about how—[Interruption.] Will the Minister listen?

If primary care is commissioned by a national board, how will it know exactly how to improve the quality of care? I know that the Minister may say—[Interruption.] It was not a partial quote. I am sure that Members can see it in last Tuesday afternoon’s evidence session. Dr Jennifer Dixon said that it was unclear how the Bill would continuously improve the quality of primary care. There may be a duty, but simply asserting something in the NHS does not, alas, make it happen.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

In that case, can the hon. Lady explain why she has tabled the amendments? The words in the clause are perfectly reasonable, but she wants to tweak and change them. Then she says that asserting things does not make them happen in practice.

Liz Kendall (Labour, Leicester West)

What I wish to do, as the hon. Gentleman will see from my amendments, is to make the duty far stronger and clearer. I will come to the word that I think should be used in a moment. The duty in the clause is weak, partial and incoherent in some ways. I shall say more about that in later discussions.

The second issue that the witnesses raised—this was the strongest link to quality—was price competition. All the witnesses, without exception, said that the evidence clearly showed that allowing competition on price will reduce the quality of care.

Dan Byles (Conservative, North Warwickshire)

I am sure that the hon. Lady was greatly reassured when Sir David Nicholson said:

“I do not accept the premise that the economic regulator is there to do price competition…We are… about competition on quality, not on price.”––[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 9, Q18.]

Liz Kendall (Labour, Leicester West)

I refer the hon. Gentleman to the evidence that Sir David gave to the Public Accounts Committee. He said that we cannot have price competition without defining the quality of services, yet no service has been able to provide such a definition. That is why the clause needs to be strengthened.

Dan Byles (Conservative, North Warwickshire)

What Sir David said to that Committee does not contradict what he said in evidence to us. He did not say what price competition could do; he did not accept the premise that the economic regulator had anything to do with price competition.

Liz Kendall (Labour, Leicester West)

I respectfully accept that Sir David has many years’ experience, but the evidence that we received from a range of witnesses shows that the Bill will allow a maximum price under which people can compete to deliver care. We shall deal with that aspect later.

Owen Smith (Labour, Pontypridd)

Was my hon. Friend as surprised as I was to hear the chief executive designate of the national commissioning board say that price competition was going to be a big factor? Indeed, other Ministers were rowing back from that premise. Given that the Bill allows a maximum tariff—

Christopher Chope (Conservative, Christchurch)

Order. The hon. Gentleman is tempting other hon. Members away from the amendment. I ask those who wish to intervene to be brief and to speak to the amendment.

Liz Kendall (Labour, Leicester West)

Thank you, Mr Hood. I am sure that we shall return to those matters later in the Bill.

There are real concerns about the impact that the Bill will have on quality. It is vital that the Secretary of State’s duty to improve continuously the quality of health and health services, set out in clause 2, should be clear, coherent and strong. Amendments 36, 37 and 39 seek to strengthen that duty.

Clause 2 states that the Secretary of State must exercise his functions

“in relation to the health service with a view to securing continuous improvement in the quality of services”.

It also states that in discharging this duty, the Secretary of State must

“act with a view to securing continuous improvement in the outcomes that are achieved from the provision of the services.”

Amendments 36 and 37 would make that provision clearer and stronger, as the clause would state that it was the Secretary of State’s duty “to secure” those improvements—not merely

“act with a view to”

or “have regard to”. Some people are concerned that the Bill could harm quality, so it is important to make the duties and responsibilities of the Secretary of State clear.

Amendment 39 deals with the Secretary of State’s responsibilities in relation to the quality standards prepared by NICE. Over the years, NICE has done some excellent work in setting out the best evidence on various kinds of care. Indeed, it is a world leader in that respect, and many health services turn to NICE’s quality standards.

What makes those standards increasingly excellent is that NICE does not focus only on drugs or health care interventions, but on prevention, involving patients and the public in making care genuinely patient centred, and defining the very best national standards in quality of care. That is vital for whoever commissions care; currently, it is the PCTs, but the Government are seeking to make it the commissioning consortia. However, the Committee will be aware that some PCTs do not always implement the NICE guidelines.

We heard from NICE’s chief executive, Andrew Dillon, on that point. He agreed that there are likely to be precisely the same problems if commissioning consortia are to implement the NICE guidelines as there are now with the PCTs. In fact, it could be more difficult for consortia to implement them.

Dr Poulter rose—

Liz Kendall (Labour, Leicester West)

I shall give way to the hon. Gentleman in a moment. If the consortia are responsible for a smaller number of people than primary care trusts, as in some parts of the country the pathfinder projects already are, just a couple of patients with very expensive health care needs could put them into debt.

We know that the Government are aware of the problem, because Jennifer Dixon revealed to the Committee that she had been commissioned by the Department to do some economic modelling to show the optimum number of patients for a consortium—the population coverage that would reduce the risk of being put into debt by one or two expensive patients. I respectfully ask the Minister whether he would be prepared to publish that modelling and evidence if it is ready during the passage of the Bill.

My point is that the key challenge for the NHS, as for any other health care system in the world, is how to get the best value and best care in the context of growing—if not infinite—demand, within finite resources. That is the key decision. The Bill simply shifts that challenge from primary care trusts to GP consortia, which may be less well able to deal with it because they cover a smaller population.

If we believe that the NICE guidelines are some of the best standards in the world, and we want them to be implemented—and Opposition Members do, as I am sure the Minister does, or he would not support them—it is right for the Secretary of State to have a clear responsibility to ensure that they are implemented, as amendment 39 would provide. Instead, therefore, of requiring the Secretary of State to “have regard to” the standards, under the amendment the clause would give him a duty to “seek to deliver” them.

We need to strengthen the Secretary of State’s duty to improve quality continuously for the reasons I have given. Quality is important and Members on both sides of the Committee support it. We need to be aware of people’s concerns that the Bill could negatively affect quality and that it is unclear who is responsible for it or how it would be secured. The amendment would resolve that.

Grahame Morris (Labour, Easington)

I want to speak fairly briefly, as I am sure hon. Members will be relieved to hear, because I do not think that amendments 36, 37 and 39 are controversial; in fact, they strengthen the hand of the Secretary of State in relation to his duties.

As my hon. Friend the Member for Leicester West has said, clause 2 focuses on the Secretary of State’s duty to ensure that there are improvements in the quality of health services that are provided as part of the national health service. On Tuesday, I and other right hon. and hon. Members spoke about the inadequacy—at least in the Opposition’s view—of the new, slimmed-down role for the Secretary of State, in so far as his powers are to be conferred on subordinate bodies. The Opposition raised concerns that the Bill would diminish the Secretary of State’s accountability to Parliament.

Amendments 36, 37 and 39 would put more emphasis on the duty of the Secretary of State and would strengthen his role in improving patient care. Amendments 36 and 37 would simply alter the phrasing of the Bill to make the Secretary of State’s duty with respect to quality improvements unequivocal. Under the clause, the Secretary of State would have to exercise his functions in relation to the health service

“with a view to securing continuous improvement in the quality of services”.

The amendments would change the emphasis because they would instruct the Secretary of State to secure the improvements. The change would apply to improvements in the quality of services and the outcomes achieved by their provision.

We know from evidence and statements by the Secretary of State and the ministerial team that they are great believers in the primacy of outcomes over targets. The Secretary of State told the Committee that the reforms are part of his quest to improve quality and outcomes for patients. In those circumstances, what reason can the Minister have for opposing the amendments?

Jeremy Lefroy (Conservative, Stafford)

I have a lot of sympathy with what the hon. Gentleman says, but let us suppose that he or I became Secretary of State for Health—no doubt I never will—and had the duty to secure continuous improvement in the quality of services. I am sure that he agrees that we live in the real world. If the Secretary of State had such a duty, it would be impossible for them to carry out that duty, however great their ability. They would be subject to legal challenge at almost every juncture. As a layman, that is my point.

Grahame Morris (Labour, Easington)

I am grateful to the hon. Gentleman for the intervention, but I honestly think that there are possibilities of legal challenge all through the Bill. I suspect that the legal profession are rubbing their hands at the thought of the additional work that they will secure as a consequence of the Bill. In response to his specific point, it is important that Ministers of the Crown have specific duties and targets by which their performance can be measured. Otherwise, how do we know whether they are successful? There is value in setting a specific duty on the Secretary of State.

The functions that the Secretary of State is to exercise under the clause are too vague and might simply refer to his dealings with the NHS commissioning board and GP commissioning consortia. Placing a stronger duty on him to improve services and outcomes would be a small but meaningful intervention and give him an impetus to take action, intervene and give instructions to the board and consortia. Accepting the amendment would make such a proactive approach more likely.

I accept that there many other factors contribute and are, indeed, imperative to improving quality and outcomes. In fact, many instruments that Labour used to secure service improvements have been stripped away by the coalition Government. We have already discussed the role of the strategic health authorities under clause 1. That opportunity and lever will no longer be available, so it is more important to strengthen the powers of the Secretary of State.

The Secretary of State and Ministers have assured us on many occasions that price competition will not be the driving force behind health provision. When my hon. Friend the Member for Pontypridd asked the Secretary of State, in the fourth evidence session, whether competition was

“going to be principally on price, cost or quality”,

the Secretary of State replied unequivocally:

“on quality”.––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 161, Q391.]

We are told that the whole system of health care set up by the Bill is focused on improving quality. If that is the case, why would it not place a stronger duty on the Secretary of State to improve quality?

Amendment 39 would strengthen the duty on the Secretary of State by requiring him to “take account of” rather than simply

“have regard to the quality standards prepared by NICE under section 218”.

Again, we are simply asking whether the Secretary of State should have a strengthened role in securing the improved quality and outcomes that he assures us are the intention behind the Bill. If NICE is to be directed to prepare statements of quality standards in the provision of NHS services, public health services and social care in England, we should expect that to influence the functions of the Secretary of State. As many witnesses have testified, the reorganisation set out in the Bill creates the risk of a loss of focus on outcomes. That could be the biggest danger to improving the quality of outcomes in the NHS.

The improvements achieved by Labour in reducing waiting lists—undoubtedly a considerable improvement, much valued by patients—increasing expenditure on the service, improving services and doubling the rate of public satisfaction, could be put at risk by the provisions. The changes in the Bill could be a huge distraction from quality and outcomes. The amendment would place a greater obligation on the Secretary of State to ensure that quality improves, despite the dangers posed by the reorganisation. I urge all hon. Members to support it.

John Pugh (Liberal Democrat, Southport)

We are in danger of having a Second or Third Reading debate on every amendment. If we do that, we will be here until Christmas—some hon. Members might regard that with less equanimity than others—and we certainly will have failed to scrutinise the detail of the legislation.

I will concentrate on the amendments’ wording and speak only about that. Amendments 36 and 37 would remove the words

“with a view to securing continuous improvement”,

and replace them with

“a duty to secure continuous improvement”.

That is not a change in emphasis; it is the substitution of a possible duty by an impossible duty. As the hon. Member for Stafford pointed out, there is no way that the Secretary of State can be guaranteed to perform the task that Parliament would be mandating him to do. There may be circumstances, for example, where a service is as good as it can be. Must the Secretary of State carry on seeking continuous improvement in a service that is perfectly satisfactory and satisfies all those who use it? Continuous change can be secured by the Secretary of State. Some people argue that that is what Secretaries of State have done and continue to do to this day, but continuous improvement is like someone being asked to improve their behaviour continuously: it is worth trying, but not something that they could guarantee to achieve.

I am not sufficiently malicious to wish to visit an impossible duty on the Secretary of State. Although I accept that the Secretary of State is powerful and can genuinely act with a view to securing continuous improvement, I assume that he is modest enough to think that that will not always be possible for him to secure continuous improvement. That is why the wording in the Bill must stand. Otherwise, we will be asking the Secretary of State to do something that is infinitely beyond his capacity.

Owen Smith (Labour, Pontypridd)

To pick up where the hon. Member for Southport left off, the Opposition and Government Members fundamentally disagree on the extent to which the clause effects a change in the nature of the duties placed on the Secretary of State. In the amendment, we seek to clarify the point that all health Acts in the past 60 years, starting with the first in 1946, have placed a clear duty on the Secretary of State.

In the National Health Service Act 1946, the then Minister of Health was under a duty to

“promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales.”

That provision was brought up to date by the National Health Service Act 2006, which states:

“The Secretary of State must continue the promotion in England of a comprehensive health service”

and must

“provide or secure the provision of services in accordance with this Act.”

Our simple point is that there is a difference between the Secretary of State securing and providing, and the Secretary of State acting “with a view to” securing and providing. The latter placing the matter at arm’s length and has the Secretary of State operating through what is effectively, as we said the other day, a quango.

Dan Byles (Conservative, North Warwickshire)

We are in danger of tying ourselves in semantic knots. The hon. Gentleman says that the Secretary of State must promote the health service, but that sounds far more like the wording of the Bill than that of the amendment.

Owen Smith (Labour, Pontypridd)

With all due respect, it does not. All the Bills referred to promotion; the significant difference between this Bill and all the previous ones is that this one talks about the Secretary of State acting with a view to or acting with regard to securing or providing, whereas all previous iterations initially placed the duty upon him to promote, and thereafter talked about him securing or providing, which is a far more direct duty than the arm’s-length, distant, free and liberating one implied by “acting with a view to”. Our simple question is: what exactly do acting “with a view to” or acting “with regard to” mean, and what happens in the event that the Secretary of State fails to do that?

Jeremy Lefroy (Conservative, Stafford)

Does the hon. Gentleman accept that there is a duty in the Bill to secure continuous improvement, which was not in the 2006 and 1946 Acts? That word, “continuous”, is vital.

Owen Smith (Labour, Pontypridd)

I absolutely accept that, and that word would be a really useful addition to the Bill were it far more clearly explained and articulated therein. I was going to come on to the inclusion of that important word in the clause. I agree entirely that it would be a valuable addition, if we could measure continuous year-on-year improvement—as is implied—right through the NHS. However, given that we have heard in discussions elsewhere that we will not have targets to the same extent as hitherto, and given that the Minister has told us that we will have only clinical targets—valuable clinical targets—it is difficult to see how, in an NHS as diverse as ours, with economic and non-clinical measurements that need to be taken into account, we can ever be certain that improvement is continuous.

The clause refers to acting with regard to securing that continuous improvement in respect of treatment, which surely implies that we will need some measurement of the volume of people being treated and the extent to which they are being treated. Such things are rather less clinical than the sorts of outcome measure that we repeatedly hear the Secretary of State and Ministers refer to as the only valuable and valid targets that might be applied under the new NHS regime. There is a contradiction between the duty to provide continuous improvement and the ability to measure it. I understand that there will be a mandate for the NHS in its various new functions to produce a document only once a year.

Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)

On that mandate and the document published once a year, if questions were asked in Parliament about the ongoing process, the Secretary of State could be referring to that document 365 days after its publication—

Christopher Chope (Conservative, Christchurch)

Order. The hon. Member is going a bit wide of the amendment.

Owen Smith (Labour, Pontypridd)

If I may, Mr Hood, I do think that my hon. Friend makes an interesting point—

Christopher Chope (Conservative, Christchurch)

Order. However interesting the point is, please speak to the amendment.

Owen Smith (Labour, Pontypridd)

My second question is that if clear targets are not enunciated in either the mandate, by the Secretary of State, or the Bill, how will patients in this new and rather more disaggregated NHS have the ability to discern whether their bit of the NHS is continually improving, or how it is performing in comparison with other parts? If the continuous improvement is a new and, as has been suggested, a valuable addition, surely we need to be able to measure it far more carefully.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

Is the hon. Gentleman seriously suggesting that hospitals and GPs will cease to do audits to monitor how their services are working on the ground?

Owen Smith (Labour, Pontypridd)

No. I am sure that all those things will continue to happen. My point is that the Secretary of State will be under a duty to act with regard to securing continuous improvement but, as patients, we will not be able to discern whether that is actually occurring, without some sort of aggregated target or set of targets allowing us to determine the truth of that. Otherwise, how will we know that there is this continuous improvement?

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

NICE will set up a national framework for clinical practice, against which local audits will be carried out. Does the hon. Gentleman agree that that is a good way of assessing whether local services are being delivered according to the national guidelines and targets?

Owen Smith (Labour, Pontypridd)

Again, I entirely agree. That is perfectly legitimate and it is how the NHS has worked hitherto. My point is that the duty to secure continuous improvement is new, but the current audit system effectively provides us with a spot check on that particular service at that juncture, and the extent of its performance against the targets set down. We will not be given a sense of whether that continuous improvement is occurring.

Dan Byles (Conservative, North Warwickshire)

The hon. Gentleman seems to be suggesting that, without the amendment, patients will not be able to tell whether the NHS is improving. I find that a remarkable suggestion. As my hon. Friend the Member for Central Suffolk and North Ipswich said, there are numerous measures and methods by which the NHS can be measured to see whether it is improving, and a semantic change in the Bill as proposed in the amendment makes no difference to any of them.

Owen Smith (Labour, Pontypridd)

I am not suggesting that patients will not be able to discern whether the NHS is improving. We can clearly see from the evidence that patient satisfaction ratings are at an all-time high, as a result of the increased investment that the Labour party put in. However, I am suggesting that the new duty and the new suggestion—political, I think—that there will be continuous improvement, which is somehow different from the improvement we have seen hitherto, will not be able to be substantiated under the terms and targets set in the Bill. Unless we also have a return to the type of targets that we used effectively, such as the 18-week waiting time, we will not be able to measure properly whether the duty is being achieved.

Finally, other aspects of the Bill militate against quality and certainly against continuous improvement in quality. Some of those we have heard enunciated, with clear evidence right across the board that price competition does not sit easily with continuous improvement in quality, but sits quite easily with continuous decline in quality.

Dan Byles (Conservative, North Warwickshire)

I found it remarkable that when Professor Le Grand gave his evidence, although he agreed with the hon. Gentleman that price competition had the potential to drive down quality, he made an interesting point:

“Although that provision in the Bill has been carried over from the previous Government’s operating framework”.––[Official Report, Health and Social Care Public Bill Committee, 9 February 2011; c. 20, Q44.]

Owen Smith (Labour, Pontypridd)

We have heard that point made several times, including my response to it, which has been very clear. We might have broached that particular change, we did not breach it. It was considered but, if one reads on, the outcomes framework also said that it would be a real step change for the NHS to go down that route. When my party was in office, we did not go down that route. New in the Bill—for the first time—is that there will be a maximum tariff, and therefore the ability to compete below that tariff, driving down quality. That is the clear lesson.

Margot James (Conservative, Stourbridge)

Why does the hon. Gentleman assume a direct link between a reduced price and reduced quality? That is often not the case. In my primary care area of Dudley, I have seen numerous examples of improvements brought about by GPs in the service at a reduced cost. Similarly, in our ambulance service, the combined operations centres have reduced cost and improved quality. Can he not accept that sometimes there can be a price reduction and an improvement in quality? That will enable the ultimate improvement in quality, which is that a greater number of patients are able to receive as good a quality of care as if it were to be maintained at an artificially higher price.

Christopher Chope (Conservative, Christchurch)

Order. The intervention should be shorter. I did not want to interrupt the hon. Lady but in future interventions should be shorter.

Owen Smith (Labour, Pontypridd)

I am grateful to the hon. Lady for her intervention, because it betrays the overwhelming philosophical bent among Conservative Members that introducing market forces—price competition being one of the ultimate market forces—may improve quality, as it does in telecoms, utilities or in other things that are not health care. The overwhelming academic evidence from America, where Medicare and Medicaid do not have price competition for that precise reason, and from Europe was given to the Committee in the evidence sessions last week. The head of the trusts, Sue Slipman, Monitor and the chief executive of the NHS could not imagine any services in which we should introduce price competition. The overwhelming evidence is that it drives quality down, not up.

The other thing that will militate against delivering continuous improvement in quality in the NHS is the effective break-up of the NHS caused by the Bill. The NHS will be a more disaggregated service with more private providers and more subcontracting.

Several hon. Members rose—

Christopher Chope (Conservative, Christchurch)

Order, at the very least we are moving towards a stand part debate, and, as the hon. Gentleman suggests, we are perhaps going down the road of reviewing the Bill’s Second Reading. Please speak specifically to the amendment.

Owen Smith (Labour, Pontypridd)

I hear your words, Mr Hood, and I shall sit down in a moment. I was simply highlighting several aspects of the Bill that are relevant to the clause because they relate to quality.

Simon Burns (Conservative, Chelmsford)

The amendment.

Owen Smith (Labour, Pontypridd)

Okay, the amendment. I shall leave it there.

Karl Turner (Labour, Kingston upon Hull East)

It is always a pleasure to serve under your chairmanship, Mr Hood.

I want to make one or two points, which I suspect have already been made by fellow Opposition Members, but I think it is important to get my concerns on the record. The clause creates a duty on the Secretary of State to act only with a view to securing continuous improvement in the quality of health care. New section 1A(1) of the 2006 Act specifically relates to the Secretary of State’s public health functions—the prevention of illness and the protection and improvement of public health—and addresses issues such as smoking, obesity and increased sexual health screening; it also states that the Secretary of State

“must…act with a view to securing continuous improvement”.

Amendment 36 would ensure that that duty is clearer and more robust. It would ensure that the duty is actually to secure continuous improvement in quality, rather than merely having a view to doing so.

The amendment would go much further than has been suggested by Government Members. It is not merely a semantic argument; it would provide assistance to the Government and secure the legislation.

John Pugh (Liberal Democrat, Southport)

We might as well get this straight. Does the hon. Gentleman really believe it is possible to secure continuous improvement across the range of NHS services ad infinitum? If so there is a disagreement between the Government and the Opposition. Could he make it clear whether he is actually saying that? I want him to say that he believes it is perfectly possible to secure continuous improvement ad infinitum.

Karl Turner (Labour, Kingston upon Hull East)

I am, yes. I am happy to have on record my belief that it is possible. The Committee has received evidence to that effect. [ Interruption. ]

Christopher Chope (Conservative, Christchurch)

Order, hon. Members should not get excited.

Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)

The amendments address the lack of individual and collective aspiration in the clause for what the Secretary of State is there to achieve. The national health service was founded on the principle that we would try to improve health outcomes for all people in this country ad infinitum.

Karl Turner (Labour, Kingston upon Hull East)

My hon. Friend’s helpful intervention assists both the Committee and me.

Dan Byles (Conservative, North Warwickshire)

I agree that the hon. Member for Middlesbrough South and East Cleveland made a helpful intervention. Change the word “try” to “seek” and he is entirely supporting the current turn of phrase. He should be voting with us.

Karl Turner (Labour, Kingston upon Hull East)

The clause also requires the Secretary of State to act with a view to securing continuous improvement in outcomes achieved from the provision of services. The amendment clearly offers assistance to the Government and would improve the Bill. Amendment 37 would make the Bill more robust and ensure that the Secretary of State has a duty to secure improvements in outcomes for patients. New section 1A(4) of the 2006 Act places a duty on the Secretary of State to

“have regard to the quality standards prepared by NICE”.

Again, the amendment helpfully assists the legislation.

Amendment 39 would ensure that the Secretary of State sought to deliver the standards prepared by NICE. Again, in my respectful submission, this amendment strengthens the Bill and ensures that the standards prepared by NICE are actively delivered, rather than the guidelines simply being referred to.

Clause 2 is about quality of services, and it signals a move away from targets towards an outcome-based approach. I am concerned that the Bill is not clear enough about what quality means. I hope that the Minister can explain his definition of quality.

I am also concerned that there is a focus on outcomes in the Bill. Again, there is no definition of outcomes in the body of the Bill. I understand that my concerns are supported by the Royal College of Surgeons, which says that the minimum standards of care are not set out in the new arrangements to introduce greater competition. Quality of services must be clearly defined if we are to avoid a race to the bottom when price competition is introduced.

Once the Minister has clearly defined what he means by quality and outcomes, the Secretary of State must be obliged to secure continuous improvement in both areas. The quality of care that our constituents expect is too important to be left in the care of an ambiguous definition in overly flexible legislation. In the written evidence submitted to the Committee, NICE welcomes its increased role. The fact that it specifically mentions the need for Government direction underlines my concerns that the clause, as it stands, is far too weak.

I agreed with NICE when it said that

“it is important that the health and social care system receives a clear signal, from Government, about how it expects it to respond to NICE standards and our other advice.”

Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)

Is it not the case that without these three amendments, the clause belies the confidence of Government Members in their own Secretary of State?

Karl Turner (Labour, Kingston upon Hull East)

I am bound to say that I agree with my hon. Friend. In fact, I could not have put it better.

The Government have laid out that they will respond to NICE standards, but they have neglected to explain how they will respond. I cannot see anyone objecting to the Secretary of State’s being mandated to defend the quality of services within the NHS given that he is exposing the health and well-being of the general public to the whims of an unfettered market. I do not intend to say any more on that point, Mr Hood, because I know that you would call me to order. For the reasons that I have outlined, I support the amendments and I urge the Committee to do the same.

Simon Burns (Conservative, Chelmsford)

Mr Hood, may I add to the comments of the hon. Member for Leicester West in welcoming you to the Chair? May I also pay tribute to the hon. Lady for what is her maiden contribution in a Committee hearing? Fluent it was. The content was not quite so good from the point of view of the Government, but there is scope for improvement and development in the coming weeks. [Interruption.]

Christopher Chope (Conservative, Christchurch)

Order. Hon. Members should not interrupt the Minister when he is complimenting someone.

Simon Burns (Conservative, Chelmsford)

Amendments 36, 37 and 39 seek to revise the duty of quality, placing the Secretary of State under a direct duty to improve the quality of services. I think that we come to the aim behind the amendments with a common purpose. Nobody in this Committee wants the national health service to provide anything but the highest quality of care. It comes as a considerable relief to me that we are united in starting from the premise of improving quality, although we begin to part company over how to achieve that with regard to the role of the Secretary of State.

As the hon. Member for Southport said in his eloquent contribution, the Secretary of State cannot be held personally, directly responsible for quality levels. Furthermore, if the level of quality is already at its highest, pushing it higher would be an impossibility.

Grahame Morris (Labour, Easington)

Will the Minister give way?

Simon Burns (Conservative, Chelmsford)

No, I am sorry. I am going to make progress.

Grahame Morris (Labour, Easington)

It is very important.

Simon Burns (Conservative, Chelmsford)

Every intervention from the hon. Gentleman is important.

Some of the ideas suggested by Opposition Members seem superficially attractive as a good way of getting things done, but their approach would undermine the devolved responsibility that the Bill seeks to establish and bring responsibility for provision of NHS services back to Whitehall, by giving the Secretary of State a direct duty to deliver improvements in the quality of the service.

The Government have said on the record and constantly repeat that we acknowledge the good ongoing work being carried out to improve and drive up standards. We recognise the importance of the work of the noble Lord Darzi in putting stronger emphasis on quality; it would be churlish not to. At least we have the confidence and maturity to accept when something is being done well or has gone well and to seek to build and improve on it further. That might be a lesson that others could learn.

Kevin Barron (Labour, Rother Valley)

Lord Darzi’s review considered quality. The national health service did a pilot scheme in the north-west called “Advancing Quality”. It was a four-year scheme and started, I think, in 2007. What evidence came from it to show that we can improve quality by using incentives in our national health system?

Simon Burns (Conservative, Chelmsford)

I am grateful to the right hon. Gentleman for that intervention. I will deal with the question of how we can incentivise, encourage and deliver improved quality. If he will bear with me, I will develop that theme, but first I will return to clarifying the role of the Secretary of State.

No one person, organisation or part of the NHS’s functions will be the engine and driving force for improving quality. That will be the combined function and job of everyone—all organisations and all proposals and plans within the NHS. However, it is clear that the Secretary of State will unambiguously set out quality expectations in the outcomes framework and the annual mandate to the national commissioning board. The duty of quality will run throughout the whole system. The NHS commissioning board and commissioning consortia will be under a duty to have regard to the need to improve quality. Members of the Committee who have read the Bill will know that.

Under its duty to secure continuous improvement in the quality of services that it arranges, the NHS commissioning board, for example, will have to give consideration to the Secretary of State’s outcomes framework. That framework will set out the outcomes and corresponding indicators that will be used to hold the NHS commissioning board to account for the outcomes that it delivers. Commissioning consortia will be under a duty to act with a view to securing continuous quality improvement in outcomes and will have to have regard to commissioning guidance produced by the NHS commissioning board, based on underlying NICE quality standards.

The NHS will have the freedom to achieve improvements in quality in ways that make clinical sense locally. Clinicians, not bureaucrats, will decide how best to improve outcomes for patients. Quality will be a key reporting theme in my right hon. Friend the Secretary of State’s annual report on the performance of the NHS, which is one of the key ways in which he will be accountable to Parliament. That is all quite clear.

