Health Bill [HL]

My Lords, I want to concentrate in my contribution today on quality accounts; but before I do, I would like to ““hover my helicopter”” over the other bits of the Bill. The NHS constitution—well, what is there not to like? I do not quite share the enthusiasm of the noble Lord, Lord Tugendhat, who—if he will allow me to say so—is a mere toddler in NHS management terms. Those of us who have been in it a long time know that the NHS produces these documents quite regularly. As many will remember, 10 years ago we had the Patient’s Charter. Whatever happened to the Patient’s Charter? We will watch the NHS constitution with interest but some scepticism. I welcome the measures on smoking; I think that they will be fine, and a good contribution. I would like to hear more detailed evidence in Committee about the efficacy of the measures but, on the whole, I support them. I very much welcome the new complaints system for self-funders in private care. Ministers promised that they would introduce this and we are extremely grateful for it. The pilot schemes for personal health budgets, which we heard wonderfully described by the noble Baroness, Lady Campbell of Surbiton, have the potential to be more far-reaching in personal healthcare than we are likely to see in the immediate future. I very much welcome the development potential of these pilot schemes. Overall, I welcome the quality accounts. I declare my interests as a board member of Monitor, the independent regulator of foundation trusts, and as a former academic clinician and NHS manager. Foundation trusts, which I shall call FTs, comprise more than half of all trusts, including mental health trusts and ambulance trusts, and will eventually encompass all trusts—even, I hope, academic health science trusts—that survive our assessment process. Greater transparency on quality of care will increase public accountability and require boards to pay greater attention to the quality of care that they offer to patients. For too long, the quality of clinical care has taken a back seat to finance in board discussions. Quality should be at the heart of the board’s agenda, and the board should be leading quality improvements within its organisation. These accounts will help to redress this balance, and over time we should strive to ensure that quality reporting has the same rigorous standards as are currently applied to financial reports. In doing so, we will need to develop tools and language so that directors and non-executive directors can be as comfortable discussing quality with clinicians as they are in discussing balance sheets with the finance director. We are not there yet. Monitor has been working with the Government and the Care Quality Commission to introduce a quality report into this year’s annual accounts for FTs to be published in the summer. It will be publishing a document shortly for consultation, and I hope that foundation trusts will provide a wealth of experience on which the Government will be able to draw when framing the detailed regulations. Given this commitment to the concept and the adoption of quality accounts, I am disappointed to have to raise some concerns about the detailed drafting of the Bill. I hope to persuade the Government to stick with the Minister’s commitment in his own report on the future of the NHS, which stated that providers would have to publish quality accounts, "““just as they publish financial accounts. These will be reports to the public on the quality of services they provide in every service line, looking at safety, experience and outcomes””." That, in my view, means measurable and auditable. If we leave trusts to self-certify their own quality, we will get the same creative nonsense as we have seen in some of the self-reported standards submitted to the Healthcare Commission. Much of it will be PR guff and self-delusion. We have often seen that in documents issued by trusts claiming that they are expert in some field. We need numbers. Quality accounts need audit and comparability, and I include mental health services in this as well. I look forward to hearing the noble Baroness, Lady Young, on this issue. I am sure that she will have clear notions on how we can take forward the quality issue. There is another problem. As drafted, the Bill fails to recognise the local accountability of NHS foundation trusts to their governors, and national accountability to Parliament. Nor does the Bill recognise the existing reporting arrangements for FTs, so it risks duplication and confusion. FTs are required by statute to present their annual report and accounts to their governors at an annual general meeting. That is central to the concept of local accountability. They are also obliged to lay their annual accounts before Parliament. The Bill ignores these existing requirements and requires quality accounts to be sent to the Secretary of State. It also allows for strategic health authorities to require FTs to correct their quality accounts, even though FTs are explicitly set free from the direction of the SHA and the Secretary of State. Surely that approach undermines the autonomy of FTs and the concept of independent regulation. As a former chair of a strategic health authority I can also say that these arrangements will distract SHAs from the crucial job they have of getting PCTs into shape and developing the commissioning function. The recent Health Select Committee report reminds us how far SHAs still have to go in this area without them acquiring more responsibilities for providers, beyond those that they already have to prepare them for foundation trust status. These concerns could easily be addressed. The requirement to produce quality accounts could be integrated into the existing accountability and reporting arrangements without damage to any of the objectives for quality accounts. I would like to see an approach where the Secretary of State required the independent regulator to integrate quality accounts into the reporting regime for FTs so that one set of accounts covered both quality and finance. Bringing those two aspects of performance together is the only way in which we will ensure that trusts are publicly accountable for their performance. I recognise that some of these concerns could be addressed in regulation, but the governance arrangements for FTs are set out in primary legislation and that is where this valuable change to the governance arrangements should also be set out. Quality is so important. This is the beginning of a long journey, and I would not want to see it subverted into the PR exercise that it can so often become in the NHS. Let us have an auditable account alongside the financial accounts. Does the Minister envisage that there may be some flexibility in the drafting of the final regulations, and indeed the final Bill, to take account of some of these overlapping accountability arrangements, which are rather confusing for at least half the trusts in this county?