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I should be very disappointed if it were felt that this Bill or the role of the care quality commission itself was a sufficient response to the demands of tackling infection control. We debated this issue last week, so I will not travel down all the paths associated with it, but it is clear that on the Maidstone and Tunbridge Wells NHS Trust, for example, the Secretary of State is hiding behind the Healthcare Commission as though it were not an inspectorate coming in to establish to what extent a body is failing in its duty to provide care; instead, he seems to be regarding it as a performance management organisation. However, it is not; as things stand, it is the strategic health authority’s responsibility to manage the performance of the Maidstone and Tunbridge Wells trust, and the Department of Health has line management responsibility for the performance
of the SHA. However, given the events surrounding the trust, it looks to me as though performance management was ignored.
The Secretary of State talked about world-class commissioning. However, the primary care trust clearly subcontracted its responsibility for infection control and quality to the health protection unit. Effectively, the PCT played no role in determining the quality of the services being provided to patients at Maidstone and Tunbridge Wells. Likewise, the SHA subcontracted its responsibility to the health protection unit, which did not get involved until an outbreak had been notified. Even then, it did not have the necessary powers. So the Secretary of State needs to think hard, and we should think hard, not only about how we strengthen the role of an inspectorate in assessing from the outside where things are going wrong, but about ensuring that performance management works more effectively inside the national health service, because at the moment, it clearly does not.
Rob Marris: I take the hon. Gentleman’s point, but may I also suggest that he think hard, as many of us do, about trying to strike the right balance between decentralisation and local control, and national priorities for a national health service? Both our parties struggle with that.
An example of that balance can be seen with hospital-acquired infections. If asked, people say that they want local control of their health facilities. They say that until something goes wrong or until they perceive a disparity of provision, which is sometimes called a postcode lottery. They then say, “We are worse off than the people next door” and they ask why somebody, usually Whitehall or the Government, does not sort it out. Hard thinking is required to strike that balance, and the Conservative party needs to do some of that.
Mr. Lansley: We have done quite a lot of hard thinking about this matter. I do not know whether the hon. Gentleman has had occasion to read the autonomy and accountability white paper that we published in May, but it expressly addresses these issues. For example, it makes it clear that the independent allocation of resources to try to achieve greater equivalence in access to health care across the country relative to the burden of disease is important. Figures that I published yesterday demonstrating the wide disparities across the country in expenditure per cancer patient are largely associated with that. Even if one were to equalise the allocation of resources relative to the burden of disease, it would not mean that the same amount would be spent, because different parts of the country would have different priorities. I do not believe that we could ever reach the point where the centre could mandate how much is spent, but a nationally funded national health service should have a national allocation system that is at least geared towards providing equivalent access to health care services for people in the same circumstances.
We can also be clear that commissioning guidelines and standards can be established nationally, which is why the Bill reproduces existing legislation. Standards should be set nationally, and the care quality commission, whose task is to assess performance against those standards and provide information on that, should be in place. I
do not know what the Government’s view is for the future, but I think that the role of patient choice and decentralised commissioning then becomes all the more effective, because performance against those national standards can be taken into account and can help to drive the local response in terms of what is being delivered. That is our view, but heaven only knows where the Government stand on patient choice.
Rob Marris: I thank the hon. Gentleman for that thoughtful response. I have not read every word of that shadow white paper, and he will correct me if I am wrong about this next point. I recall that after its publication in May the Conservative party proposed a policy of increased localism—I use that term in a broad sense—and at the same time called for a national moratorium on any proposals to close an accident and emergency hospital unit in England. That gets the balance a bit wrong; I am not saying that the Government necessarily have that balance right, but that is why I was politely suggesting that he should think a little harder about this balance between localism and centralism.
Mr. Lansley: The hon. Gentleman is, in a sense, misdirecting himself, because a moratorium is just that—it stops a process that is under way.
Rob Marris: It is a local process.
