House of Commons Hansard Debates for 14 Mar 1990

(b) promoting what appear to him to be desirable practices in the provision of goods or services under NHS contracts.

(6) In this section "health service body" and "NHS contract" have the same meanings as in section 4 of this Act.'.-- [Mr. Tom Clarke.] Brought up, and read the First time.

Madam Deputy Speaker : With this it will be convenient to take the following : New Clause 16-- Advisory Committee : supplementary powers --

( ).--(1) For the purpose of ensuring compliance with any regulation issued under subsection (Advisory Committee with respect to standards) (5) above, the chairman of the advisory committee may, at any time, cause an assessment to be made of the working practices of any hospital, establishment or other facility involved in the provision of goods or services under section 4 of this Act.

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(2) The results of any assessment carried out under subsection (1) above shall be reported to the Secretary of State by the chairman of the advisory committee.

(3) The chairman of the advisory committee may, with the approval of the Secretary of State as to the numbers and terms and conditions of service, appoint such staff as he may determine to fulfil the duties of the advisory committee under this Act.

(4) There shall be paid out of monies provided by Parliament the remuneration of, and any travelling or other allowances payable to the members of staff of the advisory committee in consequence of the provisions of this Act.'.

New clause 35-- Standards and inspection of community care services--

"(1) The Secretary of State shall establish a minimum standard for community care services which every individual may expect to receive.

(2) The Secretary of State shall ensure that there is an inspectorate that is sufficiently staffed to ensure that the minimum standards are adhered to by local authorities.

(3) In setting minimum standards under subsection 1 the Secretary of State shall consult those bodies he considers are representative of those who have the experience and knowledge of the provision and need for community care services.'.

New clause 38-- Standards and inspection of community care services (Scotland)--

"(1) The Secretary of State shall establish a minimum standard for community care services which every individual may expect to receive.

(2) The Secretary of State shall ensure the establishment of a Social Services Inspectorate sufficiently staffed to ensure that the minimum standards are adhered to by local authorities.

New Clause 45-- NHS Contracts--

(1) The acquirer of an NHS contract shall take into account not just price but a broad range of factors when considering which provider should be awarded the contract. This will include the quality of service provided taking into account both patient satisfaction and clinical effectiveness.

(2) The acquirer shall institute a thorough and ongoing monitoring of the contract as it progresses which shall be open to public inspection.

(3) A complaints procedure shall be instituted for both staff and patients with respect to the operation of the contract.'. New Clause 47-- Clinical Effectiveness --

The Secretary of State shall in pursuit of satisfactory systems of measuring clinical effectiveness and quality of treatments :-- (

(1) create an applied research agency for the NHS ;

(2) develop a clinical database to support the epidemiological research it will do ;

(3) with the data and methodoligies developed, introduce an ongoing monitoring and audit of clinical practice both to discover and disseminate best practice throughout the system.'.

We will also consider the following amendments : No. 228, in clause 3, page 3, line 11, at end insert--

1A. In carrying out its primary functions including those provided under Section 4 below, a Regional, District or Special Health Authority or a Family Health Services Authority must ensure that the quality of such goods or services that it may provide, attains such standards of quality as may be determined by the Secretary of State for those particular goods and services and must publish annually a report giving details of its attainments in monitoring and improving quality standards.'.

No. 15, in clause 4, page 4, line 36, at end insert--

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(3) No National Health Service contract shall be valid unless it specifies the quality of service to be provided under the contract and how the quality is to be measured and monitored.'.

No. 21, in page 4, line 36, at end add--

(3A) The acquirer will--

(a) publish the terms and conditions of any contract agreed with the provider ;

(b) institute a thorough and ongoing monitoring and quality assurance programme keeping the local CHC aware of developments ; (

No. 33, in page 4, line 36, at end insert--

(( )) The Secretary of State may by regulations, require any health service body acting as a provider to have regard to : (

(a) any relevant national codes of practice pertaining to any goods or services provided ;

(b) any specific outcome requirements established by him, both applicable generally and in relation to specific clinical conditions, or

in respect of any NHS contract to which the provider is a part.'. No. 4, in page 4, line 42, at end insert--

(3A) Where any health service body proposes to enter into an arrangement which will be an NHS contract in which it will be the acquirer within the meaning of subsection (1) above, it shall publish a document setting out the standards of goods and services which are proposed to be acquired under that arrangement.

