Health Bill [HL]

I also speak to Amendment 47, and will continue the themes that we have been discussing in the previous group of amendments. I was buoyed up on a wave of enthusiasm by the Minister’s first speech in his response, but was then dashed against the rocks of disappointment when he said that this has nothing to do with regulation or regulators. I cannot then think what the regulators are meant to do. I will flesh that out a little later. I have been surprised by reports in the healthcare trade press about my amendments, and therefore hope that the Committee will bear with me if I make clear my purpose in tabling them. I declare an interest as a member of the NHS foundation trust regulator, Monitor. Like my colleagues in that organisation, I feel pretty strongly about the clarity of processes of management, reporting and the regulatory system. This is not about adding burdens, but about being able to be clear in what information is available, not only for patients but for clinicians, Ministers and trust boards in managing their services. These are probing amendments. I do not expect to return to them on Report, but I want to be sure that I understand the Government's intention on the purposes of the reporting system for quality accounts. Again, we go back to the issues so ably raised in the previous group of amendments about how they are to be developed and for whom. If I touch on some of those areas again, I hope that the Committee will bear with me. First, where do those issues sit in the overall framework of the Government’s intentions for the healthcare services? I am a great fan of the Government’s declared vision of an affordable, devolved healthcare system in which patients receive excellent care and taxpayers get value for money through autonomous, well led providers responding to commissioners’ requirements and patients’ voices—a system, which is regulated in a clear, auditable way, using a toolkit of measures that allows performance to be monitored and encourages continuous improvement. I have taken these off other doctrines. I am pretty clear that that is what the Government are trying to achieve. Everyone will agree that the introduction of quality metrics is vital to that task. This is why, at Second Reading, I expressed my wholehearted support for the introduction of quality accounts, recognising that we are introducing a potentially far-reaching mechanism for encouraging clinical care improvement. I congratulate the Government on taking this forward. We have been hoping for this for a long time. The quality agenda is, of course, huge. There are dozens of players, not just the clinicians and clinical staff who deliver care and the vital support staff around them, but the many players in stakeholder organisations. It must of course be for the Government—in practice, the Secretary of State—to set the priorities in quality. They will be looking to organisations such as NICE to establish guidelines for care pathways, and professional bodies to promote good practice including, of course, the input of individual clinicians and their teams. We look to the Care Quality Commission to not only set basic and registration requirements, but also to use available information to monitor overall quality standards. I have listened to the noble Baroness, Lady Young, on this issue quite recently, and heard her aspirations to develop a culture emanating from the commission that is consonant with what clinicians want: one of hauling the worst up by their bootstraps and encouraging clinical developments and excellence. That will give us a national picture. What is the role of quality accounts? We have already touched on the problem that at least part of them will need to be different for different audiences. The noble Earl, Lord Howe, talked about that quite a bit. If I am a patient, I want clear, understandable information. I hope that simple, comparative information will be available. We may criticise the material available to the education department and parents looking at league tables but, my goodness, they have worked. They have been extremely helpful in assisting parents to decide which schools they support and which need to improve. If we can get similar data then, of course, we should do that. As a clinician, I share the Minister’s view: I want a set of metrics that are meaningful to me and my team, by which I can judge whether my team is as good as the best in the country or just the also-rans. You might say that that is rather difficult in geriatric psychiatry, but it is not. It is perfectly possible in mental health services to have measurements of how efficacious the service is for a particular family. The Minister’s intention is for quality improvements to be driven through the availability of these clinical data, some of which, as the noble Lord, Lord Walton, has said, have been available from audit. They must be comparative and matchable across different teams, hospitals and GP practices. All this stuff must be comparable if it is going to mean anything to clinicians and, of course, internationally comparable in due course. Quality accounts would surely need to be prepared for that purpose, and they could be. As a trust board member, I want data that tell me as much about the clinical realities of the care my trust is delivering as I learn as a matter of course every week from the finance director about the finances. That would allow the board to focus on what we all know really