Mr. Lansley: No, it is not a local process. This is why the hon. Gentleman is misdirecting himself. Our proposal to impose a moratorium on what is happening is us saying that we will not countenance—or would not have countenanced had we taken office following an election—a process whereby national clinical directors and Ministers in the Department of Health wander around telling people what they should be doing. They should be going to places such as the constituency of my hon. Friend the Member for Worthing, West (Peter Bottomley), where the national clinical director is saying to people that there has to be a drainage population of 400,000 plus in order to provide an accident and emergency service. That is clearly not justified by the evidence. Subsequent material, such as the report published by the Academy of Medical Royal Colleges, makes it perfectly clear that accident and emergency departments serving smaller populations are entirely viable.
What I am saying is entirely consistent, because I believe that the clinical evidence and the decision making should combine locally. The clinical evidence will not all be derived locally, and indeed much of it will be prepared by the professions nationally, but it has to be interpreted into local circumstances and be the product of local decisions. Under this Government, it is not the product of local decisions but of national influence and determinations from the centre.
Peter Bottomley:
I am grateful for my hon. Friend’s reference to the situation at Worthing and Southlands hospital. I think that the primary care trust will now have another serious look at the issue, and I am grateful to the Secretary of State if he was quietly involved in that, as I suspect he was. I put it to my hon. Friend that it is wrong for national standards to come
from papers written by tsars that are not peer-reviewed, contain no evidence and are, in effect, a series of anecdotes.
Mr. Lansley: I agree, and that is at the heart of the issue that we have presented. It is unacceptable for local managers to receive documents from the Department of Health that are not evidence-based or peer-reviewed, and are inconsistent with the professions’ collective view. Such documents are presented as though they are clinically driven and have to be translated locally, just because they are written by someone who happens to work in the Department. That is not acceptable.
Alan Johnson: I would be interested to know exactly which part of Roger Boyle’s document the hon. Gentleman disagrees with.
Mr. Lansley: I was talking about accident and emergency departments, so I meant George Alberti’s document. However, the same point can be made about Roger Boyle’s document. He presented an argument about the need to centralise stroke services, but—as the Secretary of State knows—there is no model for doing so. There is no basis for knowing what the necessary catchment population should be, for either acute care of stroke or the concentration of services for primary angioplasty. The pilot studies on primary angioplasty have not reported, been peer reviewed or provided evidence. But Roger Boyle produces his document, and the Prime Minister and others stand at the Dispatch Box and say that services must be centralised on that basis. That is why we propose a moratorium: so that such issues—the design of stroke services or cardiac interventions based on evidence—can be structured locally on the basis of evidence, rather than assertions from the Department of Health.
I shall now return to the subject of the Bill, Mr. Deputy Speaker. The House will recall the passage of the Mental Health Act 2007, and it is extraordinarily important that the introduction of community treatment orders—and the extent of compulsion under them—is the subject of independent scrutiny. That will be the role of the Mental Health Act Commission, and I hope that it will be made clear during the passage of this Bill that that should happen.
When the Minister of State winds up, I hope that he will tell us when we may expect the proposed section 60 order on the governance of the General Medical Council, because it would be helpful to consider that alongside the broader proposals to shift towards parity in lay and professional participation. The Secretary of State will know that we have accepted some of the principles. We accept the principle of parity, but we do so in the context of helping to support confidence in professional self-regulation, not helping to undermine it. I hope that during the passage of the Bill we will explore carefully the proper role of the office of the health professions adjudicator and why it has to be operated independently from the GMC. If we believe in professional self-regulation, we should be able to structure the regulation in a way that keeps the functions of investigation and adjudication within one body, even if they are functionally separate.
The Department appears to assume that responsible officers will be in place in April 2009, but that is a heroic assumption. For a start, I am not sure that it is right to assume that in most cases the medical directors of primary care trusts should be the responsible officers.
Mr. Lansley: I believe so. I understand that the date is April 2009, but if I am wrong the Minister will let us know. I think the time scale is too rapid—it is a heroic assumption.
