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Mr. Lansley: Let me develop my point for a moment.
I am not saying that every national service framework should be set out as a series of milestones and targets because the Minister would say that that was inconsistent with the way in which we wish to reform the national health service. However, we must be clear about what constitutes evidence-based clinical standards that represent cost-effective interventions for the NHS that could be achieved quickly—not necessarily in 2014—because that would be in the interests of children, patients and the service. The problem with the NSF is that it does not differentiate between clinical standards for the NHS that must be achieved and developmental or aspirational objectives and service standards, which would properly be the preserve of performance management, and thus objectives to which individual institutions and health bodies would respond depending on the commissioning decisions that were taken.
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Dr. Ladyman: I just wanted to correct the hon. Gentleman. He said that I said that the framework would be implemented in 2014, but I said that it would be implemented by 2014.
Mr. Lansley: I am sure that the record will show that the Minister indeed said "by 2014", but he did that in the context of saying that the framework did not contain milestones and targets. If the implementation has not occurred by 2014, that will happen in 2014—that is effectively the structure about which we are talking.
Dr. Ladyman: I was trying to make the point that we are not prescribing a specific pattern of implementation for the NSF because that will be decided locally. However, when the Healthcare Commission carries out inspections now, I would expect it to inspect service against the NSF standard. If it finds services that do not meet the standard, it should at least ensure that there is an understanding of when that will happen. Every area should have a plan in place that shows a clear progression from its current position to where it will need to be by 2014.
Mr. Lansley: I understand that because the Minister is reflecting accurately what is set out in the Government's health and social care standards and planning framework, which says that NSFs will be a basis on which the NHS and local authorities will need to demonstrate that they are making process. However, it does not specify the extent to which progress must be made on specific areas. There is an important difference between the elements of the NSF on services that should be subject to local discretion and developed in response to patient choice, general practitioners exercising their commissioning role, commissioning bodies or the commissioning functions of children's trusts as they become established, and those elements that should be part of a system of clinical standards. If an evidence base exists to support such clinical standards, they should be set out clearly in such a way that the NHS responds to them directly.
Let me give the Minister an example. The maternity services section of the NSF refers to caesarean sections requiring a consultant's clinical judgment. It says that they should be approved only if there would be clinical benefit for either the child or the mother. That recommendation resulted from a National Institute for Clinical Excellence investigation into when caesarean sections should occur that took account of an evidence base and cost-effectiveness. The fact that NICE undertook such an investigation means that there is a finding to which the NHS should respond now. There is not a sense that we should be doing that in 10 years' time. The distinction I am trying to make is that we should not disparage the job of NSFs, because they encompass the whole service, but identify within them clinical standards that should be the subject of action within the NHS to deliver better services now. There will be specific instances of improved quality, of understanding where the NHS's proper limits of service lie and of understanding where efficiencies can be gained and services can be reconfigured for the benefit of patients. I hope that the Minister accepts my case, at least in theory.
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Questions need to be asked about implementation. Hon. Members will know that it is not simply a matter of resources, although they are important. Resources often mean human resources, such as the number of consultant specialists. To illustrate the case, Professor Aynsley-Green has said more than once that there is only one consultant specialist in adolescent medicine. What does that tell us about the availability of service? I do not know how many consultant specialists there are in adolescent medicine now; perhaps the Minister can tell us. How many trainees are in paediatric orthopaedics? Someone told me the other day that there is only one, although I cannot say whether he was right. We need to deal with those human resource implications.
As for maternity services, it is entirely right to offer mothers a choice. That can be in the form of midwife-led units. I know, however, that Addenbrooke's cannot because it is unable to recruit enough midwives. There should also be a home-birth service. I met staff in Brecon who were offering one of the leading home-birth services in the country. Peterborough, however, did not have the midwives available to provide a home-birth service. The maternity service framework highlights the desirability—I think it is virtually a must do—of 100 per cent. midwife attention to a mother during the course of her labour. The shortage of midwives means that in some places they have to look after two mothers at the same time, so they are not getting 100 per cent. attention. The increase in the number of midwives over the past seven years in wholetime equivalent numbers is fractional and in three regions there has been a reduction.
It is right to want to know the standards for which we are aiming, and maternity services allow us to see what we want to achieve, and what quality we want to have, in a straightforward way. For years the focus of public and political debate has been on specific deficiencies—in particular the length of time that people are on waiting lists—in hospital services and the NHS in particular. By and large, that has not been the issue for children's services. Instead of remedying specific deficiencies of that kind, we need to raise the general quality of services for children. That is a more diffuse but arguably more logical way of approaching the development of NHS services.