matters to patients—the clinical realities of care. I also want material which will demonstrate to the local population, and to my governors and members of the trust, what we are developing and how we compare with the other local hospitals. If we are to do that, quality accounts must be published in a way that serves performance management requirements, and the requirements of contracting commissioners and those discharging regulatory functions. I remind the Committee that within two or three years all trusts will be foundation trusts or something similar. There will be no direct performance management. It will be management via the contract and the regulatory system. The CQC, Monitor, the NPSA and many other bodies will need access to this information. The Secretary of State has every right to collect and collate data to give a national picture of the progress of quality improvements. Will accounts be suitable for that? I have a clear picture of where the Minister feels that they are clinically, but will they serve these other purposes? If not, how will they be meaningful nationally? Again, I add my cheers, but if quality accounts are to be meaningful, they must be as measurable and obvious as financial accounts. Since finances and quality are integrally tied not only to the development of value for money but are very subtly intertwined, we must have a reporting system that enables them to be assessed together. The intention in tabling these amendments is not to oppose or dilute the concept of these accounts, nor to remove the Secretary of State from the sight of them. I simply question the drafting of the legislation and the accountability route. If we are to move towards an NHS focused on quality, these accounts must have the same attention and scrutiny as financial accounts. They cannot be an add-on to any discussion of performance, but must be central to it. I believe that including this in the system of reporting would support clinicians within what they are trying to achieve. Quality accounts and financial accounts should be presented together to allow a coherent view of performance to be assessed and should be fully integrated into the reporting and accountability arrangements for NHS bodies. They cannot be seen as part of a separate and less important process. At the moment, the foundation trust regulator collects very crude performance data, which is provided by the Healthcare Commission. It assesses performance against specific targets, such as MRSA, the 62-day wait and all those other things that are uppermost in the minds of most trusts. It gives a broad indication of the governance, efficacy and leadership of trusts. That is all the regulator has to go on in terms of assessing efficacy. The regulator is often asked whether cost improvement demands on trusts impact negatively on the quality of care. We can usually say with confidence that in our experience they do not impact on performance against the specific government health targets but, at the moment, that is as far as we can go. We need far better data on the quality of care to be sure about the impact of financial shifts. Let us be clear that significant shifts are likely to come our way in the next five years. Does the Minister accept that quality accounts could have an important function in relation to this aspect of regulation? If not, I am not sure how quality accounts will be incorporated into a system that takes care of the whole system. Briefly, the amendments are intended to achieve two goals. They would insert a requirement to produce quality accounts that establish reporting arrangements for foundation trusts, which would send a clear message that the quality accounts are central to the reporting regime. They would also establish a fully integrated approach that includes the information that the Secretary of State requires and agrees the form of quality accounts to the Secretary of State. This is very similar to the approach in the requirement for financial accounts, which are devised by Monitor but agreed by the Treasury. They would also allow quality accounts to be laid before Parliament in the same way in which financial accounts are, with both elements of performance being considered together. This appropriately reflects the devolved system that we are trying to develop as well as the future design. The amendments would remove the role of strategic health authorities in ensuring the accuracy of quality accounts. I am not sure how SHAs would do that. They have no relationship with foundation trusts; they have no supervisory role in any way. I am really worried that the current system will take us back to a centralised system that the Government have worked so hard for the past 11 years to break, and away from developing something new and responsive. Such a role would also divert the SHAs’ commissioning function. I am not going to get hung up on individual amendments. They set down a challenge to remove the Secretary of State, and they are probing. They are worded to pose a challenge to the way in which the reporting system works in the Bill. I do not want to focus too much on that at the moment. Rather, I want to understand the rationale for the unusually retrograde reporting proposals, which could play such an important role. I wish the quality account processes every success, but we must understand where they sit in relation to the reporting of performance in the system that we are trying to develop. I beg to move.