I want to respond to the hon. Member for Kingston upon Hull East, who asked about the definition with regard to outcomes. If he had read the legislation that we are debating today, he would see it quite clearly on page 30 of the Bill. That, hopefully, answers his points.

Owen Smith rose—

Simon Burns (Conservative, Chelmsford)

I will not give way; I am going to deal with questions raised in the debate. The hon. Member for Leicester West raised several, including who was responsible for driving up quality. As I have said, but I will repeat it to her, not one body or person but all parts of the system have a responsibility and will exercise it. It will happen primarily through better commissioning, based on NICE quality standards, and clinicians will have an important and critical role in improving quality. The Bill lets them do that.

The hon. Lady asked whether the duty of quality will apply to providers. I can tell her that providers will be held to account for quality of service through contract commissioners, provider quality accounts, health and well-being boards, HealthWatch and CQC maintaining essential standards. I hope that that deals with her point.

The hon. Lady also asked where responsibility for deaneries will sit within the new system. As the hon. Lady is aware, we are consulting on the future of professional education, because I agree with her that it is absolutely crucial that we have the highest quality education and training to ensure that not only do existing staff within the NHS maintain their professional standards, but that we have the next generation and beyond being trained for a high-class NHS. We are consulting and we will consider the responses before making a decision, which will be taken in the best interests of patients and staff.

We had a fairly long and protracted debate about the question of acting “with a view to” and the meaning of “have regard to”. The duty to act with a view to securing continuous improvement in quality is not weak, nor is it unclear. The Secretary of State would have a statutory duty under the legislation to exercise all his functions in a way that is best calculated to achieve quality. The Secretary of State could be challenged in court by anyone who thought that he was not doing what he could to achieve the objective of improving quality.

On the meaning of “have regard to”, I warn the Committee that I am not a lawyer. Those who are lawyers will understand the full significance and meaning of what I am about to read. A former Lord Chancellor, my noble Friend Lord Mackay of Clashfern, spoke about the term when it was being debated in the context of the NHS constitution. He said:

“It is a very common phrase…and I have been involved in arguing cases and sometimes deciding cases in which it was a crucial phrase. I will not be giving a definitive meaning for it, but I think what, in principle, it means, is that, in making a decision, you take account fully of all the provisions of the document so far as relevant to the issue in hand and you take account of them properly and seriously, not in a dismissive way…It is a compendious phrase with very considerable legal lineage in which it is applied. I do not think there are many cases in which the judges have attempted to say what it means; they know how to apply it.”—[Official Report, House of Lords, 28 April 2009; Vol. 710, c.159-60.]

Emily Thornberry (Islington South and Finsbury) (Lab) rose—

Simon Burns (Conservative, Chelmsford)

A lawyer is about to intervene on me. I warn the hon. Member for Islington South and Finsbury that if she is going to ask me a question on a point of law, I may, sadly, have to side-step it.

Emily Thornberry (Labour, Islington South and Finsbury)

I reassure the right hon. Gentleman that I would not be tempted to do that. However, speaking as a lawyer, I ask him why he is giving extra work to lawyers. Why use phrases that mean that we need to have expensive lawyers to help us interpret the clause? Why not just stick to plain English, which is what the amendment seeks to do?

Simon Burns (Conservative, Chelmsford)

I will reply, and not as a lawyer. As the hon. Lady will understand, many of us have for a long time begged and prayed for legislation to be written in plain man’s and woman’s English. Sadly, it is not; we have not won that argument. As long as that is the case, we have to abide by the language and tone of legislation that has lasted us for generations. Not only do we have to go by precedent in drafting legislation, but we have to ensure that it achieves what we want it to achieve. I am confident that the phrase does that.

Karl Turner (Labour, Kingston upon Hull East)

Does the Minister not accept that the phrase itself is subject to interpretation? It is the type of thing that lawyers want to deal with. It is open to interpretation by people and lawyers.

Simon Burns (Conservative, Chelmsford)

I am terribly sorry. The hon. Gentleman will have to tighten up in one or two ways. He said that there is no definition of outcomes in the legislation when there is, which suggests that perhaps he has not read the whole Bill. He now raises this point within three minutes of my reading out what it means in a legal form to lawyers. There is not the confusion or misunderstanding that he says there is.

Jeremy Lefroy (Conservative, Stafford)

Will the Minister give way?

Simon Burns (Conservative, Chelmsford)

Yes. Another lawyer.

Jeremy Lefroy (Conservative, Stafford)

I am delighted to say that I am not a lawyer at all; I am a business man.

Is the Minister confused, as I am, about the meaning of the amendment? It would make the clause read, “The Secretary of State must seek to deliver the need to reduce inequalities.” I find it a little difficult to understand how one can seek to deliver a need. Perhaps he could enlighten me.

Simon Burns (Conservative, Chelmsford)

First, I apologise to my hon. Friend. I do not know why, but I have it fixed in my mind that he is a solicitor. That was a dreadful slur; I withdraw the comment and apologise.

I share my hon. Friend’s confusion, highlighted by his reading of the clause as it would be amended by the Opposition. Fortunately, I am not responsible for their utterings, writings or draftings. If the hon. Member for Leicester West catches your eye, Mr Hood, and makes a further contribution in winding up the debate, my hon. Friend might be able to try to elicit an explanation from her.

I do not want to delay the Committee because the Opposition’s amendments, however well-intentioned—I do not question or doubt that they are—are neither needed nor necessarily relevant. The way we have dealt with the matter gives the Secretary of State adequate and totally all-embracing powers, as he wants to have to ensure that quality is the driving theme of these reforms. He, plus the board, the consortia and the providers, with the back-up of the health and well-being boards, HealthWatch and local authority engagement, will—together with everyone who works within the national health service—be focused on improving and driving up quality.

For that reason, I ask the Opposition, having probed a very important issue, to think again and consider withdrawing their amendment. If they are not prepared to do that, I invite my hon. Friends to join me in opposing their amendments.

Liz Kendall (Labour, Leicester West)

I thank the Minister for his kind words about my speech. I shall, indeed, place a duty on myself to secure continuous improvements in my speeches as I go forward.

I shall be brief. We have not tabled the amendments for semantic reasons; we have done so because we are genuinely concerned to ensure that there are strong and clear duties to improve continuously the quality of services. The hon. Member for Southport has a lot of experience and I am very respectful of him and his opinions, but he questioned whether it is realistic to seek to improve quality continuously. If he does not agree with that particular point, why is the duty in the Bill?

We are concerned about quality. My hon. Friend the Member for Pontypridd pointed out that the legislation represents a weakening of the duty compared with previous Bills, which is why the amendments have been tabled. I say to the hon. Members for Southport, for North Warwickshire and for Stafford that the specific wording in the duty does not just relate to the Secretary of State; it is repeated for the national commissioning board and for commissioning consortia.

Hon. Members, particularly the hon. Member for Southport, rightly asked whether it is realistic to expect the Secretary of State to secure improvements in quality. Other hon. Members said, “Isn’t it down to the commissioning board or consortia?” I would say, “Yes, it is.” However, this is the same duty. They do not have a duty to secure improvements; it is to act “with a view to” and so on.

I say respectfully to the Minister that I am also thankfully—not “thankfully”; lawyers are fantastic—not a lawyer. The wording has changed in comparison with previous Bills, which is why we have raised the point. My hon. Friends and I think the measure still needs to be strengthened, not only in terms of the duty for the Secretary of State but in terms of the duty for the commissioning board and commissioning consortia, because somebody has to be responsible for securing improvements in quality.

John Pugh (Liberal Democrat, Southport)

My point is simple. If the hon. Lady is suggesting that the Secretary of State should have a duty to secure continuous improvement, presumably in her view it is always possible for the Secretary of State to improve any service continuously. In other words, it will never be okay, satisfactory or perfect. That is the kind of Maoist view of public services that I think her and I probably reject.

Liz Kendall (Labour, Leicester West)

The hon. Gentleman raises an important point about whether a service can continuously improve. I differ from him in that I think services should and need to because health needs change. I shall give a brief example in relation to children’s heart surgery. I have a unit in my constituency, but I will not go into a review of that. Babies get born younger and younger because of technological advances. If they survive and they need congenital heart surgery, the type of surgery that is needed changes and evolves.

Jimmy Hood (Labour, Lanark and Hamilton East)

I remind the Committee that with this we are discussing the following: amendment 37, in clause 2, page 2, line 29, leave out ‘with a view to securing’ and insert ‘to secure’.

Amendment 39, in clause 2, page 2, line 38, leave out ‘have regard to’ and insert ‘seek to deliver’.

Liz Kendall (Labour, Leicester West)

To recap, the reason we have tabled the amendments is not semantics, but real concern that there needs to be clear and strong duties for the Secretary of State and, I remind Members, the national quality board and the commissioning consortia to improve quality.

My final point relates to what the Minister said about education, training and strategic health authorities. I am well aware that the Government are consulting on the proposed changes to education and training. My concern is that SHAs will be abolished under clause 28 before we know what is to happen in education and training. As that is so important to quality, I urge the Minister to be clear about the implications.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

Will the hon. Lady explain what role SHAs play in training at the moment? I am not aware of any.

Liz Kendall (Labour, Leicester West)

There is regional co-ordination on education, training and workplace planning. The deaneries are closely involved at that level. That point was raised with us by the junior doctors committee of the British Medical Association.

Simon Burns (Conservative, Chelmsford)

The hon. Lady rightly raises an important subject. We all want to ensure that the highest standards of education and training are maintained and that, where need be, standards are improved. As she rightly says, consultation is ongoing. I assure her that the matter will be resolved before the SHAs are abolished, because we do not want any hiatus whatsoever.

Liz Kendall (Labour, Leicester West)

On that point, I wish to press the amendment to a vote.

Stephen Crabb (Conservative, Preseli Pembrokeshire)

On a point of order, Mr Hood. Will time be allowed for Members who are not here yet to arrive?

Jimmy Hood (Labour, Lanark and Hamilton East)

Yes, the doors will not be locked for two minutes, or until the Whips have identified to me that they wish them to be locked.

Liz Kendall (Labour, Leicester West)

I beg to move amendment 38, in clause 2, page 2, line 33, leave out from ‘show’ to end of line 36 and insert—

I know that members of the Committee are keen to make progress, so I shall be swifter in speaking to the amendment than to the previous group.

New section 1A(3) of the National Health Service Act 2006, inserted by clause 2, lists three outcomes that the Secretary of State should seek to deliver when having a view and having regard to securing continuous improvements in quality: the effectiveness of services, the safety of services and the quality of patient experience. Effectiveness, safety and patient experience are crucial elements of a high-quality service, but they are not the whole story. Amendment 38 would more clearly define the factors that make up a high-quality service.

Members of the Committee will recall that several witnesses who gave evidence last week emphasised how difficult it is define and measure quality. My right hon. Friend the Member for Rother Valley rightly asked Stephen Thornton of the Health Foundation, Jennifer Dixon of the Nuffield Trust and Julian Le Grand of the London School of Economics,

“what evidence do we have…that quality is something that can be measured, something we can put faith in, as opposed to a target, and something that is going to improve services?”

The responses to that question are important when considering clause 2 and the amendment. Stephen Thornton replied:

“As everyone knows, quality in health service delivery is notoriously difficult to get your head around and to define.”

He referred to standardised mortality ratios. Surely whether some is dead or alive is clear, but in fact, the point emphasised by Nigel Edwards was that it is difficult to get from those standardised mortality ratios a clear understanding of whether, for example, the issue is the case mix of a particular hospital. If a hospital deals with very difficult cases, its standard mortality ratio will be much higher. Dr Jennifer Dixon said that

“quality is not very observable”,

and Julian Le Grand, who, as I am sure Government Members know, is in many ways a champion of the Government’s reforms, said that

“it is so difficult to measure quality. To some extent, we have to rely upon inferring improvements in quality from changes in other areas.”––[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 22-23, Q47.]

We need to look at inputs and processes as well as outcomes. That is rightly acknowledged in the Government’s outcomes framework, which says that there is no pure outcomes-alone approach that we can measure all quality on. I am not going to repeat the arguments about why it is important to define quality, but I believe that the provision would benefit from greater specificity and clarity.

Members of the Committee will be aware that a huge amount of work has been done in this country and internationally on the different elements that make up a high-quality service. The most groundbreaking work was done 10 years ago by the Institute of Medicine in the United States. Its report, “Crossing the Quality Chasm”, began the efforts to improve quality internationally and in this country. The Nuffield Trust report, “The Quest for Quality”, built on that report, and has been influential in shaping thinking, including that reflected in Ara Darzi’s report. Both reports identify six key areas that go to make up quality health services.

First, the reports specify safety, which the clause already includes, saying that care should avoid injuries to patients from the care that is intended to help them. The second element is effectiveness—in health care that usually centres around the need for services to be based on scientific knowledge, so that all who could benefit from them do, and to refrain from providing care from which patients are not likely to benefit.

The third element of quality is to do with care being patient-centred. I am sure that some people will again think that that is semantics. Patient experience is vital to measuring the quality of care, but a patient’s experience is not the only thing that makes care patient-centred. It is also about whether services are tailored to meet individual needs, whether they include the views and concerns of family members, and so on. Patient-centredness is a much better way of expressing those things.

The fourth element is that services should be timely. I am not going to open up a huge debate about waiting time targets and whether they are politically motivated; suffice it to say that the timeliness of services is vital to their quality. There have been big debates about the outcomes of cancer care and whether this country does worse than others. In fact, it is on the very first set of diagnoses that we often fall behind. Timeliness is vital not only in clinical care, but because patients want it—at the top of their list of concerns and priorities is the wish for care to be timely.

The fifth element of quality care—I am surprised that it has not been specified by a Government who are rightly concerned with spending—is the concern that services should be efficient and avoid waste, not only waste through bureaucracy but the waste of equipment, supplies, ideas and energy.

The sixth element of quality is that care should be equitable. It should not vary in quality because of a personal characteristic such as gender, ethnicity, geographic location and socio-economic status. I am sure that we discuss equality and the duty to promote it at greater length under the next clause. Although the new section 1A(3) that clause 2 would insert into the 2006 Act attempts to set out the key features of quality, I firmly believe that it does not go far or deep enough.

A health care system that made improvements in those six key areas would be far better at meeting patients’ needs. If quality is really at the heart of the Government’s plans for the NHS, clause 2 should spell that out in greater detail. The clause says only that safety, effectiveness and patient experience are key to quality. I think that we should go much further, and amendment 40 would achieve that broader and clearer definition.