Should a responsible officer combine clinical governance responsibility with the assumption of part of the management responsibility? Let us consider that point in the context of primary care. If GPs as contracting providers have a developing relationship with the primary care trust, is it necessarily right that the responsible officer as a member of the PCT board should also have responsibility for their clinical governance arrangements? I have no doubt that clinical governance should be improved and strengthened, even more so in primary care than in secondary care, but we must do that in a way that commands the greatest possible confidence among the professions. It is important that clinical governance be conducted by somebody who has only that responsibility, with no risk of conflict of interest with other responsibilities.
I repeat my question about the scrutiny process of the professional practice of doctors. On the one hand a revalidation structure is being set up; on the other, where there is the possibility of serious failings there are fitness to practise investigations and, in the middle, there is the question of what happens when someone has difficulties in their professional practice that are not such as would give rise to an investigation by the GMC. Such cases are pursued by the National Clinical Assessment Authority, alongside the National Patient Safety Agency. I have never understood why. If there is a spectrum of issues relating to professional practice, from making sure that people are up to date to the correction of serious problems, one body should be responsible for all of them.
On standard of proof, the Opposition Front-Bench team have made it clear that we accept in principle that we should move from a criminal to a civil standard. The medical profession is concerned that the loss of livelihood of its members would be accomplished on the basis of a more-likely-than-not calculation and, it would argue, on evidence that might not substantiate the loss of livelihood and its resulting impact on the individual. I do not think the profession is right about that; it is important to recognise that in practice a graduated scale is applied by tribunals, and courts, even with a civil standard of proof, which relates the nature of the evidential test—the quality of the evidence provided—to the penalty that would eventuate from the conclusion that somebody was guilty of an offence.
We need to make it clear in the legislation that that is the case, to try to set minds at rest, and that it is true, as my hon. Friend the Member for Worthing, West in effect said in his intervention on the Secretary of State, that when a court is presented with the proposition that somebody will lose their livelihood—which is very significant for doctors, as they may not easily be able to
pursue another career—there must be almost a criminal standard of proof before that result is achieved. I think that that is pretty much what the court was saying—so there is a precedent for saying that the civil standard of proof must be applied in a way that is sensitive to the nature of both the allegations and the evidence. As we incorporate that provision in the statute, we must attempt to give the medical profession that assurance.
Dr. Howard Stoate (Dartford) (Lab): The hon. Gentleman is making a balanced argument, but if we use the civil standard of proof how will he ensure that we word legislation that allows us to slide up the scale towards the criminal standard for some offences and not for others? How can we make that clear without it leading to more and more legislation as people take tribunals or the GMC to court because they did not get the answer they wanted?
Mr. Lansley: The hon. Gentleman’s expertise is medical, not legal, but those who write the legislation will have to try to ensure that the guidelines are at least very clear. We will have to see to what extent they can be incorporated directly into the primary legislation and in the schedules to it, but I am sure that the House will have noted his declaration of interest in these matters—or not.
I will not delay the House on the part of the Bill dealing with public health. On the face of it, the updating is pretty straightforward. The powers requiring people to be quarantined or to submit to medical examination if they are infectious have been extended quite a long way, so we need to ensure that the safeguards exist. I have no doubt that there should be such powers but, taking the wider view, I just wish that we also had public health legislation that helped to achieve the things that we have proposed to create a much stronger separately funded public health service that works with local authorities to deliver better on our public health objectives.
The Secretary of State will know that only a third of the dedicated public budget of £300 million that the Government have allocated since the White Paper “Choosing Health: Making healthy choices easier” has been spent on public health objectives. He will also recall that Ara Darzi’s document on “A Framework for Action” in London expressly sets out the fact that primary care trusts spend on public health in inverse relation to their deprivation. For example, Tower Hamlets, which is one of the most deprived areas in London, spends £6 a year on preventive health spending.
Mr. Lansley: I beg the hon. Gentleman’s pardon. Tower Hamlets spends £6 per head, whereas the Bromley primary care trust, which is not among the most deprived, spends £33 per head per year on its preventive spend. Frankly, that is an outrage.