(3B) Prior to making a decision about the standards of goods and services which are proposed to be acquired, a health service body shall seek the views of Community Health Councils within their district on the standards of goods and services, and shall also seek the views of such other persons as seem to them to have an interest in the matter or to be representative of the interest of patients in their district on the matter, and shall, in determining the standards of goods and services, take account of any views or representations received on the matter.'.

No. 5, in page 4, line 42, at end insert--

(3A) The Secretary of State shall by regulations specify, for each category of services, the standards of goods and services which shall be the minimum standards for goods and services which may be specified by any health service body which is an acquirer in the terms and conditions of any arrangements which is a National Health Service contract.'.

No. 57, in page 4, line 42, at end insert--

(3A) Any contract made under subsection (1) above shall provide that services supplied by NHS consultants shall be subject to the professional standards of care then in force under the regulations of the Royal College having jurisdiction for the place in which the contract is made.'.

No. 6, in page 5, line 33, at end insert--

(7A) The terms and conditions of any arrangement which is an NHS contract shall include a statement of the means by which the acquirer will satisfy himself, throughout the term of the arrangement, that the standards of goods and services provided under that arrangement are sufficient to meet the standards specified in the terms and conditions of the arrangement.

(7B) Where the terms and conditions of any arrangement which is an NHS contract include a statement referred to in subsection (7A), it shall be the duty of the provider under that arrangement to make available any facilities, information or services necessary to permit the acquirer to satisfy himself as subsection (7A) requires.'. No. 135, in clause 28, page 26, line 33, at end insert

(2A) No National Health Service contract shall be valid unless it specifies the quality of service to be provided under the contract and how the quality is to be measured and monitored.'.

No. 136, in page 26, line 38, at end insert--

(3A) The acquirer will--

(a) publish the terms and conditions of any contract agreed with the provider ;

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(b) institute a thorough and ongoing monitoring and quality assurance programme keeping the local CHC aware of developments ; (

No. 37, in page 27, line 22, at end insert--

( ) Where a reference is made to the Secretary of State under subsections (4) and (5), he or the person appointed by him, shall take into account the distance a patient would otherwise have to travel when determining what is "practicable" under subsection (5).' No. 45, in clause 5, page 6, line 42, at end insert--

( ) In exercising his powers under this Section, the Secretary of State shall have particular regard to ensuring that there exists a sufficient range and quality of services both in a local area and nationally to ensure that the functions of the National Health Service contained in the principal Act are carried out.'.

Mr. Tom Clarke (Monklands, West) : I beg to move, That the clause be read a Second time.

I shall refer to new clauses 15 and 16, and I hope that the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) will not mind if I say a few words about new clause 38. Hopefully, I shall not anticipate his speech too much.

Hon. Members who served on the Standing Committee will recall that in Committee my hon. Friend the Member for Leicester, East (Mr. Vaz) moved a similar amendment to establish a national inspectorate under the director of patient services. In his excellent speech to the Committee he explained that he had the support of several important bodies and people, including the Royal College of Nursing. At this time in the evening I do not wish to be provocative, so I hope that the Secretary of State will not mind if I mention one last opinion poll. The RCN conducted an opinion poll among Conservative Members. It discovered that 80 per cent. of Conservative Members support the setting of national standards and 70 per cent. support the establishment of a national inspectorate to monitor health care provision. Most people would welcome those views.

We are trying to find ways of ensuring that those views are recognised in the Bill, particularly in view of the clear support for them within the House and elsewhere. When the hon. Member for Ross, Cromarty and Skye speaks to the new clause he will probably broaden the arguments to deal with proper monitoring and inspection of community care in Scotland.

