Health Bill [HL]

My Lords, we had a useful and wide-ranging debate in Grand Committee about possible ways in which quality accounts might be quality assured, in the sense of their being subject to external audit or being otherwise validated for accuracy and reliability. The Minister, if I do not misrepresent him, expressed a good deal of sympathy with the concept of validation, but saw no need to insist on a formal audit as such. I respect the Minister’s point of view, and I do not propose that NHS bodies should be burdened with any additional regulatory requirements. However, I still see accuracy as one of the cornerstones for the success and credibility of quality accounts. My concern has been brought into sharp focus by the recent publication of the Audit Commission’s report on data quality in the NHS, Figures You Can Trust. If noble Lords have not read this report, I respectfully recommend that they do. The Audit Commission’s research—which was partly desk-based and partly involved inspections of several trusts—found that there is, to put it mildly, a great deal of room for improvement in the reliability of NHS data. The error rate in clinical coding, for example, ranged from 0.3 per cent to 52 per cent, a range described by the commission as varying from excellent to wholly unacceptable. The average error rate was 9.4 per cent. The commission identified four main factors that it believes lie behind this. One is the training of staff; another is lack of involvement by clinicians; another is a lack of clarity in specific areas of the coding system; and the fourth is the quality of the source documentation and records. The reviews found that although trust boards devoted a significant amount of scrutiny to financial information, there was little evidence that they discussed or challenged the quality of other data. Indeed, the responsibility for quality assurance of data is typically delegated to information managers. The result of that is that many trusts do not have the knowledge or expertise at senior level to challenge the reliability of the data that are submitted to them. Not enough importance is attached to data quality at board level and there are no systematic programmes to enable trust boards to review the accuracy of such data. In general, the need to make sure that information is accurate is not seen as being an organisational responsibility of which everyone in the trust has a duty to take ownership. Against that backdrop, it is not surprising that the commission sounded a warning about quality accounts. It said: ""If quality accounts are to have the same status as financial accounts and if patients and the public are to have confidence in the data that they contain, the quality of the data should be subject to internal and external review"." That is paragraph 56. It goes on to say that it does not think that this needs to be on the same scale as for financial accounts, which are subject to detailed internal and external audit, """But we do consider that boards should put in place the kind of assurance programme outlined above and declare in their quality accounts that they have done so"." The assurance programme it refers to is the one currently being piloted in NHS North West for payment by results. There is an obvious read-across here to quality accounts because quality accounts, as the commission points out, will rely on accurate clinical coding and secondary-uses service data. The report usefully suggests that commissioners of NHS care could play a much stronger role in scrutinising information provided to them by trusts, which is surely right. The same applies to strategic health authorities. We need think only of Mid-Staffordshire in that context. It also suggests that regulators have an important part to play in improving data quality in the NHS. The noble Baroness, Lady Young, was very quick to dismiss this idea when we debated it in Grand Committee. I was suggesting then, if noble Lords remember, that the Care Quality Commission should be given the task of auditing the accuracy of a trust’s quality accounts. The noble Baroness did not like that idea at all—and I guess if she does not want to do it, it will not be done—but the suggestion that I made could be finessed if, instead of an audit role, we were to give the CQC the responsibility of assessing at the pre-registration stage how accurate and reliable an NHS body was in collating and analysing the data that it produced for its quality accounts. Competence in that area could be one of the standards that a trust had to meet before being allowed to operate. The amendment I have tabled makes this proposal, and I make it in all seriousness. The importance of data quality in the NHS has never been higher. Leaving aside quality accounts, we have to think only of payment by results and the tariff system. But, at the same time, the problems identified by the Audit Commission could be considerably ameliorated simply by involving and engaging clinicians in the whole process. Generally speaking, that does not happen at the moment because much of the data that are currently collected relate to targets and processes rather than to clinical practice or the quality of care. I am sure the Minister will agree that the closer involvement of clinicians is inherently more likely when quality accounts come on stream because clinicians have a direct interest in making sure that the facts are not misrepresented. At the same time, the commission’s report suggests that if a trust submits poor quality data, there need to be punitive consequences built in to the performance management process. So the answer lies in a top-down as well as a bottom-up series of initiatives. I hope that the Minister will think carefully about these suggestions. I put them forward in a genuinely constructive spirit, although I realise that I may be at risk of being shot down again by the noble Baroness, Lady Young, when she reads Hansard. I hope not. For now, I beg to move.