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Mr. McCabe: I made no reference at all to the Health Service Journal, but I did refer to the motion before the House, and to the fact that the Opposition spokesman referred only to the first four lines of it.
I want to turn to the second aspect of the debate, which is the effectiveness of indicators, the need for greater transparency and the question of whether the way in which trusts operate is distorted—a matter that the hon. Member for Tiverton and Honiton (Mrs. Browning) raised. I am not at all convinced that the indicators are ineffective. I would be the first to accept that they can always be improved, which probably explains why they have been revised at least three times already. As I understand it, acute trusts are currently using 44 indicators. Some 13 are the same as the originals, 23 are broadly similar and there are eight new ones. That has happened because in talking to the trusts and taking account of the other clinical governance exercises that have taken place, the Commission for Healthcare Audit and Inspection has been responding to demands for change. It has been told that some of the indicators are not particularly effective, are rather time-
consuming in terms of the way in which the data are processed, and do not deliver that much. As a result, it has been asked whether they can be got rid of or changed, and whether other factors that have not been taken into account could be included. That seems a sensible approach.I am constantly told that the indicators are useless, but it is important to bear in mind what young and adult in-patients say about the quality of care, the level of safety and the degree of co-ordination. Cancelled operations are a good indicator, and clinical negligence is another important factor that I would want to know about if I was going to a local hospital. The number of deaths following heart bypass operations might also offer a reasonably good clue as to how the hospital in question is performing. One might also want to take into account deaths following non-elective surgical procedures. Emergency readmissions following discharge are also worth knowing about, as are readmissions following discharge in respect of fractured hips.
Dr. Stoate: My hon. Friend makes a very important point. Opposition Members say that it is their policy to scrap star ratings, thereby denying us, presumably, the information that he has so eloquently given on these extremely important indicators. Such knowledge would certainly influence my choice of hospital if I needed an elective operation.
Mr. McCabe: My hon. Friend is absolutely right. I am not saying that the system is perfect. I have never heard a Minister say that it is perfect, and nor did the Secretary of State claim that today. What we are saying is that we have a method of measuring, and of giving trusts and the public an idea of what is happening. That is important.
Mrs. Browning: It is not possible to make a choice in respect of non-elective surgery, so what does someone do if they are in an ambulance following an accident and the hospital to which they are being taken for treatment is terrible?
Mr. McCabe: The hon. Lady knows as well as I do that, in that circumstance, the average individual would not be in much of a position to do anything. My point is that we have indicators that allow us to measure performance, and to try to drive it up.
Mr. Lansley : Will the hon. Gentleman give way?
Mr. McCabe: No, I have been very generous already.
Mr. McCabe: As it is the hon. Gentleman, I shall give way.
Mr. Lansley: The hon. Gentleman has indeed been generous, and I am grateful to him for giving way again. I want to correct what might otherwise be a misapprehension on his and his colleagues' part. He asks us to look at the motion, but if he does so he will see that its purpose is to stop "excessive reliance" on indicators, not to remove the information that patients
need. But star ratings are an essential part of that excessive reliance, and as my hon. Friend the Member for Tiverton and Honiton (Mrs. Browning) pointed out, they are part of a system of targets that leads to distortions.
Mr. McCabe: I am grateful for that intervention. If the Opposition spokesman had discussed the rest of the motion during his speech, rather than dwelling on the first four lines, perhaps we would not have needed that intervention.
The indicators are owned by CHAI, which reports to Parliament, so they are hardly open to manipulation by Ministers. And what of the effect on trusts? We are told that the indicators distort the allocation of resources and inhibit the independence of professionals and managers. I asked my local acute trust how it makes use of them, and whether they in fact constitute an onerous chore. It gave a couple of examples that are worth pointing out. It examined the time involved in accident and emergency situations, and concluded that it had to change some of the doctors' practices. For example, more weekend work for consultants was mentioned. That may be a real drag in terms of time spent on the golf course, but sometimes such changes have to be made. It also examined some of the cancer indicators, and although it measured some progress, it discovered specific areas in which there were capacity problems. As a result, it knows that spending must be skewed to address that issue. Frankly, cancer sufferers will be delighted, rather than saddened, to hear that. Funnily enough, the trust also noticed that it has to do better in respect of people's complaints, an issue to which the hon. Member for Tiverton and Honiton referred earlier. It wants to deal with complaints openly and transparently.
These indicators are not perfect, but they do give us and the public some indication of what is happening. In terms of their development, there is interaction between the trusts, the patients forums as they come on line, and CHAI. We also know that they are used in a practical way by good trusts that want to improve, in order to move matters forward. The choice is between sweeping that away or coming up with a credible alternative. When Opposition Members come up with a credible alternative, I shall listen to it seriously.