I remind the House that earlier this evening the hon. Member for Great Yarmouth (Mr. Carttiss)--I hope that I spare his blushes--made a thoughtful and courageous speech. He said that many issues which had not been resolved in Committee were meant to be debated on the Floor of the House. They will not be reached because of the guillotine motion. The issue dealt with by the new clause is just such an item. I was glad that the hon. Gentleman made that point and I sincerely welcome what he said.

In Committee, under pressure from my hon. Friend the Member for Leicester, East, the Under-Secretary of State for Health said : "The Government will reflect on how best to improve standards. We do not believe that it should be through a national inspectorate, or through a national accreditation scheme. However, there are ways to improve the service, for example by a national advisory committee. My right hon. and learned Friend the Secretary of State will reflect on and bring forward proposals for such improvement. The health advisory service advises on the quality of care provided to the mentally ill and the elderly. Its work with the mentally ill is

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under review. It could provide a useful model for advising DHAs, and hospitals with which they have contracts, about standards of care."--[ Official Report, Standing Committee E, 23 January 1990 ; c. 347.]

The Committee welcomed that in so far as it went and in anticipation of something more extensive--a bigger commitment--perhaps even a new clause or amendment on Report. So far as I can see, that has not happened. I hope that when the Secretary of State replies he will appreciate that in new clauses 15 and 16 we aim to respond to what we consider to be the Government's assurance to improve standards by enshrining the advisory committee in legislation. 11.15 pm

When the hon. Member for Ross, Cromarty and Skye dealt in his new clause with community care, many of us felt that he was absolutely right. That is why earlier this evening, in the debate on the guillotine motion, I was particularly surprised when the hon. Member for Lancashire, West (Mr. Hind), who unfortunately is not in his seat now but, in fairness, was here for most of the evening, said that the House had discussed Scotland. That comes as no surprise. Scotland is part of the United Kingdom. Scotland is dealt with in the Bill. Community care in Scotland is important. Frankly, we have not debated the matter enough. Therefore, I am pleased that community care in Scotland and the need for proper monitoring and inspections are dealt with in this group.

I hope that the importance of that is not lost on the House. Many people are convinced that community care in Scotland is not properly monitored. Moreover, it is difficult to do because of the present limited nature of joint planning, despite the legislative opportunities that the Secretary of State and the Under-Secretary of State for Scotland have not so far embraced or introduced. The new clauses would be an ideal opportunity for the Government to show their commitment to standard setting and improving quality within the NHS. New clause 15 would establish the advisory committee and give it the power to establish minimum standards of care. That is terribly important in the light of the evidence of the accident of geography, where in some areas standards are high, yet in others they are not only far too low, but entirely unacceptable for community care.

New clause 16 gives the committee supplementary powers to assess local working conditions to ensure minimum standards. The case for that is self- evident. It is self-evident that we are attempting, particularly in the absence of real advocacy, to ensure that basic standards are met and that there is accountability and proper monitoring. We have a great deal of support for that.

I referred earlier to the Royal College of Nursing. In its evidence to the Select Committee on Social Services, it said :

"Therefore, in order to ensure a high quality of standards of care, the College wishes to see an independent, nationally trained inspectorate working at local level to monitor the care that is delivered by the private, the voluntary and the public sectors. This would be an independent body which would maintain quality and which is neither purchaser nor provider. Precedents for this include the HMI in education and, more recently, the directors of consumer services established in the privatised water, gas, telecommunications and electricity industries to safeguard consumer interests and uphold standards."

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The very important point which emerges from that evidence is that we are dealing with consumers. The frail, the vulnerable, the elderly, the physically disabled, the mentally ill and the mentally handicapped are consumers. Unfortunately, because of the restrictions on our debate, we have not had many opportunities--we have had far too few--to discuss those groups in the context of community care. None the less, if there is a commitment to consumers, these new clauses give the Government an opportunity to go beyond mere words, to go beyond a mere oral assertion that they will issue circulars, and so on. We are offering them a statutory opportunity to do the minimum necessary to ensure that the standards of care that are insisted upon are proper and reasonable standards that can be monitored and for which there can be proper accountability.