The shape of services needs to be decided in a number of ways, but different bodies will take responsibility for that. The Minister did not touch on that, but I would be interested to hear his views, and those of other hon. Members, on it. We have managed local children's clinical networks, which are reflected in the framework, and I am attracted to a model in which those clinical frameworks emerge from combinations of clinicians and professionals, but how will that interconnect with children's trusts? They were at the core of the Government's response to Herbert Laming's report. However, they are still in the pilot stage, and most of those differ substantially from each other.
The process of trying to establish a model from the pilots is clearly not under way. It may be entirely proper to allow local authorities, health service bodies and others to work together to establish the responsibilities of a children's trust. However, the health service must
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ensure that clinical networks are not squeezed out by the statutory formation of children's trusts. How will trusts interact with the Government extension of Sure Start and Sure Start plus? Initially, there will be 800 children's centres, but how will they relate to children's trusts? Those organisational matters are not necessarily reconciled in the national service framework. Organisational change of this kind often has an adverse impact on efforts to establish a clear framework of standards, for which someone is directly responsible.
Dr. Tonge: Does the hon. Gentleman not agree that the success of networks and liaison between different groups and trusts comes down to resources? I have worked in this field, and unless there are enough people who can spare the time outside their normal duties to undertake liaison and other necessary tasks a proper service is never established. The hon. Gentleman said that it was not just about resources, but in the end it is about having enough well-trained and well-paid staff with the time to do all the things that we want them to do.
Mr. Lansley: I am not sure that I agree with the hon. Lady. Of course, it is difficult to construct clinical networks in services that are so hard-pressed that people have no spare time at all. One can hardly say that staff working in coronary disease and cancer services are free of pressure. None the less, in my experience, they think it worth while to get together and create clinical networks in their specialisms.
Dr. Tonge: They are the glamorous ones.
Mr. Lansley: I do not think that they got together to create clinical networks because they thought that it was a glamorous thing to do. They did so, because they thought that they would be able to influence a process for which, I accept, additional resources are available. They would be frustrated if they tried to develop services and assign bottom-up rather than top-down priorities in circumstances where there was no room for growth. We are committed to increase health service expenditure, as well as the number of people who work in the NHS and the resources that they deploy. Children's services should certainly receive their share of those increases, so people who work in them have an incentive to develop clinical networks, and we hope that they will do so.
Finally, as the Minister may have learned from my intervention following that of the hon. Member for Bury, North (Mr. Chaytor), I am concerned about the implementation of recommendations in Sir Ian Kennedy's report on Bristol royal infirmary. I have said in previous debates, including my Adjournment debate on children's health and social services in Westminster Hall on 10 June—the last time that we debated these matters—that I was concerned that various recommendations on the configuration of acute services have not been followed up. Sir Ian says in recommendation 178:
"Children's acute hospital services should ideally be located in a children's hospitals, which should be physically as close as possible to an acute general hospital. This should be the preferred model for the future."
He went on to recommend piloting a system in which children's hospitals took over the running of children's acute and community services through a specific
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geographical area, which is effectively an outreach service based on the example of the Philadelphia children's hospital, and that specialist services should be organised so as to provide best available staff and facilities. That obviously has serious implications—with which some areas are wrestling—for the continuation of paediatric services in some hospitals.
From what the Minister said it seems, as I feared when we had a debate back in June, that the Government have abandoned the recommendations made by Sir Ian Kennedy in his report. They do not intend to address the issue of whether specialist services for children should be concentrated to ensure that there are all the necessary support facilities, and that the throughput of activity is sufficiently great to ensure that the specialisation is sound and continues to meet high standards.
The particular illustration of that was the subsequent review of paediatric congenital cardiac services, which reported to Ministers. The Minister suggested today that in these matters the Government are guided by external advice. The advice of that review was straightforward: that there should be a process whereby the number of hospitals providing paediatric congenital cardiac services should be reduced over time. Ministers said there was no evidence that current services were delivering poor clinical practice, so they did not propose to do anything about them.
That was an "It's all right at the moment" approach, as opposed to adopting an approach recommended after the Bristol royal infirmary tragedies, to try and ensure that in the future we concentrate services, if necessary, in a way that provides the maximum opportunity to raise or validate standards.
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