The Secretary of State did not dwell at length on the issue of health in pregnancy. My hon. Friend the Member for Eddisbury (Mr. O'Brien) has reminded me that I am taking up some time, but I will talk about more things than the Secretary of State mentioned; we need to mention some things that he did not. The health in pregnancy grant was announced in the 2006 pre-Budget report as something that would merely
bring forward child benefit payments to pregnancy, but it now has a slightly different character. It is not designed in precisely the same way.
I have two questions about the grant. Is it to be administered entirely by Her Majesty’s Revenue and Customs and will it be paid for by the Treasury directly? I will not dwell on HMRC’s administrative potential and the nature of the data that will have to be supplied, when they will be supplied, by whom they will be supplied and to whom HMRC may supply them. The House needs an answer because there is no impact assessment to tell us not only what the overall costs will be but who will pay the cost of implementation of £8.4 million in the next financial year.
The Secretary of State seems to think that the health in pregnancy grant is the best way of spending the relatively large sum of £175 million a year to support nutrition in pregnancy. May I direct him to the draft guidance from the National Institute for Health and Clinical Excellence that was published just a couple of months ago? Paragraph 3.5 says:
“Interventions which ensure that a woman is nutritionally equipped for pregnancy are likely to have the greatest effect if delivered before conception and during the first 12 weeks”.
Later the guidance considers the gaps in the evidence and says:
“There is a lack of well-designed interventions on how to...improve the nutritional status of women before and during pregnancy”.
“There is a lack of well-designed studies that have evaluated the use of food vouchers to encourage health eating.”
Let us leave aside the simple fact that the grant may be spent by pregnant women on things other than what is necessary for their diet. The guidance also gives rise to the question as to whether this is a well-calculated and evidence-based intervention even in terms of improving diet.
That brings us to question of weighing and measuring children. It has always been our argument that not only should children be weighed and measured, but there should be an effective follow-up. I see nothing yet in the Bill—perhaps the Secretary of State will add more in terms of policy—about an adequate follow-up. The report from the National Institute for Health and Clinical Excellence clearly shows that universal interventions by midwives, health visitors and school nurses are critical. However, what is the actual situation? Let us consider health visitors. In 2004 there were 10,137 full-time equivalent health visitors. By 2006, that figure had reduced to 9,376. It is clearly not possible for us to deliver the kind of improvements in childhood obesity that we want to see, when the number of health visitors is declining.
Let us consider what the Government have said about school nurses. The then Minister of State said in March 2006:
“Because we know school nurses make such a difference, we want at least one, full-time qualified nurse working with every cluster of primary schools and their related secondary school by 2010.”
There are 3,343 secondary schools in England. According to the Minister of State, Department of Health, the hon. Member for Exeter (Mr. Bradshaw) on 23 October this year, there were 815 full-time equivalent nurses with the
appropriate nursing qualification working in England. So we are nearly 2,500 short of what is required by— [ Interruption. ] The hon. Member for Wolverhampton, South-West says from a sedentary position, “Cluster.” There are 3,343 secondary schools. The policy is for one full-time qualified school nurse per secondary school and its cluster of primary schools. I am using the number of secondary schools, so the comparison is entirely valid.
On the social enterprise investment fund, I welcome what the Government are proposing, and the benefit of that. We already know the potential impact of social enterprise in the health care sphere, if only by reference to what hospices do for palliative and end-of-life care. In that context, it is astonishing that the Government are going down this path without at least ensuring that they have provided, through the publication of the end-of-life care strategy and the development of the tariff for palliative care, a full cost-recovery structure for hospices, if they wish to take it up, for the delivery of end-of-life and palliative services. Hospices are social enterprises that do a remarkable amount, and they should at least have the option—even if they are not required to do this—of providing services to the NHS in a fully supported way.
The Government propose, under clause 134, to extend direct payments. We have always welcomed that. Some Members will recall that when the “Our health, our care, our say” White Paper was published on 30 January 2006—excuse me, Mr. Deputy Speaker, but I am going to quote myself—I said:
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