Jeremy Lefroy (Conservative, Stafford)

I understand the hon. Lady’s argument. She made several good points and the additional four aspects of services—that they should be patient-centred, timely, efficient and equitable—are all extremely valid. I would add two or three others; they arise from my experience at Stafford, but I think that all right hon. and hon. Members will be aware of them. I have in mind the importance of care, respect and dignity—particularly respect and dignity.

Reports this week have revealed many cases from around the country of insufficient respect and dignity for elderly patients. Although I have a lot of sympathy with the points made by the hon. Lady, and acknowledge that the wording of the Bill could perhaps be improved if I could think of the correct word—I cannot—the phrase “quality of experience” includes those softer aspects such as respect and dignity that are not included in the harder, more measurable outcomes that she has set out in the amendment. I believe that Bill’s wording encompasses more of what we want to see in quality of care, even though I understand her reasons for proposing the outcomes listed in her amendment, which I think are important and need to be taken on board by anyone involved in the health service. I am sure that Ministers are doing that.

Simon Burns (Conservative, Chelmsford)

Amendment 38 would reword and extend the definition of quality. In a way, this debate is linked to the one we had on the previous group of amendments and it picks up on the concern expressed by the hon. Member for Kingston upon Hull East, who before lunch accused the Government of not defining quality or outcomes in the Bill. It is quite clear that early in the Bill—on page 2, in fact—we have done so.

What is interesting, and the reason why I welcome the conversion of the hon. Member for Leicester West and her party, is that Lord Darzi was desperate for the previous Government to define quality and outcomes in primary legislation, but that was resisted by the Labour Government. In one way, we are all taking a giant step forward because we—certainly on the Government side of the Committee—recognise the need to put down a comprehensive definition, so that no one can doubt our commitment to improving and enhancing quality and to ensuring that we, with everyone else in the health service, work in that ongoing endeavour.

The duty to seek improvements in quality sits at the very centre of the Bill and the definition of quality used is the one that was agreed and embraced by both clinicians and the public during the next stage review of the NHS. I accept that Opposition Members are seeking to improve the Bill, but I fear that the amendment would do little to bring clarity to the meaning of quality. In fact, it would make extremely unhelpful distinctions. I know that that they are not doing that deliberately, but there is always the law of unintended consequences. If the service is timely, it has to be delivered safely, effectively and in a way that improves the patient experience—it cannot be otherwise. Our definition of quality does not distort clinical priorities but supports our work on the outcomes framework. That is why our definition is the accepted one. It works, and it has the bonus of being recognised by both clinicians and the previous Government.

The three domains of quality—patient safety, patient experience and effectiveness—were identified following a review that was led by 2,000 front-line clinicians and other local health and social care staff, involving thousands more staff, patients and members of the public. Opposition Members will no doubt remember that. Given that the review was published in 2008, I suspect that the hon. Lady not only remembers it, but may well have been involved in the work leading to the publication of the review, as she had the distinction of being a special adviser to Patricia Hewitt in the Department of Health until the change of regime in June 2007. As she probably knows, the review concluded:

“If quality is to be at the heart of everything we do, it must be understood from the perspective of patients. Patients pay regard both to clinical outcomes and their experience of the service. They understand that not all treatments are perfect, but they do not accept that the organisation of their care should put them at risk.

For these reasons, the review has found that for the NHS, quality should include the following aspects.”

It went on to name them as safety, experience and effectiveness—precisely what we have put in the Bill. Because the wording is all-embracing in many ways, it should go a long way to reassuring my hon. Friend the Member for Stafford, who made some extremely valid points about the patient experience and how patients feel about their treatment by the NHS. Extending and rewording the definition of quality would only add confusion to a principle that is understood, accepted and owned within the NHS.

For those reasons, I believe the changes proposed in the amendment are wholly unnecessary. The issues raised are of course important, but the Bill already places a duty on the Secretary of State to reduce inequalities, as well as duties on the NHS commissioning board and commissioning consortia to reduce inequalities, to promote patient involvement and choice, and to exercise their functions effectively, efficiently and economically. The duty to seek to improve quality would need to be considered alongside those other duties, although I find it inconceivable that there could be quality alongside inequality, inefficiency or a service that did not take into consideration the needs of its users. The Royal College of Physicians picked up on that point in its response to the consultation on the NHS outcomes framework, acknowledging that health care that is not safe could not be described as efficient, effective, or sustainable.

The definition of quality is comprehensive and clinically owned. The amendment adds nothing. I ask my hon. Friends to vote against the amendment if the hon. Lady is not prepared to withdraw it. While she reflects, let me say that we are united with the previous Labour Government on the definition of quality and outcomes that we have chosen to put in the Bill.

Liz Kendall (Labour, Leicester West)

I realise that the definition in the Bill was worked on by Lord Darzi, but we are concerned that measures in the Bill could threaten quality and that is why we feel that quality needs to be more clearly defined.

Simon Burns (Conservative, Chelmsford)

Will the hon. Lady give way?

Liz Kendall (Labour, Leicester West)

Let me make some progress first.

I am sure that the Minister did not mean to say that I and other Labour Members have somehow suddenly been converted to caring about quality in the NHS.

Simon Burns (Conservative, Chelmsford)

I certainly did not. My point was that I was delighted that the hon. Lady had been converted to putting a definition of quality and outcomes in primary legislation, given that the previous Labour Government were not prepared to do so, contrary to what Lord Darzi wanted.

Liz Kendall (Labour, Leicester West)

The Labour Government set up Lord Darzi’s review. We would not have brought him in had we wanted anything to the contrary. I do not want to debate the point with the Minister, but I hope that he will accept that we initiated that review because we wanted to improve quality even further.

Simon Burns (Conservative, Chelmsford)

The hon. Lady has not quite understood my point. I was saying that Lord Darzi wanted the previous Government to put a definition in legislation, but they were not prepared to do so.

Liz Kendall (Labour, Leicester West)

Mr Hood, I am sure you want us to focus on the amendments, which is exactly what I will do.

I want to make two other points. The hon. Member for Stafford rightly raised the issue of respect and dignity. I am sure we could go around the houses about the meaning of patient-centred care and the patient experience and so on. I simply want to put on record that I absolutely support him in wanting to achieve that goal.

My third and final point is to put on record for Government Members that quality is difficult to define, and outcomes are difficult to define. We had a brief debate about politically driven targets. I believe that the previous Government’s targets were always about improving quality and outcomes for patients, but there are different ways to get those outcomes. Sometimes we have to measure what is called inputs, such as the time spent waiting for treatment, because the ultimate outcomes are often difficult to measure. I therefore respectfully urge hon. Members not to think that defining quality or outcomes is simple; it is a difficult process. The definition has to be as broad as possible if we want to improve patient care. On that point, I would like to press the amendment to a Division.

Liz Kendall (Labour, Leicester West)

I beg to move amendment 40, in clause 2, page 2, line 39, at end insert—

The amendment provides that when Secretary of State is discharging his or her duty to act with a view to continuously improve quality, he or she must consult local people before any significant changes are made to their health services. The Committee has been given clear evidence, and it has been the experience of the NHS over the past 10 years, that achieving a step change in quality, particularly of hospital services and care, will require significant changes to the way services are provided. We know that, for many aspects of specialist care, the chances of patients surviving and doing so with fewer disabilities are greater in specialist centres—I refer to services such as stroke and trauma care and children’s heart surgery, with which I am closely involved. Changes to services at regional level will also be extremely important if the NHS is to meet the efficiency challenge set by David Nicholson, chief executive of the NHS.

A couple of witnesses last week mentioned stroke care in London, which was also raised on Second Reading by the hon. Member for Ealing Central and Acton (Angie Bray). I shall go into that in a little detail to explain what we are seeking to achieve through the amendment. As some hon. Members will know, NHS London, which is the strategic health authority for the capital, went through a controversial reorganisation of stroke care in which eight hyper-acute stroke units were established. That was very controversial at the time, but in just five months those specialist centres have more than tripled the number of patients receiving clot-busting drugs to the highest rate of any large city in the world. It is estimated that that will save 400 lives a year, as well as significantly reduce the disabilities of people who survive a stroke.

As I said, that reorganisation was controversial, but the strategic health authority worked hard to involve patients and the public, as well as clinicians, to achieve those service improvements. I do not want to go beyond the scope of the amendment, but when we get to the provision abolishing strategic health authorities later in the Bill, people will rightly ask how those big regional-level service changes will occur if there is no longer any kind of regional tier in the NHS.

As witnesses have said to the Committee, commissioning consortia could take on such a role if they work together across larger areas. However, witnesses, including Stephen Thornton, said that the Health Foundation has done a lot of research into the issue, with initiatives that have involved GPs in commissioning. That research shows that GPs tend to be better at making changes in out-of-hospital care—community health services and so on—rather than at the hospital level.

We also need to remember that commissioning consortia will not hold contracts with providers until April 2013. Strategic decisions that can improve the quality of care should be being made now, but they are being delayed because people are uncertain of what the reorganisation will mean.

I turn back to the amendment. If we are going to have a duty to improve quality continually—whether that relates to the Secretary of State, the national commissioning board or GP consortia—that will inevitably mean changes to services. Sometimes there will be very significant changes to services, such as the one I described in stroke care in London. Those big changes must involve patients and the public, as well as clinicians.

I have, perhaps wrongly, anticipated the point that will be made against the amendment. I know that further on in the Bill we will discuss the duty to involve the public and patients in more detail, but I hope that the Committee will see why including a duty for public consultation should also be identified early on, up front and at the top of the Bill, where this very important duty to improve quality is contained.

Kevin Barron (Labour, Rother Valley)

On a point of order, Mr Hood. My understanding is that there will not be debate on this clause stand part. If that is correct, I would like to participate in the debate on the amendment. Or am I wrong?

Jimmy Hood (Labour, Lanark and Hamilton East)

I will probably announce at the end of this debate that we will not have a stand part debate, because of the exhaustive discussion on the amendments to the clause.

Kevin Barron (Labour, Rother Valley)

Thank you, Mr Hood. That is very helpful. On the issue of quality and the amendment that we are discussing, the Minister was right to say that the next stage review was the next stage on from where the previous Government had the national health service, to bring in a better measurement of quality.

I asked the Minister whether he had received any feedback from the pilot scheme that was taking place in the north-west. That pilot scheme was based on a United States health provider called Premier—a not-for-profit provider—and considered in great detail how we could measure better quality in our system, as opposed to the quantity that we have been good at measuring for many years. I want to ask the Secretary of State—sorry, the Minister of State, although he may have some ambition—whether he can help me in relation to the clause and, in particular, subsection (4), which states:

This will be crucially important if we are to advance a best practice in the NHS. Indeed, in the evidence we took last week, both the chief executive of the NHS and the Secretary of State spoke about improving quality by the use of National Institute for Health and Clinical Excellence guidelines.

In clause 218 (5) the Bill says that

“A quality standard… must be endorsed by the relevant commissioner”.

I assume by that that the commissioner—whether it is a GP consortia or a national commissioner endorsed by the national board—will have to endorse the quality standard. That is my reading of it. I ask the Minister how that relates to clause 4, on duty as to promoting autonomy, which says that persons

“exercising functions in relation to the health service or providing services for its purposes is free to exercise those functions or provide those services in that manner that it considers most appropriate”.

So the Secretary of State has to take regard to it, and it must be endorsed by the relevant commissioners, but clause 4 tells us that commissioners do not have to endorse it—

Jimmy Hood (Labour, Lanark and Hamilton East)

Order.

Kevin Barron (Labour, Rother Valley)

Mr Hood, I will sit down now. I wonder whether the Minister—

Jimmy Hood (Labour, Lanark and Hamilton East)

Order. We are discussing this amendment to clause 2. I ask the hon. Gentleman to speak to the amendment.

Kevin Barron (Labour, Rother Valley)

I am talking about clause 2, new section 1A(4) of the National Health Service Act 2006, which you can see refers to clause 218 of the Bill, which states that

“A quality standard… must be endorsed by the relevant commissioner”,

and how that relates to clause 4 of this Bill, that says commissioners have autonomy—there is a great contradiction in that. I may not have to debate anything on clause 4 if the Minister can tell the Committee what this means.

Nick de Bois (Conservative, Enfield North)

I will be very brief on amendment 40 that the hon. Member for Leicester West put forward. I listened very carefully and with great respect to what she said, particularly on the issues surrounding stroke care. My observation is that—certainly in the case of Enfield—there was not actually any consultation about the proposed changes to stroke care. This came about because the acute hospital chose not to apply to be considered and GPs were not consulted. That is the situation we are coming from, and it is worth registering that the extensive local democracy and accountability that appear later in the Bill will address the issue. I support local engagement but there is a wealth of clauses that address that—I was going to list them but frankly I do not think there is time.

Grahame Morris (Labour, Easington)

I am aware that there are time pressures so I will try to be disciplined and confine my remarks to the wording in amendment 40. I speak in support of this amendment, which essentially seeks to give some additional responsibilities to the Secretary of State in respect of responsibilities on consultation. As the Bill stands, the duties of the Secretary of State, if not entirely conferred or devolved onto subordinate bodies, could be weakened. Clause 2, subsection (1) says that the Secretary of State must act

“with a view to securing continuous improvement in the quality of services provided to individuals”

and indeed

This includes his public health functions, those functions the Secretary of State exercises in relation to the NHS and its commissioning board, and the GP commissioning consortia. The amendment would add a significant but fairly simple function that Members could support irrespective of party, especially given the remarks made by the hon. Member for Enfield North and his fellow Government Members on the need for full public consultation about various issues that affect the delivery of local health services.

As we know from our discussions on clause 1, the current duty on the Secretary of State to provide or secure the provision of services for the health service has in effect been removed. Opposition Members are, therefore, genuinely concerned that there might be a democratic deficit, whereby Members of Parliament of all parties are unable to hold the Secretary of State to account on issues related to the health service.

The amendment would strengthen democracy in the NHS, although not by far enough. It would ensure that the Secretary of State consults local communities where significant changes to health services are to take place. The function of the Secretary of State is to act

“with a view to securing continuous improvement in the quality of services provided to individuals”.

So significant changes may well occur that affect services within or across communities.

As clause 2 addresses the Secretary of State's duty to improve the quality of services it seems appropriate that, as part of the Government’s slogan or mantra, “No decision about me, without me”, there should be local involvement in service changes. I understand that we will be moving on to the issue of service providers failing, perhaps due to market conditions, later in our consideration of the Bill. Therefore, I do not intend to address it now, but it might exercise local communities that are considering these issues.

