Health Bill [HL]

My Lords, I must admit that I was tempted to set aside my speech after listening to the noble Baroness, Lady Tonge, and get into a dialogue with her about what, from my experience as chair of Barnet and Chase Farm Hospitals NHS Trust, I think really happens out there. However, I have prepared for this debate and worked very hard with people inside my own trust to make sure that I get the important points over. More importantly, my noble friend Lord Darzi is well equipped to respond to the points made. In my NHS trust, we have already been looking at the quality agenda under the title Getting to grips with the 2009-10 Quality Agenda. Before I move on to what that looks like, I want to congratulate my noble friend on his first piece of legislation going through this House. I welcome the opportunity to contribute to the debate and to hear his thinking, particularly about Chapter 2 of Part 1, which deals with quality accounts, to which I will address myself today. Last year, 2008, was a year of ideas, concepts, initiatives and proposals, particularly in London and specifically in the quality agenda. The challenge for provider trusts, PCTs and the NHS is to agree how we may turn these often embryonic concepts into an agreed framework to direct, monitor and achieve our shared objectives. The NHS Next Stage Review, High Quality Care For All, by my noble friend Lord Darzi, published in June 2008, contained a number of new concepts and definitions that set the scene for the 2009-10 quality agenda. The report gave a commitment to place a legal requirement on providers to publish information on the quality of their health services in a quality account. In doing so, they must ensure accountability to users of our services and support clinicians, commissioners and patients in driving forward improvements. We can only do that if everyone supports us. Quality accounts meet the clear and consistent message that we hear more and more often: people want to have more control over their health. Having information means being in control. Quality has been defined in three components: patient safety, effectiveness of care and patient experience. Therefore, it may reasonably be proposed that the quality account should reflect those three components. Such a consistency of structure would contribute to another proposal that there should be a clear commitment to bring clarity to quality, a phrase often used in my own trust. Specifically, measured and published quality data should be accessible to a wider audience—to the stakeholders, including, most significantly, patients, potential patients and their carers. In the Department of Health publication High Quality Care for All—Measuring for Quality Improvement: the Approach, principles for change are given to guide the implementation of the new quality initiatives by the Department of Health, SHAs, PCTs and trusts such as mine. Those quality initiatives are co-production, subsidiarity, clinical ownership and leadership and system alignment. While each of those principles is most apposite for the introduction of quality accounts, I wish to draw special attention to system alignment. The Barnet and Chase Farm Hospitals NHS Trust has a well developed model of clinical governance that is quite specific in the expectation that clinical teams will collect and publish internally data that relate to clinical outcomes. That includes corporate standards, mortality, a risk-adjusted mortality rate, healthcare-acquired infection rates, venous thrombo-embolic events and surgical site infections. We also require that a minimum of five locally agreed outcomes are devised and data collected by each clinical department. That is happening in real life. The second aspect of our clinical governance model is to systematically record the published advice that supports the evidence based on the specific areas of clinical practice such as NICE and NCEPOD in addition to the reviews and audits already carried out. This work could provide not only a basis for data collection, but a wide and varied source of clinical initiatives in the quality outcome measurements applicable, I think, to the quality accounts. My trust is also developing a patient safety strategy, which is in its final draft form and has been consulted on throughout the trust. It will be presented to the Governance and Safety Committee at its next meeting. The information coming from this tool fits ideally with what will also be required in a quality account. I hope that my noble friend agrees. The suite of initiatives that will complete our quality agenda for 2009 is the Patient Experience Strategy, which is entering its second highly successful year in Barnet and Chase Farm. This strategy is based on eight campaigns, each with between six and 19 subprojects. They include: getting the basics right—providing the best possible care for our patients; safety first—preventing accidents and keeping patients safe; keeping clean and preventing infections; dignity in care—making sure that our patients are treated with dignity and respect; dignity in death—caring for our patients with kindness and compassion at the end of their lives and supporting those they leave behind; and food for life—delivering the best food and nutrition to our patients. I participated some time ago in the debate led by my noble friend opposite on the quality of food and how that has been dealt with, which is a key issue for us. In addition, there is the important issue that first impressions last—people will recall lots of things that have happened to them, but they will remember and repeat to all their friends the first thing that happened to them when they entered hospital. In recommending the legislative basis for the requirement to present quality accounts we should ensure that they are built on the firm foundations and previous investments that the NHS has organisationally made in safety, efficacy and patient experience. We should require that our systems are aligned; I am sure that my noble friend will convince me that that will be the case. We may ask why Barnet and Chase Farm Hospitals NHS Trust agrees that quality accounts are important. I will tell you why. Quality accounts will inform patients, carers, managers and clinicians of the overall quality of our hospital. This will make our local services more accountable to patients and the public, who will have the clearest and most detailed information they need to make choices about their care and to demand the best-quality services. As I stated earlier, quality accounts will ensure that providers of NHS healthcare will focus more on quality improvements as part of their core function and help clinicians to benchmark their performance to support PCTs and SHAs in receiving information that they can use to monitor our performance. I seek assurance from my noble friend in two areas. The first is that adequate time will be devoted to the preparation and dissemination of the promised guidance. If accounts are to be presented for the financial year 2009-10, data collection must logically begin on 1 April 2009—in 55 days. My second concern is that we should maintain the concept of an account, and not by default allow this to be reduced to a conventional report on quality. As a noble friend said, that would be ticking boxes. The concept of a quality account is clearly based on a financial analogy. However, what is simple in finance may prove to be a challenge in the expression of quality metrics. There can be no direct equivalent of a balance sheet, although measurement against a benchmark or improvement against a baseline measurement would allow for the expression of the quality measure as a percentage. To complete the statement of account a budget will have to state the expectation against which the actual achievement is then compared—a target of which I am very fond. I say to my noble friend that the value of this initiative will be diminished if this unique presentational device is not fully utilised. It has certainly captured the imagination of the clinicians with whom I regularly discuss issues. I have this week, as one would expect, been doing that in great detail and obtaining clinicians’ understanding and belief about what should come from this initiative. Clinicians with whom I have discussed this feel that it will far better facilitate the involvement of the public. They will then understand the concept of balancing an account, as they would with anything else in their lives, and therefore more readily hold their local provider of healthcare, including our trust, to account. We are keen to ensure that quality provision determined by us has regard to guidance issued by the Secretary of State for Health and that it is compliant with all registration requirements. Our clinicians and managers are already working towards what a quality account will look like. They suggest that the key to this process is an agreement with the commissioner of services about the areas where improvement is required. The trust must then be allowed to work out an improvement proposal and suggest this to the PCTs, which will monitor both the project and the expected final outcome. That is the only way in which we will have a substantive measure of how much we are improving and what value our patients are getting. This, we feel, would be a very appropriate interpretation of the proposal of my noble friend Lord Darzi and would demonstrate co-production, subsidiarity and clinical leadership, as recommended in the DoH guidance. In conclusion, patients and the public deserve the best quality services, and not just clinically; more importantly, they deserve a service that respects them and recognises them as people whom we want to care for and treat in a dignified manner. If we get these aspects right, we will deserve to be their ““hospital of choice””. Co-operation in ensuring that they have the information they need to make this decision will be our focus from now on, and we will feed this into quality accounts.