The amount of money involved is considerable. There is much talk of value for money. We are entitled to an assurance that taxpayers' money is being spent in a way that is consistent with the principle of value for money as well as with the rights of the consumer. For all those reasons, I thought that the excellent case that my hon. Friend the Member for Leicester, East and others made in Committee would have persuaded Ministers to accept some reasonable proposals. Unfortunately, Ministers did not at that stage accept any of our amendments. I recall only one promise from the Parliamentary Under-Secretary of State for Scotland--the hon. Member for Stirling (Mr. Forsyth). That is a matter that we shall follow closely, but it is not particularly relevant to these new clauses. Beyond that promise we were offered not just very little but nothing at all, except, as in respect of so many other matters, the promise that, by the time of the Report stage, the Government would have taken advice, would have involved themselves in consultations, and might even surprise us by saying that they agreed to our modest proposals. In presenting these new clauses, we are giving the Secretary of State an opportunity--not just at the 11th hour but almost at the 12th--to show just a little generosity. Generosity is something that was absent from his dealings with the Committee and the House. In that spirit I commend the new clauses to the House. I look forward to hearing from the Secretary of State a response that is as positive as I am sure the House would want.

Mr. Tim Devlin (Stockton, South) : Amendment No. 57, which stands in my name, deals with two essential points--one is a general point and the other clears up an existing anomaly. Perhaps I should first declare an indirect interest in that my father is a member of the council of the Royal College of Surgeons and joint author of the "National Confidential Enquiry into Perioperative Deaths". I wish to refer to the monitoring role of the royal colleges of surgeons, anaesthetists, obstetricians, gynaecologists and others. It is right to ensure in any Bill of this kind that the services delivered to the public meet certain minimum quality criteria. That is the aim of my amendment.

I shall be interested in the response of my right hon. and learned Friend the Secretary of State to my point about the anomalous positions of the royal colleges of England and those of Scotland. The standard maintenance role of the royal colleges of England is being upset by that of the colleges of Edinburgh and Glasgow. This is a particular difficulty. A member of the Royal College of Surgeons of

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England who practises in Scotland is not subject to the authority of the Royal College of Surgeons of Edinburgh or Glasgow. Because he is beyond the territorial jurisdiction of the English college, he cannot be monitored from there either.

Similarly, a small number of Scottish practitioners who practise south of the border are beyond the geographical jurisdiction of the Scottish colleges, yet when they are monitored by the English colleges they say that they are members of the Scottish college and therefore do not wish to submit to the jurisdiction of an English college.

This is a small, but important, point. If we want a system in which there is professional peer group pressure to improve standards of health care, that pressure must be exercised through the appropriate royal college. That does not happen with those two minority groups.

Sir George Young (Ealing, Acton) : The new clauses and the amendments have the same objective, but they would achieve it in different ways. Amendments. Nos. 4, 5 and 6, which stand in my name, are slightly less bureaucratic than new clause 15 in that they avoid setting up an advisory committee, but their objectives are the same--to use the new regime to drive up standards, to improve the quality of services and to increase confidence in the NHS. Amendment No. 4 provides the machinery for delivering those objectives--machinery which is not explicit in the Bill. It would require that, for any NHS contract, the acquiring body should consult on the standards of service to be provided under the contract. There needs to be a mechanism for ensuring in each case that the quality of service that patients can expect is understood publicly and that there is a quality yardstick by which a contractor can be assessed. Patients and the organisations which represent their interests have the right to know what they can expect from a contractor in the Health Service. The amendment provides such a mechanism. It would require that the quality standards are consulted upon and made public.