Where there are service changes, perhaps as a consequence of the Secretary of State, or a local authority acting on his behalf, seeking to secure improvements in outcomes, why should there not be a safeguard in place to ensure further accountability? My fear is that some aspects of the Bill will in certain circumstances remove the voice of elected officials such as Members of Parliament and, by default, our constituents. So I would urge Members on both sides of the Committee to support the amendment.

John Pugh (Liberal Democrat, Southport)

The hon. Member for Leicester West will probably be told by the Minister in a few minutes that the amendment is redundant, which is a common ploy when amendments are moved in Committee. One could argue that the legislation actually provides what the hon. Lady is seeking, it just does not ask the Secretary of State to ensure that it is there. One could also argue that there is something rather odd about asking the Secretary of State to see that the law is enforced, because one assumes that is what the Secretary of State would like to do. The hon. Lady, however, seems to have a point, so I will address what I think is the real nub of the matter.

The amendment is work in progress. If the hon. Lady wishes to move it on Report, it is probably advisable not to press it to a Division now. She is suggesting that there should be a level of consultation on regional services. It is not obvious that the amendment applies exclusively to regionally important services, but one can see why people would want to be consulted on regional services.

The hon. Lady mentioned children’s services. She might be aware that some time ago it was proposed that Alder Hey, which is a significant children’s service in the north-west, would move out of Liverpool. People have a right to be consulted about such things, but it is not clear what rights people currently have if such proposals are made, or what rights they will have under the Bill. Obviously, such matters would not necessarily be dealt with by health and well-being boards.

There is a question about what voice people have when services that might not be distinctly local—they might be bigger than that—but are important to all local people are subject to a reconfiguration proposal of one kind or another. The Alder Hey case is one that leaps to mind.

The amendment does not focus sufficiently precisely on that. It uses words such as “local area” and “significant changes”, which obviously are debatable. What is a local area, and what is a significant change? In dealing with the legislation, we have to bear in mind when we talk about local areas that the concept of area is up for debate as well. At one time, under the primary care trust arrangement, it was possible to talk about a health area and a local authority area, but now the commissioning units will not be area-based, and that problem will go right through this legislation as we try to read through the implications.

The hon. Member for Leicester West has a perfectly valid point. I dare say the Minister will put us at ease in respect of some of the issues that she raised, but we need an explanation from him, in terms of the legislation, of exactly what will happen when services of enormous regional popularity and significance get modified in some way. For example, what will happen if Alder Hey decides in the future to move out of Liverpool and go to Widnes, as it has said it may? What voice will the public have, and how will it be expressed?

Owen Smith (Labour, Pontypridd)

My point follows on from the one made by the hon. Member for Southport. In essence, it is a simple point about strategic planning. The amendment seeks to offer an additional safeguard in respect of strategic planning, which is an aspect of the NHS that we feel will be undermined as a result of the changes being made elsewhere in the Bill, notably the abolition of SHAs and PCTs.

The concern we have is that services may be reconfigured, either as a result of changes in demand by GP commissioning consortia determining that they want to change the nature of the services, or the nature of the provision that they can access locally—Sir David Nicholson seemed to suggest in his evidence that that might happen—or supply-side changes, whereby NHS trusts determine that they want to change the nature of the service that they offer, perhaps through merger or reconfiguration in other respects.

Our concern is that the only way in which those potential changes might be held up is if they are deemed by Monitor, the economic regulator, to be in breach of competition law. However, there may be other reasons not related to competition law such as clinical reasons or political, with a small “p”, long-standing views on the part of the local population which lead them to believe that it is important that services be locally held, or that the current configuration ought to be maintained.

The amendment is simply about trying to put in an additional safeguard, and, in keeping with the spirit of localism that the current Government are so keen on in this Bill and elsewhere, it simply seeks to ensure that the Secretary of State observes that and makes sure that local people have a say if the services that they deem to be important to their local population are in jeopardy. For that reason, I support the amendment.

Nicky Morgan (Conservative, Loughborough)

It is a pleasure to serve under your chairmanship, Mr Hood. I was stung into speaking by the Minister’s earlier comments about lawyers and solicitors. As a solicitor, I have to plead guilty. I was originally planning to speak about the amendment, but about the words “significant changes”. I spent many happy hours in my former career talking about what is or is not a significant change, but I see that the word “significant” is used later in the Bill, so I shall not talk about that.

I want to make some brief points about the amendment. I totally understand why the hon. Member for Leicester West proposed it, but it is in the wrong place in the Bill. My hon. Friend the Member for Enfield North spoke about the other duties in respect of public involvement later in the Bill which relate to the national commissioning board and GP commissioning consortia, and I think that that is the right place for patients to be involved in service changes.

The hon. Member for Leicester West spoke about reconfiguration occurring. That was recognised by those who gave evidence last week, and strategic decisions are currently being made. She spoke about heart services. I, too, am a Leicestershire MP and am also concerned about the future of children’s heart services at Glenfield hospital. Speaking as someone who was very involved in the campaign for the Loughborough walk-in centre, which is an essential part of the health service in Loughborough, my concern with the amendment is that it states that

“the Secretary of State must ensure the people…are consulted”.

The trouble is, as the hon. Member for Easington said, that there is a semantic difference between consultation and involvement. I am sure that we will speak about that a lot when we deal with patient and public involvement, but consultation is not involvement—involvement goes wider.

My concern about consultation in this context is that it is very easy for the Secretary of State to say that people must be consulted, but as we have heard today—all power to the Government’s elbow in relation to the dreaded word “forests”—we have heard people, we have listened and we have changed what we are consulting on. We are to be congratulated for listening to what people have said. That is something new and refreshing in politics in this country.

Finally, the hon. Member for Pontypridd talked about localism. I do not think that the Secretary of State has a place in localism; the whole point about localism is that services are delivered and decisions are taken closer to people. That is why the patient and public involvement parts of the Bill will deal with the concerns of the hon. Member for Leicester West. We will discuss those further when we get to the relevant clauses.

Jeremy Lefroy (Conservative, Stafford)

My hon. Friend the Member for Loughborough has covered most of what I wanted to say. I just stress the importance of going into some detail about public involvement and consultation later in our deliberations. There are some questions about what precisely public involvement and consultation means. Looking ahead, I see that public involvement can refer to being provided with information, and that alone. That, I believe, will not be sufficient. I rest my remarks there. I will not support the amendment, but the discussion will be important later, along the lines that my hon. Friend has pointed out.

Simon Burns (Conservative, Chelmsford)

The amendment, as has become abundantly clear during the debate, would require the Secretary of State to ensure that local people were consulted before significant changes were made to their health services. We fully support the involvement of local people in shaping their local health and social care services; that is why we have put forward proposals to enhance significantly the role of councils and local authorities in relation to health services and to increase their local democratic legitimacy in health.

We want far more local involvement and for the voices of local people to be fully considered. I do not want to stray beyond the bounds of this narrow amendment into the whole area of reconfigurations, Mr Hood, unless you allow me to, because I know we will discuss it in great detail during our discussion of subsequent clauses.

Jimmy Hood (Labour, Lanark and Hamilton East)

Order. I advise the Minister to follow his natural instincts.

Simon Burns (Conservative, Chelmsford)

Mr Hood, I am very grateful for that ruling. I was hoping that you were going to say that, so that I would not get any trouble from Opposition Members.

The Government have done a number of things since last May and my hon. Friend the Member for Loughborough touched on one of them. When the Secretary of State was concerned that not enough consideration was being given to the views of local people and local clinicians with regard to reconfigurations, he strengthened the criteria substantially on any reconfigurations that had to go through, ensuring that when a consultation process is happening, those criteria are fully met before a proposal advances further.

To keep within your ruling, Mr Hood, I will stop there on that narrow point so that I do not explain the full procedures of reconfigurations in great detail. We will deal with those later. However, before coming back to the hon. Member for Leicester West’s overarching points, I will pick up one or two points raised by the right hon. Member for Rother Valley. First, he reiterated his point from an earlier debate about the north-west pilot scheme and what has been learned from it. I can tell the right hon. Gentleman that the North West Strategic Health Authority responded to the Department of Health’s consultation on the outcomes framework, and the Department is working with them to share best practice and learning as we continue work to develop the outcomes framework. I hope that that helps to clarify the situation.

The right hon. Gentleman’s other point was about the identity of the commissioner. In that context, the commissioner is either the Secretary of State or the board, but it could be both. In that context the commissioner is either the Secretary of State or the board, but it could be both. NICE provides a quality standard when asked to do so—on matters of public health or social care if asked by the Secretary of State, and on the NHS if asked by the NHS board—but both can ask for a care pathway. The standard is set when the Secretary of State or the board endorses it, which is right, as they are accountable to the service and NICE is not. I hope that that goes some way to helping the right hon. Member for Rother Valley.

On the more complicated and slightly distracting amendment to clause 4, I hope that the right hon. Gentleman will forgive me; I shall respond to him, but I would rather do so on clause 4, as I do not want to fall foul of you, Mr Hood, and wrongly expand our debate when we are dealing with a relatively narrow amendment to clause 2. I hope that the right hon. Gentleman appreciates that.

Kevin Barron (Labour, Rother Valley)

I am very happy to do that. It seems a contradiction, given that we can visit the subject at a later stage.

Simon Burns (Conservative, Chelmsford)

I give the right hon. Gentleman the assurance, provided we do not canter too quickly towards clause 4, that by the time we reach it there will be a great deal of clarification that I hope will explain the situation and reassure him.

A specific question was asked by the hon. Member for Leicester West, who wanted to know how regional changes will happen without strategic health authorities, and whether clusters of consortia can manage. I shall explain the first point. NHS commissioning boards will consult on specialist services. If the proposal covers a number of local authority areas, the commissioning board will consult all the relevant local authorities—as she would expect. If appropriate, the local authorities can establish a joint scrutiny function to consider the proposals.

Derek Twigg (Labour, Halton)

That is very helpful, but can we be clear about it? Why consult the local authorities if the collective view is that they wish to go a certain way? Would the board be bound by that decision?

Simon Burns (Conservative, Chelmsford)

Let me get this right. If the board decided to go one way and the local authorities disagreed—

Derek Twigg (Labour, Halton)

Yes, the Minister can put it that way as well.

Simon Burns (Conservative, Chelmsford)

Okay. In that case, the local authorities could write to the Secretary of State, asking him to refer the matter to the independent reconfiguration panel. I believe that I am right, but if not I shall let the Committee know as soon as possible.

Derek Twigg (Labour, Halton)

I accept that this is a detailed point. I do not have a problem with it, but I want to be clear. What I am getting at is whether the mechanism is in place. It does not seem to be. I know that the Minister needs clarification on the matter, but he seems to be saying that if a proposal goes out—it is not necessarily a review—even if all the local authorities in the region decide that they want to go another way they cannot overrule what the board has said.

Simon Burns (Conservative, Chelmsford)

I do not need clarification. I now fully understand the point being made by the hon. Gentleman. If the board makes a recommendation, and if, after consideration, the relevant local authorities do not like it, they will have the power to write to the Secretary of State to ask for the matter to be referred to the IRP. [ Interruption. ] Let us not complicate it; that is the system. If the local authorities do not like the board’s proposal, they will have the opportunity to send it to the Secretary of State, asking him to refer it to the IRP. To all intents and purposes, that is what happens now. I hope that I have clarified the matter for the shadow Minister.

Derek Twigg (Labour, Halton)

We may return to it later.

Simon Burns (Conservative, Chelmsford)

I am sure that we will when we debate reconfigurations, but that will be the situation under the board.

John Pugh (Liberal Democrat, Southport)

Will the Minister also clarify whether, in those circumstances, the board will be under obligation to consult in the first place? That would certainly be good practice and ideal, but is there a statutory requirement for it to do so when a significant change occurs in the regional services?

Simon Burns (Conservative, Chelmsford)

Yes, there certainly is. The changes are coming, which may lead to some of the need for clarification, because of the establishment and the role of the board. There will be consultations with the affected local communities, local clinicians and, more importantly, the local authorities. The shadow Minister may like to hear this, because it is quite important. That is, however, in the context of designated services. He might want to reflect on that.

Following that diversion towards later parts of the Bill—we will be coming to reconfigurations in great detail later—the reason that I am not desperately happy with the amendment is that it would duplicate the existing duties on NHS commissioners and providers to consult patients and the public when considering changes to services under section 242 of the 2006 Act. We are amending those duties to apply them to the new architecture, including GP commissioners and the commissioning board.

I am sure that Opposition Members will agree that that is absolutely the right thing to do, because with reconfiguration of services at whatever level—whether designated services in the case of the NHS commissioning board, local service provision through providers or something consortia-driven—there must be local involvement and the views of local communities must be taken into consideration.

The proposal for duplicating section 242 of the 2006 Act is in addition to our proposed changes to section 244 of the 2006 Act, which will enable us to retain existing duties to consult with respect to local authority scrutiny on proposals for significant service reconfigurations of designated services and to extend, for the first time, the regulation-making powers to enable scrutiny of all providers of NHS services, including private and voluntary sector providers. I hope that putting that on the record will help the hon. Member for Halton, because he perked up when I mentioned the whole question of designated services. I am talking about regional reconfigurations of services.

Taken together, the current duties and proposed modifications in clause 175 already ensure that there will continue to be legal duties to consult local people on proposals for substantial service reconfiguration. To accept the amendment would be to add to the duties unnecessarily, and I urge the hon. Member for Leicester West to withdraw it. If she will not, I urge my hon. Friends to join me in rejecting the amendment. Although there will not be a clause stand part debate, I hope that hon. Members agree that the clause has had full scrutiny through the debates on the amendments.

Liz Kendall (Labour, Leicester West)

The hon. Member for Loughborough has rightly said that some decisions about big changes to services are taking place, such as to children’s heart surgery. Those are the responsibility of the national specialist commissioning board, so it has not been affected by the re-organisation. My point was that there are some decisions, both at local and regional level—particularly about the much-needed changes to trauma services that I was involved with when I worked at the ambulance service—being put on hold because they are tricky and they are difficult. I am concerned about that with regard to patient outcomes.

The point about regional-level decisions is important. Indeed, the chief executive of the NHS, in his evidence—not to this Committee, but to the Public Accounts Committee and the Health Committee—has been pushed many times to say that they are looking at whether there should be some kind of regional outpost of the national commissioning board. He, at least, recognises that there are going to be challenges with GP commissioning groups coming together to make a really big decision on issues such as the future of trauma services. So, we will come back to the issue of a regional tier, to improve quality and effectiveness, later on in the Bill.