2.27 pm
Mr. Stephen Dorrell (Charnwood) (Con): I want to begin by making it clear that I am in favour of the principle that better management of the health service, better care for patients and better use of resources will be achieved if we require health service institutions to publish evidence of how they are performing against key performance indicators. I embrace that principle wholeheartedly, and for some fairly conventional reasons. I do not believe it right that this public service should be managed in secret, and that the people who pay for it and use it should be unaware of its performance. Nor do I believe that special rules in this respect apply to the clinical professions. In respect of NHS institutions, it is just as important that evidence of clinical performance be published, as well as non-clinical performance. It would be strange if I thought
any different, because as I said in an intervention on the Secretary of State, that was the route that we took when in government. It was my immediate predecessor as Secretary of State, my right hon. Friend for South-West Surrey (Virginia Bottomley), who introduced the principle. I developed it, and I share in the implied criticism offered by the current Secretary of State in respect of his predecessor, the right hon. Member for Holborn and St. Pancras (Mr. Dobson), in that the policy was not developed during the years immediately after our leaving office.It is not the principle of the Government's requirement that the NHS publish evidence of its performance that is wrong; what is wrong is the way in which the Government develop that principle in practice. I want to go through some of the reasons why the Secretary of State finds himself in such deep water as a result of the story published just before Christmas by the Health Service Journal. The story is powerful evidence that the Government are failing in practice to pursue the good principle that the NHS should be seen to be accountable. Why are they so failing? The first fact that anybody introducing performance indicators has to understand is that if they are going to influence performance in the hospital quoted by my hon. Friend the Member for Tiverton and Honiton (Mrs. Browning), for example, the indicators against which the institution is to be judged must have a broad measure of support within the institution itself, and within the wider health community. That does not mean that every single person working in the health service has to accept every single indicator, but it certainly means that we cannot be content with a position in which only 15 per cent. of primary care trusts believe that the star indicators published last year were fair. If only 15 per cent. of those people believe that the star system is fair, that is powerful evidence that the Government are failing to deliver their policies in practice.
Why is that the case? There are several reasons, some of which have already been mentioned, some of which have not. One that has already been referred to—and it is hugely important—is the point made by my hon. Friend the Member for Tiverton and Honiton that indicators must reflect the local circumstances of the community that the NHS trust seeks to serve. We have an absurdly over-centralised management system in the health service, when there should be much greater flexibility to allow local PCTs and the local community to set indicators that reflect the particular circumstances of the community that the institution seeks to serve. That is preferable to setting single blanket indicators that apply across the board—the one-size-fits-all approach, which does not work.
The second principle that the Government violate was made crystal clear in the Secretary of State's speech. His central defence to the charge that the South Durham NHS trust indicators had been fixed for political reasons was, "Oh no, they haven't." He reminded the House that the negotiation continued four months after the end of the period ostensibly being measured. He said that the negotiation in July determined the star ratings of NHS trusts during the period ending in the previous March.
It is a pretty basic rule of influencing performance by setting targets or measuring performance through indicators that the targets should be set at the beginning
of the period in which one is seeking to influence performance, which allows people to respond to the incentives. If the hospital in the constituency of my hon. Friend the Member for Tiverton and Honiton sets, as it should, key performance indicators at the beginning of the period specifying that trauma patients should be treated within an acceptably short period of time—the maximum in that hospital was probably 48 or 24 hours—there is some chance that the hospital will manage its affairs to meet the target. However, if the key performance indicators are decided four months after the period has ended, it invites all the criticisms to which the Secretary of State has been subjected as a result of the Health Service Journal story about the South Durham trust.The first principle is that the indicators should be more local and the second is that they should be clear and set before the period that they are designed to influence starts. The third, of course, is that the detail of the targets themselves should be seen to be fair and reasonable, and to reflect a reasonable interpretation of both the efficient use of resources and clinical priorities.
I cite one simple example from my own constituency in Leicestershire—the 12-hour trolley wait target for accident and emergency cases, which is wholly reasonable. I agree with the Government that people should not have to wait on trolleys for more than 12 hours in accident and emergency cases, but it is not surprising that Leicestershire acute hospitals trust finds it bizarre that a maximum of 10 patients in a year are being allowed to escape that target, because it applies as much to the neighbouring trust in Kettering, despite the fact that the Kettering trust treats only 20 per cent. of the the number of patients that are treated in the Leicestershire trust. One is therefore five times more likely to be caught in a 12-hour trolley wait in Kettering, which still achieves its target, than in the bigger trust in Leicestershire. That is an example of a target that is rightly viewed as bizarre in its effect. Targets must be local, clear and accepted as fair by those operating the system.
The Secretary of State is operating a system that does not obey the simple rules of setting targets of accountability in order to affect NHS performance. It is not surprising that he has been subject to the criticism that he is fixing the system to accommodate the South Durham trust. That trust provides a good political anecdote, but it is also an important example because it attracts attention to inadequacies in the accountability mechanism for the health service.
That example also illustrates a broader truth—this is my final point—that Whitehall hates accountability. When Ministers say to civil servants that it would be a good idea to set a series of indicators to judge the performance of a particular aspect of government in a clearly measurable way that is known in advance and makes the Government accountable to the public, the civil servant replies, in that hallowed phrase: "Minister, that is a brave policy, but it puts you at risk of an unhelpful statistic being published in the second week of an election campaign, and what would that do for your career?" What the civil servant really means in providing such paternal care for a Secretary of State's career is that it would not do much for his career as a civil servant if such a statistic were published in the second week of an election campaign.
The whole issue of targets needs to be addressed more seriously in order to ensure that we enforce proper accepted accountability in the health service and for public services more generally. Unless and until we do so, our taxpayers and service users will have to continue to accept second-rate service because none of us will be allowed to know any better.
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