Amendment No. 5 clarifies the regulatory responsibility of the Secretary of State in relation to standards of health care. Where resources are limited, as they always will be, there may be a temptation for a hard-pressed Health Service body to cut corners on standards. Some health authorities and budget-holding general practitioners may therefore be tempted, when entering into contracts for the provision of care, not to specify adequate standards from their contractors. The amendment would limit this temptation by giving to the Secretary of State the role of setting for each category of service minima below which the quality of health care should not fall. At the moment, the Department provides a substantial amount of material regulating the standards of provision, and the amendment simply makes that explicit.

Amendment No. 6 deals with monitoring. The working of contracts for health care should be closely monitored to ensure that contractors meet the standards expected of them and that the terms of the contract are met. The amendment would require that the means by which monitoring and evaluation of quality of care provided under contracts should be set out in the contracts and would require contractors, by statutory duty, to co-operate with monitoring and evaluation procedures. That would help patients to feel secure, in that a system of

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monitoring and enforcement would guarantee that high standards are maintained and ensure the full co-operation of contractors. The three amendments are fully consistent with the objectives in the White Paper. They simply seek to write into the Bill a procedure for guaranteeing the high quality of service that we all want to see.

11.30 pm

Mr. Kennedy : New clauses 35 and 38, to which the hon. Member for Monklands, West (Mr. Clarke) was kind enough to refer in his opening remarks, are partly based on the learning curve of the hon. Member for Glasgow, Cathcart (Mr. Maxton) in Committee. They refer to standards of inspection of community care services in Scotland, England and Wales, and take account of the slight differences in the role or existence of the inspectorates in each.

Despite earlier exchanges in Committee, there remains considerable doubt that the Bill's objectives in respect of community care will be fully realised. The Secretary of State might have acknowledged in our earlier debate on the timetable motion that it is regrettable that the House cannot devote more time to important aspects of the Bill. However, I suspect that new clause 15 and other parts of the Bill will have much more of an uphill struggle when they reach the other place, and I shall be watching its progress--and, hopefully, the alterations that are made to it--very closely.

The Bill makes welcome provision for local authorities to publish plans for community care, but there is no proper agreement on a mechanism to ensure that minimum standards are met, and therefore there is nothing positive or indicative for which inspectors can look.

If one considers the education system, it should not be so great a problem as is feared in the minds of Ministers or civil servants at the Department of Health. The education system proves that it is possible to set minimum standards and to operate an inspectorate without necessarily imposing too much centralisation or inhibiting scope for personal initiative and development.

One must question how community care plans will be properly assessed in the absence of minimum standards--particularly as it is more than likely under present budgetary constraints that there will be disagreements between the health authority or health board and the local authority.

The Secretary of State repeated earlier today that heavy reliance is being placed on contract setting to ensure quality of service. The right hon. and learned Gentleman spoke of competition in the hospital sector being based on quality. The same applies to the care in the community approach. The quality control aspects of a contract, whether it concerns health or community care, are currently minimal and are unlikely to provide an adequate safeguard, at least in the short term.

The guidance issued since the Committee stage is encouraging. The word "quality" is used in the very first sentence and recurs throughout. Ministers appear to have become more sensitive to that aspect than they were earlier. Nevertheless, there remains genuine anxiety that minimum standards will be fastened upon by the providers and contractors of care rather than serve as a starting point.

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My final point concerns the social services inspectorate. Exchanges between the Minister for Health and me in Committee revealed that in the past few years the number of inspectors in England and Wales has doubled. That is welcome, and it will probably increase further if the Minister is successful in realising her ambition to extend the scope and the role of the inspectorate. However, such a major and fundamental change as the community care aspect of the Bill surely contains scope for a further inspectorate. In Scotland, the need for minimum standards still exist, but the establishment of a proper inspectorate is crucial.