I would like to return to a point made by the Minister. I do not want to stray, but it is important, because the Minister made it in his closing comments. At the moment, if local authority health scrutiny committees do not like a re-organisation, they refer it to the Secretary of State, and the Secretary of State refers it to the independent reconfiguration panel. I am not clear how what the Government propose is any different. We will come back to that point, but the Secretary of State has said that the proposals on patient and public involvement and local democratic scrutiny will transform patient and public involvement. The Minister has just said that the process will be exactly the same.

Simon Burns (Conservative, Chelmsford)

We will go into that in far greater detail, but briefly, so that the hon. Lady understands, there will be differences in reconfigurations at the local level that have been driven by providers or consortia. There will be a far greater involvement of local government, including the full council of the lead local authority voting on the views put forward by their scrutiny committees, in what shape or form it does. The structures and the procedures are more or less the same, except for a greater increase in the involvement of local authorities. The crucial thing that has changed already, which my hon. Friend the Member for Loughborough mentioned, is the change in the criteria, on 20 May 2010, that strengthened the rights and powers of members of the public and local clinicians in the consultation process, and having a check system to ensure that those criteria are adhered to during a consultation process.

Liz Kendall (Labour, Leicester West)

The Minister may not know now, but may want to come back to me on that. Under those so-called strengthened criteria, would he like to tell Members how many of the proposals have still gone through, or how many have actually been stopped? Under the so-called strengthened criteria, how many proposals have actually been changed, or stopped, as a result?

Simon Burns (Conservative, Chelmsford)

As the hon. Lady will be aware, there are a number of consultations being carried out at the moment. A number were carried out in the second half of last year, and they are still at different parts of the process. Off the top of my head, one has been referred by my right hon. Friend the Secretary of State to the IRP. I cannot, off the top of my head, think of any others at the moment. The process is still ongoing, because, as the hon. Lady will understand, the consultation and the rest of the process are quite lengthy, relatively speaking.

Liz Kendall (Labour, Leicester West)

I thank the Minister for that response. I shall just make the point that the so-called strengthened criteria by the Secretary of State are in fact the criteria that many services have used. It would be interesting if the Minister set before the Committee, when we come to the relevant part of the Bill, all the issues that have been rejudged under those criteria and say whether any have been stopped as a result. I am not yet convinced—we will come on to this point—that any of the changes on public scrutiny and accountability will make a difference if, in the end, the local authority still refers it to the Secretary of State, who refers it to the IRP.

I believe the debate has shown the strength of feeling among Labour Members, and equally among Government Members, who passionately believe, as do we, that greater patient and public involvement is needed. I welcome the comments of my hon. Friend the Member for Pontypridd, and of the hon. Members for Enfield North and for Loughborough. I would particularly like to thank the hon. Member for Southport, who made some very good points about the amendment. He understood that the purpose of the amendment was designed to look at strategic services at regional level, and he made some good points about how it could be improved. I will not press the amendment, but I will bring it back for consideration on Report, to see whether it can be improved and strengthened, based on the helpful comments made by Members on both sides of this Committee. I beg to ask leave to withdraw the amendment.

Clause 3

Emily Thornberry (Labour, Islington South and Finsbury)

I beg to move amendment 5, in clause 3, page 3, line 4, leave out from beginning to end of line 7 and insert—

Jimmy Hood (Labour, Lanark and Hamilton East)

With this it will be convenient to discuss clause stand part.

Emily Thornberry (Labour, Islington South and Finsbury)

After debating the principles of these amendments and of this clause, if we are not successful in achieving the changes we wish to make, we wish to move on to a number of other amendments that we would make instead.

This morning, the Minister prayed in aid Lord Clashfern and said that there were times when complex language was appropriate. I see his Lord Clashfern and I raise to him Lord Denning, who was the people’s judge and was famous for his simply worded judgments, delivered in a Hampshire burr. Lord Chief Justice Lord Bingham said that Lord Denning was the best-known and best-loved judge of this or perhaps any generation. He was a legend in his own lifetime. The reason for that was because, as Lord Irvine said,

“The name Denning was a byword for the law itself. His judgments were models of simple English which ordinary people understood.”

It is very important for this Committee when we are considering these matters—and I know m’learned friend, the hon. Member for Kingston upon Hull East, will agree with me—that, if we are talking about the law of the land, it should be in simple English that English people will understand. We should not be using language which is unnecessarily complex. That is the purpose of our subsequent amendments. However, I will be moving on to those later.

Equality is a principle of such importance that it brought many of us into politics. Our national health service is a manifestation of that commitment to equality. It is at the heart of the NHS. There is a belief that no matter who someone is, or from what background they come, they must be allowed access to the best care and treatment, and that treatment should be free. That is seen as idealistic, but may I join the Nye Bevan club again, and quote his remark that the

“collective principle asserts that … no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”?

That is absolutely right. Although it may be regarded as unfashionable to be idealistic, all the people I know who work in the national health service are idealistic. They want the national health service to work in this way and for us all to have equal access.

The reason I begin with this broad sweep is that we have a fundamental concern that the legislation undermines equality and equality of access in the national health service. That is why we are completely against this measure. We are against the Bill in total and this clause in particular. If this is the clause that relates to equality, it needs to be a great deal stronger to hold back the difficulties that this Bill will introduce by undermining equality of access.

The King’s Fund has conducted an assessment of health care policies. It judged that the basic funding structure of the NHS—this is in an assessment of the NHS between 1997 and 2010—which has few financial barriers to accessing services, is broadly equitable, although the way in which services are arranged can create problems. For instance, there are fewer GPs in areas of greater need. Despite the public service agreement target, reducing inequalities in health outcomes, such as life expectancy and infant mortality, is proving hard. The targets based on closing the gap between poorer areas and average areas were abolished by the incoming Government in May 2010. If those targets had remained, they would almost certainly have been missed.

No one is saying that it is easy and no one is saying that it has been achieved, but we must continue to work at it. We argue that this measure is not helping in the absolutely vital work of the NHS of trying to equalise health outcomes. The fundamental problem is the way in which the Bill allows the market to walk into the middle of the NHS, thereby directly impacting on equality. The Government talk about patients having more information and being able to sit down with their GPs and making a choice about the most appropriate treatment. Perhaps that is some sort of working of the market. Perhaps, in some superficial way, patients feel that it is an improvement to be given proper information, to discuss it with a GP and to get the best choice and help that they can. For some groups, it may be effective. The difficulty is that it does not work for everyone. In fact, it can exacerbate the inequalities that exist at the moment.

Let me give another example. We all know that some foundation trusts are not as strong as others, but will this legislation, which will see people deciding to go to the stronger foundation trusts as opposed to the weaker foundation trusts, simply exacerbate the differences? As a foundation trust gets weaker, has fewer people going to it, generates less income and perhaps even goes bankrupt, what about its patients? What kind of equality of outcomes are they getting if they are going to a weaker foundation trust that continues to get weaker? What happens about GP consortia?

Simon Burns (Conservative, Chelmsford)

The hon. Lady asks about foundation trusts. Does she not remember that it was the previous Labour Government who wanted all trusts to be foundation trusts?

Emily Thornberry (Labour, Islington South and Finsbury)

The right hon. Gentleman must remember—he is in danger sometimes of forgetting this—that he is in government. It is his legislation and it is his Government who are attempting to drive the market into the centre of the NHS. It is not a managed market any more, but simply a market of a type that will undermine any equality of access to services that we have had until now.

Simon Burns (Conservative, Chelmsford)

The hon. Lady must remember that to be credible, one has to be consistent. Just because 6 May 2010 happened, that does not mean that she is going to abandon all her principles and all the things that before 6 May she thought were important to achieve for the country and the health service.

Emily Thornberry (Labour, Islington South and Finsbury)

Before the right hon. Gentleman gets too carried away, may I assure him that I will never give up my principles? My fundamental principle is an absolute commitment to equality. If Monitor were to have its role taken away, in terms of the support that it gives to financial trusts, and instead morphs into some kind of monster within the NHS that is pushing a market on to the NHS, the Minister would not be defending equality of access to patients in the NHS, but instead, be doing the opposite. That is a great danger, and that is why we need a stronger clause than the one before us. It is not just me who is saying this. The Committee has heard from many witnesses, and much of the evidence, which I know the Committee listened to carefully, supports the arguments that I am making.

I have made the argument that a foundation trust may flounder. What happens to the patients who use that foundation trust? They will get an increasingly weak trust and increasingly bad health care. There is an additional problem if the GP commissioning consortium that covers someone’s area is not strong. Under the influence of the market, it would become increasingly weak. Who falls through the cracks? The most weak, the most vulnerable and those who will find it most difficult to move from one consortium to another. We will exacerbate health inequalities by promoting this measure.

If we go back to the picture of the patient sitting down with the GP who, with the additional information, can make a decision, what happens when the patient himself or herself is so sick as to be unable to simply sit down and make that free choice? We had the great privilege of listening to Jenny Bogle—the only patient who appeared before us—who, despite being diagnosed with terminal cancer, gave compelling evidence to the Committee:

“Speaking as someone who was diagnosed with ovarian cancer 18 months ago, I can tell you that when that happens out of the blue, you are physically ill, you have massive things to take on board, and however clued up you are, the last thing you want to start doing is quality controlling—trying to sort out which is the best hospital for you, or the best consultant, or the best treatment. You are not an expert, but you suddenly have to become an expert overnight. I am certainly convinced that I would not have been equipped to do that”.

Hon. Members will remember what an impressive women she was. For a woman who felt that she would have not been in a position to be able to exercise that free choice, that is very strong evidence. She continued:

“I am pretty convinced that my GP, who has seen very few cases of this, would have been in the same position. You just want to be confident that you are having the appropriate treatment. You do not want to have to start making complicated decisions. Choices about which hospital for convenience or whatever are fine, but what can be overstated is the ability of vulnerable people to be involved to such an extent and to take on what feels like a rather unfair responsibility to become an expert in a rare cancer overnight.”––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 117, Q277.]

I could not have said it better myself.

Margot James (Conservative, Stourbridge)

I, too, was very impressed by that evidence. As the hon. Lady said, it was compelling. However, there are carers who can accumulate a large amount of expertise, given the amount of information that is available through patient groups, the internet and so forth. They are in the position to help the patient become more informed and able. Many patients want to take more of a role in the decisions affecting their treatment, beyond the choice of hospital and consultant and so forth. The hon. Lady rather underestimates the potential of patients, the public and carers in this respect.

Emily Thornberry (Labour, Islington South and Finsbury)

The point that the hon. Lady makes is a good one. If, by attempting to make my point powerfully, I seem to underestimate the power of some patients, I take that back, because I do not mean to do so. People with a long-term condition in a relatively stable state, such as those who live with multiple sclerosis for a number of years, can develop expertise. I have met MS sufferers and their carers who are experts in that condition in a way that some GPs are not. I understand that, and people can develop an expertise in other conditions, too.

The difficulty, as I am sure the hon. Lady is aware, is that there are other groups. People might have a mental health condition with a complex range of difficulties. They might not speak English as their first language; they might not be in secure accommodation; they might have alcohol problems; and they might have a chaotic lifestyle. The idea that such people can sit down with their GP and make a decision about the best outcomes of their care highlights my case. On the one hand, there might be someone with those conditions, and on the other there might be a university graduate who has MS, who might be supported by a family and be able to sit down with a GP and make such decisions. My point is that it is not fair—it is not equal.

Simon Burns (Conservative, Chelmsford)

Can I explain the matter to the hon. Lady, because she seems to be getting lost in the mists of time? That is a right of choice that patients may not, on occasions, wish to exercise. Listening to her words flowing, it is a little difficult to understand her point when one remembers that she took part in a hard-fought election campaign in Islington last May on a manifesto commitment that stated:

“We will expand patient choice, empowering patients with information, and giving individuals the right to determine the time and place of treatment.”

Emily Thornberry (Labour, Islington South and Finsbury)

I am grateful to the Minister for raising that, because there is a misunderstanding, deliberate or otherwise, about of our position. There are times when the public can make decisions on a managed market basis. For example, if a patient had a hernia condition, they might be able to sit down and talk to their GP. It is a completely different matter, however, to bring in a measure that relates to all care and drive it into the centre of the national health service. To release the NHS, to allow the market to affect everything, will mean that the protection that is needed for the most vulnerable, which comes with a managed market, is no longer available.

Dan Byles (Conservative, North Warwickshire)

The hon. Lady seems to be suggesting that if not everybody can exercise choice, no one must be allowed to do so. Is that her position?

Emily Thornberry (Labour, Islington South and Finsbury)

I am happy to repeat what I have just said. Before the hon. Gentleman spoke, however, I was trying to address the point that he has made. We need a market in some areas of the NHS, but it must always be managed. The Bill undermines that, and in doing so, it attacks the principle of equality.

Dan Byles (Conservative, North Warwickshire)

I thank the hon. Lady for letting me intervene again. She confuses the concept of market and any willing provider, and the concept of choice. It is about who is providing certain services on the one hand, and patients choosing where to go and whom they want to be treated by on the other. Although the two overlap, they are distinct parts of the Bill and what it tries to achieve.

Emily Thornberry (Labour, Islington South and Finsbury)

I am conscious that at this stage of the debate we should focus on equality, and although I am happy to continue the argument with the hon. Gentleman, it may be veering down a different path. I have to say, as a glancing blow before I move on, that the Government parties seem to confuse the idea of democracy with shopping. Someone going to a GP and being able to make a choice does not in itself equate to democracy. The Bill’s weak provisions that relate to democracy do not help with equality, pushing up services or standards.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

I am sympathetic to the hon. Lady’s important point about inequalities in health care. That is part of the reason for the Bill, which deals with such matters. She is discussing the way in which the Bill is further expanding choice and how that will undermine equalities in health care. How does she equate that view with the previous Government’s choose and book system, and other measures that still stand in the NHS?

Emily Thornberry (Labour, Islington South and Finsbury)

If I may, without meaning to be unnecessarily tedious, I remind the hon. Gentleman, as I have reminded the Minister, that the Conservatives are in government now, and that we are scrutinising legislation, which the two parties are attempting to push through, that will have a radical effect on the health service. It is important to focus on that and on any problems that anyone may have, and to scrutinise the legislation in an honest and straightforward way, which is what I am attempting to do.

Dan Byles (Conservative, North Warwickshire)

Will the hon. Lady give way?

Emily Thornberry (Labour, Islington South and Finsbury)

If the hon. Gentleman will allow me, I am conscious of the time. I have been on my feet for half an hour and am still on the first page of my notes.

Dan Byles (Conservative, North Warwickshire)

How many are there?

Emily Thornberry (Labour, Islington South and Finsbury)

A few. Moving on to some of the evidence that supports my case, we heard from Paul Jenkins, the chief executive of Rethink, who said:

“There is a whole strand here. I think we are all happy that there will be a group of consortia with knowledgeable and active GPs, who will do everything that we want. In a national health service, the concern is what happens in areas in which that expertise does not exist. What happens in areas of greater social disadvantage, where standards may lag behind the best?”

It is important that the Minister hears what I am saying about areas of greater social disadvantage, where standards may lag behind the best. The chief executive of Rethink is very concerned about the effect that the legislation may have on those areas. He continued:

“Certainly, mental health is bedevilled by the fact that you can go from one area to another and outcomes and experience will be very different.”––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 122, Q283.]

We already have differences geographically, and it is sometimes a matter of luck that someone may be in one area rather than another. Will not the fragmentation of the service and the luck of the draw get worse as a result of less regional and localised direction and the development of consortia? The issue was raised by Paul Jenkins, and it should not be dismissed lightly.

We also heard from Sarah Woolnough of Cancer Research UK. She talked about cancer networks, which are regionally based centres of excellence from which a GP can get advice before someone moves into secondary care to be looked after, regionally, by experts. The problem is that, although some cancer networks are good, some are not so good. The expert from Cancer Research UK said:

“Where there are really good cancer networks, they are thinking about the future, about social enterprise status and how to make themselves most useful. An obvious concern is about potential inequality. In the areas where the networks are already very strong, they get their act together more quickly and continue to be the fantastic resource that they can be. In areas where they are less good, there is a potential vacuum.”––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 119, Q281.]

Those were the words of an expert on cancer care when she gave evidence to the Committee about the possibility of cancer care getting worse in certain areas as a result of the diminution of the standing of cancer networks in weaker areas.

We are talking about equality of access to absolutely vital services. I hope that the Government parties will take that important critique very seriously. They need to be confident that they can address it in the Bill. I suggest that they make it do exactly the opposite of what it does at present.

Jeremy Lefroy (Conservative, Stafford)

I have great sympathy with much of what the hon. Lady is saying. The problem of inequality in the health service and the importance of equality are vital. However, I should like to press her on one thing. In my experience and that of a lot of people, it is not so much the structures that lead to local inequalities, but the people involved and the professionalism, or otherwise, of—let us be frank—the PCTs or GPs. At the risk of making a speech, I would like the hon. Lady to comment on that and how her amendment would deal with it.

Emily Thornberry (Labour, Islington South and Finsbury)

The hon. Gentleman is absolutely right. We can talk and write about structures, but it is people who deliver health care. That pushes me back to the arguments that I was making earlier. We know that when a hospital is successful, it attracts people. When a cancer network works well, people want to work there. However, if the differences between good and bad become exaggerated by the market system introduced in the Bill, excellence will get stronger in some areas and weaker in others. The best people will know that it is not worth remaining in an area where a cancer network is getting weaker.

In the end, people are only people. They want to work with the best and deliver the best services; they do not want to come home at night and worry that their service is not as good as it should be and as they would like it to be. That is why I respectfully submit that we need more regional management of the health service than we will ever have if the Bill is passed as it is, to ensure that we keep the service together rather than allowing it to fragment and hoping for the best.

Jeremy Lefroy (Conservative, Stafford)

Does the hon. Lady not see the point that the localism that the Bill seeks to introduce is a better protection against poor performance? Primary care consortia are much more likely to keep a close eye on what their colleagues are doing than a more distant PCT, or even an SHA.

Emily Thornberry (Labour, Islington South and Finsbury)

Tempted though I am to tell the hon. Gentleman my ideal, I think that we ought to focus on what the Bill can and will do. Without the structures that have existed in the health service until now, we will be taking a risk that, for the sake of our constituents and NHS patients, we should not be taking.

I return to the further evidence. I do not wish to labour the point, but it is important. We heard from Paul Farmer, the chief executive of Mind. Even within the structures for which I have been arguing, there are times when things do not work. At the moment, NICE can write best practice and make recommendations, but there are times when GPs simply ignore it. Paul Farmer said rather elegantly:

“It is important, first of all, to recognise that we are not sitting in a world in which NICE-recommended guidance is universally utilised”.––[Official Report, Health and Social Care Public Bill Committee, 10 February 2011; c. 118, Q280.]

Even now, when the attempt is made to ensure that certain standards are kept throughout the country, it does not work everywhere. If the service is fragmented, surely things will simply get worse.

In the end, GPs are the gatekeepers. They are in charge of the fund and will decide whether patients go to hospital. At the end of a financial year, if somebody wants a hip replacement and somebody else wants a new heart valve, who will make the decision and how will it be made? How will it be made equally, and who holds the reins? The Bill throws up such difficulties, which go to the heart of the idea of equality of access that are enshrined in our NHS and that it is incumbent on us to protect.

Dan Byles (Conservative, North Warwickshire)

That is exactly what happens now, but it is the PCTs that make the decision. Before Christmas, NHS Warwickshire started a policy it called “fast, slow, stop” because it saw a problem looming in its finances. It decided to slow down certain treatments and stop others altogether.

The George Eliot NHS Hospital Trust in my constituency is still offering certain procedures to people referred from Hinckley and Bosworth, but not to people who live up the road—because people from up the road come under NHS Warwickshire, whereas people from Hinckley and Bosworth come under another PCT. What the hon. Lady describes—“End of financial year, will we start slowing things down?”—is happening right now in NHS Warwickshire under the system that we inherited from her Government.

Emily Thornberry (Labour, Islington South and Finsbury)

The hon. Gentleman makes an important point. Of course, in the end, limitless money for limitless services will not be available. However, if the organisations or individuals commissioning services cover a small area and have a relatively small budget, the decisions that they must make at the end of the financial year will be more exaggerated and could be more extreme.

For example, a GP or GP commissioning consortium might suddenly find that two new families have moved into the area. I met a family yesterday that had two boys with extreme disabilities. If that family moved into a GP consortium’s area, that could make a huge difference to the money spent by that consortium. They are a lovely family, and no one would want to say that they are a burden, but they would make a great difference to the budget of a particular GP consortium.

If three or four such families suddenly moved into an area, or if, for example, a housing association changed its lettings policy and decided that it would only allow in people who had disabilities, who would have sufficient points to be able to be housed—this happens with many housing associations in areas of acute housing need, such as mine—we might find a concentration of people with disabilities living in particular geographical areas. That could have a great effect on a GP consortium’s budget. That is neither equal nor fair, and it is not what the NHS ought to be about.

Dan Byles (Conservative, North Warwickshire)

I recall having a discussion during the evidence session about the minimum size for aggregating risk. There was agreement that there is a minimum size. I do not remember which witness suggested this, but someone said that about 100,000 patients appears to be the right minimum size. The argument is not against GP consortia in favour of PCTs; it seems to be about where the level for a minimum reasonable patient number should sit to aggregate risk properly.

Emily Thornberry (Labour, Islington South and Finsbury)

Anyone can see the point that I am about to make. The risk for a larger area, such as a PCT area with assistance from an SHA, is clearly not going to be the same as the risk for a fragmented system of many small GP consortia. On the one hand, the Government argue that there is a best size for GP consortia, and on the other they argue that they are not going to dictate to GP consortia what size they should be. The Government cannot have it both ways.

If the Bill is focused on measuring outcomes, and its success or failure is outcomes-based, what priority will be given if someone has a condition that does not have an easily measurable outcome? For example, if I was suffering from schizophrenia and went to see my GP, they would not, no matter how hard they tried, be able to cure me of it. There would not be a box that said, “That is an outcome.”

My schizophrenia could be managed, but that is not the same as an outcome. In those circumstances, if a GP is trying to commission things and focus on outcomes, then people who have conditions that do not involve dramatic changes or outcomes are in danger of being pushed down the priority list. [Interruption.]

Jimmy Hood (Labour, Lanark and Hamilton East)

Order. When I can hear hon. Members going on as they have been, they are out of order. I invite hon. Members to pay attention to the Member who is speaking to the amendment.

Emily Thornberry (Labour, Islington South and Finsbury)

Thank you, Mr Hood. The Opposition are not alone in having concerns about the impact of the changes on equality in the NHS. On Tuesday, The Guardian contained the headlines, “Liberal Democrat cracks appear over NHS reform plans”. The second paragraph of that article states:

“Party critics claim the reforms will increase health inequalities”.

One critic, Charles West, a GP—and, incidentally, a former Lib Dem parliamentary candidate for Shrewsbury —said:

“‘I am loyal to the Liberal Democrats, but I also love the NHS, and these reforms go in the wrong direction. The NHS needs improving, but the record shows it is not in the state described by the coalition, as authoritative institutions such as the King’s Fund have shown.’ He said patients with some of the most difficult health care requirements, such as elderly patients with multiple…conditions, were likely to benefit the least from a competitive market.”

He is concerned, like us all, about the effects of such reforms on equality and equality of access—particularly for the most vulnerable, who are not likely to be able to advocate for their needs as well as others. That is why the chair of the Royal College of General Practitioners, Clare Gerada, gave the very important evidence that hon. Members heard:

“We are concerned that the Bill risks widening health inequalities and could lead to worse patient care, and that introducing competition based on price will reduce quality.”––[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 43, Q94.]

She could not have said it more clearly. It is important that hon. Members on the Government Benches hear this. I also refer to Karen Jennings, the assistant general secretary of Unison. She spoke of the danger of “two-tierism” as a result of the Bill.

Perhaps the advocate who Government Members will find most compelling is the BMA. It said, on a different point, that if in making decisions the easier conditions and patients are focused on rather than the more difficult patients with complex needs, there is a danger that cherry-picking treatment for the less complex conditions will destabilise other provision, so the treatment of more costly, complex and time-consuming conditions becomes unsustainable or significantly reduced. How bad does it need to be? The arguments and evidence that hon. Members have heard on this is alarming.

Finally, I move on to the specific points in the amendment. Given the dangers inherent in the legislation, equality provision must be much stronger than it is. Frankly, we have come a long way on equality legislation. After the Equality Act 2010, passed by the previous Government, it is surprising that the clause deals with equality in such a “wave of the hand” fashion. I am sure that that was unintentional, but it is important when dealing with equality that the benefits are spelt out better than they are in the Bill. Inequality is such an important subject that we can do better than this.

One reason why we particularly wish to spell out in the Bill the different groups whose inequalities we ought to focus on is the treatment of the elderly, which I am sure is at the forefront of hon. Members’ minds given the terrible publicity that it has received in the past few days. The Bill should talk about the importance of treating the elderly in a fair and equitable way.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

The hon. Lady is right to raise better care for older people. All of us on the Committee agree with that, but if the Labour party is so keen on supporting the elderly, why did the capitation formula for health care funding fail to recognise it as an important criterion in the past?

Emily Thornberry (Labour, Islington South and Finsbury)

I do not want to sound like a cracked record, but the hon. Gentleman needs to remember that his party is in government now and we are scrutinising the Bill that is before us now. It is very important that we do not get distracted by party political point scoring, because without sufficient focus we could allow a Bill such as this to pass, which will radically undermine our NHS. [ Interruption. ] Spending time scoring points in this way is, frankly, beneath the hon. Gentleman. I have a great deal of respect for him and we have worked together on all-party health groups for some time, so I know him well.

Please can we move on and focus on how elderly people are not treated fairly or equally as things stand in the NHS? How much better will it get under the Bill? We need to focus first and foremost not on structures or party political point scoring, but on how the Bill will help patients. How will the Bill help patients to be treated more fairly?

We all heard the evidence coming out from the health ombudsman. For the Health and Social Care Bill to achieve more positive health outcomes, it must be explicit that improvements are to be achieved across a whole population. We know that older people’s needs are often under-prioritised and under-recognised in the NHS. We also know that ageism in clinical practice persists, with older people often lagging behind other groups in terms of better health outcomes. A clear obligation is needed in the Bill to demonstrate that improvement is being achieved across a whole population. That is what the amendment is about.

For example, despite improvements in cancer outcomes, a 2007 study of breast cancer patients in Manchester found that older women are less likely than younger women to receive standard management for breast cancer and are less likely than younger women to have surgery for operable breast cancer, even after accounting for differences in general health and co-morbidity.

The health ombudsman’s recent report showed terrible failures in the care of older people. Of the 9,000 complaints to the ombudsman about the NHS last year, 18% were made about the care of older people. The ombudsman accepted twice as many cases for investigation about older people as for other age groups put together.

The aim of amending the Bill in the way proposed is to ensure that the Secretary of State’s duties are clear and specific, that he has a proper focus on the elderly and that people across England can be sure that their access to health care, and the quality of the health care that they receive, will be assured regardless of who is providing the service.

The areas where the Secretary of State can demonstrate improvement to reduce inequalities should be balanced and fair in their focus. Otherwise, the risk is that commissioners across the NHS will be incentivised to invest their efforts in improving health outcomes for those groups for whom they believe they can make the easiest and quickest gains. I have made that point before. It is easier to deal with a bright, alert, fairly compos mentis patient with one specific condition than it is to deal with some of the more complex needs that, frankly, most of us will develop as we get older.

Dan Byles (Conservative, North Warwickshire)

The hon. Lady has been very generous about giving way. She seems to have given us a litany of Labour’s failures in dealing with elderly patients during the last 13 years. Is that not a classic example of why the Bill, which seeks to drive up quality across the board in the health service, is so important and why simply sticking with the status quo in relation to structures and everything else that the Opposition want to do is the wrong way to go?

Emily Thornberry (Labour, Islington South and Finsbury)

The hon. Gentleman’s point is like a curate’s egg—good in parts. I do not think that any Labour Members have ever claimed that we left the national health service in a perfect state. It is not perfect, but it is so much better than it was when we inherited it. We were doing the right things. There is much more work that needs doing, and we would certainly wish the Government to build on our many achievements.

Some of the Government’s initiatives—for example, the mental health strategy and the cancer strategy—we have been pleased about on the whole, because they have been building on our achievements. The difficulty is that it is all very well having strategies of that sort, but they are only strategies for the short term, because in two years’ time, if the Bill is passed, we will all be heading over a cliff together. There will not be the levers any more for those sorts of strategy to be able to continue. That is the concern, and it is very serious.

No Labour Member has ever said—or they should not have—that the elderly were treated as well as they should have been in the national health service. Of course not. Of course much more work needs doing, and frankly there is a great deal of cross-party agreement on what should be done. The question is really how we do it. We believe that the Conservative party is fundamentally misunderstanding how it can be done and how we can drive up standards.