I am indebted to the Royal College of Nursing for its assistance with amendment No. 33. The amendment aims to give the Secretary of State a reserve power to establish a series of minimum standards of care which health care providers would have to observe. In effect, it would establish a safety net for quality in future. There is no time to go into the details of the argument behind the amendment, but perhaps in the short time available I should commend back to the Secretary of State his own words on 10 October 1989 at that marvellous occasion, the Conservative party conference. The Secretary of State referred to the two prime problems which arise if all decisions about acceptable standards are left to individual contracts : first, will the purchaser be in a strong enough position to face a monopoly provider and, secondly, will minimum standards vary significantly throughout the country from Plymouth to Inverness? In his speech at the conference, the Secretary of State listed a catalogue of inexplicable anomalies between districts and regions and concluded :

"These failings are not fair to the patients when the treatment you receive (and the delay you experience) depends entirely on the luck of the draw. Above all, on where in the country you live and whether you have an illness which is well-treated locally or not." Amendment No. 33 aims to provide a permissive regulatory framework for the Secretary of State to be able to exercise the power to address precisely the problem that he highlighted on that occasion. �Amendment No. 37 expresses the concern that hospitals, particularly in rural areas, will be in a monopoly position under contracts because they are the only providers of a service in that region. What effects will there be on people having to travel, as that clearly will be a logical component of the internal market, and on the fact that the Secretary of State will view a local monopoly in an entirely different way from patients because many patients in rural areas have to travel significant distances to receive treatment? [Interruption.] If the hon. Member for Wirral, South (Mr. Porter) finds this boring, I am sure that he can find entertainment elsewhere. Perhaps these are rough and ready arguments because those of us who served on the Committee did not pursue many of the points as we had hoped for a proper debate.

Amendment No. 45 embodies the plea that

"the Secretary of State shall have particular regard to ensuring that there exists a sufficient range and quality of services both in a local area and nationally to ensure that the functions of the National Health Service contained in the principal Act are carried out."

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There is genuine anxiety about the future of the service because of the step into the unknown that the Bill represents. Even at this late stage the Secretary of State has a chance to offer some reassurance.

Mr. Michael Morris : I am happy to associate myself with amendments Nos. 5 and 6, in the name of my hon. Friend the Member for Ealing, Acton (Sir G. Young), and I hope that they will appeal to my right hon. and learned Friend the Secretary of State. If we are not talking about medical audit, we are talking about performance review. There is a great deal of experience of performance review among professional organisations across the Atlantic and I had hoped that we might learn from that experience.

Certain questions need to be asked. Was the operation necessary in the first place? Was it correctly undertaken? What is the rate of readmission and cross-infection? What was the cost of performing the operation, and was the patient satisfied? Certain initiatives can be taken to guard against inappropriate surgery, unnecessary blood transfusions and the unco- ordinated treatment of intensive care patients. The amendments address the question of who is to check the quality of care. Every other industry in the country has quality control, and I cannot believe that it is right that the NHS should not. That is why I support the amendments.

Mrs. Maria Fyfe (Glasgow, Maryhill) : I support the proposals of the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy). I am sure that we can all agree that it ought to be perfectly possible to set minimum standards and to have inspectorates to ensure that they are achieved. The hon. Gentleman cited the example of schools, for which we have minimum standards, and inspectors to ensure that they are met. An even more useful example, perhaps, is the example of the factory inspectorate, which ensures that the conditions in which people work are adequate.

Similarly, we should want to ensure that a large number of criteria are satisfied in relation to the suitability of the conditions in which old people are looked after in small premises. I have been shocked by some of the cases of which I have heard in the course of my constituency work and by the conditions in which some old people have been made to live.

There is also the question of the charge made for services. I heard of one old lady who was persuaded to leave the home in which she was living to go into a private house where her rent was doubled after two months. That old person felt vulnerable and unable to do much about her plight. The attitude seems to be that the Department of Social Services will pick up the tab, and that it does not matter if the public purse is robbed to pay people to provide the services. There is also a danger to old people's privacy. Some people seem to view old people as having lost all right to be treated as thinking and sentient human beings. They open their mail, listen to their telephone conversations and generally engage in a lot of unwarranted interference that would not be tolerated by someone who was capable of defending himself. But many old people are powerless unless they have a relative to stand up for them.

What about the items that are provided for old people? In one case, for example, a person who was virtually immobile was given only a commode and felt extremely embarrassed and ill at ease. That person could no longer

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