Leaving the national health service to the market is not the way to improve standards for everyone. It may be for some, but not for everyone, which is why I am making a speech on equality. Our NHS is based on the principle of equality, which is fundamentally at odds with the principle of introducing the market and allowing a free market that is not managed in relation to services across the piece.

I am sure that the Committee will be glad to hear that I am about to finish my speech. Before I do, may I return once more to the statement from the BMA? The Government have often cited the BMA as a supporter of the Bill. However, the BMA has made many important criticisms of the Bill that are not a laughing matter. [Interruption.]

Jimmy Hood (Labour, Lanark and Hamilton East)

Order.

Emily Thornberry (Labour, Islington South and Finsbury)

The BMA said that it would like to see provision in the Bill for any new manifestations of health inequalities that arise as a result of reforming the way in which the NHS will commission services, particularly at a time of huge pressures on financial and public finances to be addressed. It said that there must be mechanisms in place to ensure that, if the range of services commissioned by consortia varies to such a degree that patients living in one part of the country are severely disadvantaged in comparison with those living in another, the NHS commissioning board has the ability to work with consortia to address such inequalities. The BMA added that those should include consideration of adding new services to the list of those that are more appropriately commissioned at a national level.

If the Bill is passed and inequalities do arise, is there anything in this provision? Are the Government prepared to look at any additional safety nets to ensure that those who have the misfortune of having a GP in a relatively weak consortium within a disadvantaged area, where their lives could be shortened, are also being properly looked after by the NHS?

Margot James (Conservative, Stourbridge)

I am pleased that the hon. Member for Islington South and Finsbury finally got round to talking about older people in respect of equality of delivery of health care, because that was the topic I wanted to address. Before I make a few points on that matter, I should say that the main reason why I oppose the amendment is that the clause as currently drafted is a succinct summing-up of the fact that the Secretary of State should have a duty, as far as possible, to deliver equality. We do not need to spell out all the various groups that we should bear in mind that do not have equal access to health care.

Liz Kendall (Labour, Leicester West)

One reason why the former Government introduced the single Equality Act 2010 was to try to get a level playing field between many different groups whose needs had not previously been met. One challenge of promoting equality is to understand the very different needs of different groups. Will the hon. Lady agree that sometimes—particularly with groups ignored in the past—specifying them might help focus attention on them?

Margot James (Conservative, Stourbridge)

I do agree that by looking at groups individually as the hon. Lady suggests, one can sometimes develop a better understanding of why access has been unequal in the past, and what can be done to improve matters. I do agree with that, but I think the equality duty set out on public bodies now should make that intrinsic to the governance of the NHS, as it would with any other public body.

Liz Kendall (Labour, Leicester West)

My experience of working with NHS organisations is that unfortunately they often do not understand the very different needs of different groups—either those for whom care is provided or those who work for them. I have been involved with training, for example, to promote people from different ethnic minorities within the NHS. That is a real challenge for what is still often a “white cat” service. We need to bear that in mind.

Margot James (Conservative, Stourbridge)

I respect the hon. Lady’s point of view, but my experience as a director of an NHS trust—albeit some time ago—does not bear that out. Considerable effort was made in my trust to enable the promotion of BME candidates within it, and an understanding of the needs of BME patients. Of course, things can be improved throughout the NHS and all public bodies, but I draw the hon. Lady’s attention to the fact that the clause states that the Secretary of State’s duty is to

“have regard to the need to reduce inequalities”

among the various groups of people with whom we are now well versed. When exercising that duty and improving inequalities of treatment, surely my right hon. Friend will have regard to the points made by the hon. Lady. Under the Bill, we are devolving power and decision making throughout the NHS, and thus devolving responsibility, so it is not necessary to include in the Bill the needs of different groups.

The point that I really wanted to make was about the care of older people and their equal access. The hon. Member for Islington South and Finsbury made several good points and drew on some examples, and I want to add a few more by considering access to treatment since NICE was introduced. Older people had to wait years before NICE agreed that the treatment of dementia in the early stages could be benefited by the Aricept class of drugs. For many years, older people suffered that discrimination. When a new treatment was licensed for macular degeneration, older people were not able to access it to many years. Those in certain parts of the country went blind waiting for the treatment. I shall not give further examples, but believe me there are many more.

Liz Kendall (Labour, Leicester West)

I agree with the hon. Lady that such waits are unacceptable. Does she agree, however, that waits of more than three years for cataract operations, hip operations and knee operations, which is what many older people faced in 1997, were also unacceptable, but such long waits were completely eradicated under the previous Government, while waiting times as a whole were down to an absolute maximum of 18 weeks?

Margot James (Conservative, Stourbridge)

I seem to be agreeing with the hon. Lady quite a bit, but I wish to point out certainly in respect of cataracts that improvements in waiting times were brought about only by the introduction of competition into the system, more of which will be enabled under the Bill. I trust she will agree that we might see even more improvements to even more conditions due to the introduction of greater competition and choice within the system.

I want to conclude by echoing the remarks of my hon. Friend the Member for Central Suffolk and North Ipswich, who said that some issues can be addressed only by looking at the funding formula. I understand Opposition Members’ point that we are in government now, but we have inherited the situation whereby the equality agenda of the Labour Government was so biased towards helping the areas of the country where people were subject to higher deprivation and of lower socio-economic groups that it compromised the equality of treatment of other groups. A lot of evidence shows that the usage of health care resources is far more determined by age than socio-economic status.

Grahame Morris (Labour, Easington)

The evidence base is in the Black report and the Townsend report. There is a clear causal link between poverty, lack of income, social deprivation, poor housing conditions and poor health outcomes. It is disingenuous to suggest otherwise.

Margot James (Conservative, Stourbridge)

I apologise to the hon. Gentleman if he feels that I was ignoring that body of evidence. I accept the links he mentions, but I am talking about the usage of health care resources, which is a different matter—that is what I am focused on. I do not dispute the points he made, but tackling them is sometimes not as expensive as the care, treatment and interventions involved in managing the health care of older people. Many of the causes of the illnesses he described are in fact related to lifestyle factors, such as obesity and smoking, although poor housing is a strong contributory factor, I certainly agree.

Grahame Morris (Labour, Easington)

In many of the older industrial areas, such as the Durham and Northumberland coalfield, Teesside with its steel industry—

Owen Smith (Labour, Pontypridd)

Or south Wales.

Grahame Morris (Labour, Easington)

—or south Wales, which had coal and steel, many chronic conditions have shortened life and caused ill-health. Such conditions include chronic bronchitis, emphysema and many others directly related to the work environment. It is not strictly true that ill-health is largely down to lifestyle choices.

Margot James (Conservative, Stourbridge)

The hon. Gentleman makes an excellent point.

Daniel Poulter (Conservative, Central Suffolk and North Ipswich)

The hon. Member for Easington makes a good point, but what my hon. Friend is saying—I hope she agrees—is that, while deprivation is an important factor, and we can all sign up to having to deal with health care inequalities, in particular in certain parts of the country, another important issue is dealing with the fact that older people, and their specific needs, consume a larger proportion of health care. That fact has not been addressed properly in the funding formula in the past. Deprivation is not the only game in town—there is also looking after older people.

Margot James (Conservative, Stourbridge)

I thank my hon. Friend.

Owen Smith rose—

Margot James (Conservative, Stourbridge)

I have concluded my points so, rather than give way again, I suggest that the Opposition Members make their speeches.

Grahame Morris (Labour, Easington)

I feel passionately about this problem, which impacts directly on my area, as I indicated. I remind the Committee of the wording of the clause:

“the Secretary of State must have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service.”

Personally and politically, I strongly support the need to place a greater duty on the Secretary of State to reduce such inequalities, and that is exactly what the amendment does.

I draw the Committee’s attention to the evidence given by Stephen Thornton, the chief executive of the Health Foundation, in our first sitting. He called for a similar duty to be placed on the NHS commissioning board and on the GP consortia, so as to embed shared decision making in all care and treatment, in order to tackle health inequalities.

Clause 19 is relevant to amendment 5. It places exactly the same duty as clause 3 does on the Secretary of State—having regard to the need to reduce inequalities —on the NHS commissioning board. As a marker on the consistency of the Bill, we might look to strengthen that clause in the same way as we propose doing to clause 3 with amendment 5.

The Committee should understand why the need to strengthen the obligation to reduce inequality is important. The justification for the amendment is that the new structures move away from the more co-ordinated, integrated service and towards a competition-based service where in some circumstances, failure is considered necessary or desirable to improve services. [Interruption.] I see the Minister is pulling a funny face, but I refer him to the evidence given by Chris Ham in our second sitting. It is a contentious point, but in his view it was good to have some instability in the system. The fact that instability will arise out of this competition-based system is a factor we must take into account. It may have a deleterious effect on health inequalities and provision.

In its evidence, the BMA called for a co-operative and co-ordinated environment that a fully open market would make impossible. Dr Clare Gerada, chair of the Royal College of General Practitioners, during our second evidence session, expressed a number of serious concerns

“about the duplication of care and fragmentation…about the under-provision of care once competition starts kicking in, the pace and extent of change, and the capability capacity and competence of GPs”

to deal with the extent of health needs. Most importantly, she said that

“the Bill risks widening health inequalities and could lead to worse patient care,”.––[Official Report, Health and Social Care Public Bill Committee, 8 February 2011; c. 43, Q94.]

Liz Kendall (Labour, Leicester West)

Will my hon. Friend confirm that one of Dr Gerada’s main concerns about widening health inequalities was that the GP consortia will have duties only in relation to their practice population, not the whole population in the area? It is true that local health and well-being boards will have responsibility for the whole population area, but the consortia will focus on their practices. That could lead people such as homeless people, or those with drug and alcohol problems, out of the system. That is what Dr Gerada was worried about.

Grahame Morris (Labour, Easington)

That is an important point and I hope that the Minister will feel able to address that issue in his remarks. It is one reason why the amendment is essential. The Bill changes the fundamentals of our co-ordinated health system and risks making inequality, in terms of access to health services and outcomes, ingrained in the NHS. The only way to counteract that is to place a binding duty on the Secretary of State to reduce health inequalities.

There is a significant difference between inequalities in access to health services and outcomes and the broader problem of health inequalities based on ingrained issues such as socio-economic variation—the hon. Member for Stourbridge mentioned that point. The amendment specifies those areas that should be addressed, and that is key. In 1977 the chief scientific adviser to the Department of Health, Sir Douglas Black, produced a report on the extent of health inequalities in the UK and how best to address them. The report proved conclusively that death rates for many diseases were higher among those in lower social classes. It acknowledged that the NHS could do much more to tackle the situation, and it called for increases in child benefits, improvements in maternity allowances, more pre-school education, an expansion in child care and better housing.

I mention that not to digress but because there is the stark danger of a reversal of the progress that we have made in addressing health inequalities. That may be exacerbated by decisions that are taken elsewhere in government. It is important to take the opportunity to try to mitigate or ameliorate that situation. This is an important issue that I have long campaigned on, and I believe it is vital that we put a duty on the Secretary of State to be proactive in the campaign to reduce health inequalities.

Under the previous Labour Government, in June 2008 the then Health Secretary, my right hon. Friend the Member for Kingston upon Hull West and Hessle (Alan Johnson)—the constituency next to that of my hon. Friend the Member for Kingston upon Hull East—made a speech on health inequalities in which he said:

“It is inconceivable today that any Secretary of State could be so dismissive of an issue so critical to the life chances of so many.”

Remarkably, we are now considering proposals to water down the way we tackle that critical issue. Most valuably, amendment 5 sets out the areas in which inequality must be considered and acted upon.

My constituency, a former coalfield district, is affected, as are those of a number of my hon. Friends and perhaps of others too, by long-term unemployment due to serious ill health, which is often associated with former industrial occupations. It is against that background that we have identified this most pressing need to act against inequalities created by socio-economic variations. It is no coincidence that health inequalities follow every other poverty and deprivation indicator. If a stronger duty is not placed on the Secretary of State to tackle inequalities, and there is no accountability function to Parliament, I am concerned that there will not be the full and proper requirement for the Government to examine and scrutinise progress. Requiring the Secretary of State to report annually to Parliament would be a powerful safeguard, and would ensure that the issue of health inequalities remained at the forefront of Government policy. I ask the Minister and Government Members to support the amendment, or to consider improving the checks and balances on this most important issue.

John Pugh (Liberal Democrat, Southport)

This is a very important debate and I think that all members of the Committee agree that tackling heath inequalities must be an objective of any health legislation. It is rather churlish of the Opposition not to acknowledge that the Government are setting it as an objective and putting it right up front in the legislation. I do not know if that is unprecedented, but it is certainly very welcome and should be welcomed by everyone, even though some might not agree with the methods that the Government will use to achieve it.

Research this week has shown that inequalities are not getting any better. There has been some research by Margaret Whitehead, professor of public health, on the north-south health divide that might be of interest to the hon. Member for Easington. She has established that health inequalities between the north and the south are worse than at any time in the past 70 years. That has happened under a number of Governments, all of whom have tried to address the issue. The 1997 Labour Government had a cross-departmental group working on health inequalities but, contrary to what the hon. Gentleman said, Labour has not had a great deal of success. It has raised the overall standard of the nation’s health, but inequalities are just as severe as they ever were. It is not just that “it’s grim up north”; the causes are deep-rooted socio-economic ones as well as purely medical and clinical, which is why the inequalities have persisted despite huge improvements in medical facilities and GP practices. It is genuinely not an access issue; the most deprived part of the borough in which I live has the best access to health facilities.

Liz Kendall (Labour, Leicester West)

I am sure that the hon. Gentleman is aware of research by Dr Julian Tudor Hart, which has shown that people in the poorest areas have the poorest access to health care. The previous Government did a great deal to improve access with, for example, their programme to tackle under-doctored areas, under which GPs—into whose hands £80 billion will be going—who tended not to go into poor, deprived areas were brought into them. Does the hon. Gentleman seriously suggest that there is no evidence that people in the poorest areas also have the poorest access to care?

John Pugh (Liberal Democrat, Southport)

I can only judge from the local point of view. I live in the borough of Sefton. Bootle has better access to health services than does my constituency of Southport, but outcomes are better in Southport. There is no direct correlation between good access and getting rid of inequities, but there is a perfectly valid point that the attempt to performance-manage GP practices, particularly in poor areas where a number of practices were not up to the job, produced real benefits.

The rest of the debate is in Hansard.