Mr.
Andrew Turner: How many areas will be visited each year,
and how many of those will be top rank? It would be helpful if we had
some idea of what the Minister expects for this year or next. Also, how
many of those visits will involve the whole of an NHS trust, and how
many of them will involve operations, some of which may be less good,
within an NHS
trust?
Mr.
O'Brien: We have an idea of the quality of some trusts
through knowing about those that are hitting basic standards and
through reports published in relation to inspections by CQC and its
predecessor bodies, so we have some ability to assess the quality by
which a trust performs its services. Information on individual medical
teams and the extent to which components of trusts, which is what the
hon. Gentleman has asked about, are performing to the highest
standards, is less available, although there are some data in relation
to that on the NHS Choices
website. I
have no doubt that within the medical profession, a consultant knows
whether another consultant at a hospital down the road is better and
who is the best at a particular speciality in the country. Such
information is available in the medical press, no doubt, but we want to
provide accessible information to the public, so that they can see a
relatively brief report reasonably easily. We have made it clear that
we do not want lengthy, unreadable documents, because they are intended
for members of the public, who will be able to see the quality
delivered by, and the performance of, their local NHS organisation.
More than that, we want the public to see the improvements that an
organisation wants to make to the way in which it delivers quality
during the coming year and in the
future. There
will be a fair amount of freedom for the various organisations to say
what they want to look at or whether they have a particular specialism.
There might be a specialist team in orthopaedics, and it will be able
to say, “We have got a medical team that is able to do something
like this. It is not being done anywhere
else in the country, we are at the forefront.” Such organisations
will be able to advertise the areas in which they are the best, but
they will also have to indicate areas where they are mediocre and state
what they plan to do about it. An organisation might be above the
minimum standard and pass tests by delivering what it needs to deliver,
but it still might not match the best. It must say how it will improve
over the coming years and what it is delivering in terms of patient
quality. Patient quality is not a general concept; it has been set out
my noble Friend Lord Darzi in his report, and we want to focus on it as
something that the NHS will seek to deliver over the coming decade or
more. I
will tell the story going back over the past 10 years. At the start of
the decade, we recognised that there was a problem of underfunding and
understaffing in the NHS—we had recognised that before, but we
always had expenditure constraints. At that point, we started to put
funding in, and we used the basic tool of targets in order to see what
return we were getting. In the second tranche of change, we recognised
that we had to go beyond merely putting in more money and setting
targets for delivery and that there needed to be fundamental reforms in
the NHS
organisation. Therefore,
we went through a period of NHS reform. It was very painful and
involved reconfiguration, the reorganisation of some NHS structures and
trying out different ways of doing that until we felt that we had
reached a system that could enable the delivery of better quality
administration in the NHS. We think that we have broadly arrived at
that, and we do not plan significant further administrative
changes.
We now need
to move to the next stage, which is where quality accounts will take
us. The review by my noble Friend Lord Darzi focused on the issue of
improved quality, so we have gone through a period of dealing with
underfunding, understaffing and the necessary administrative changes,
and we are now moving on to look at improving the quality of what the
NHS does. It is a step-by-step improvement and in due course, as we
fulfil the quality agenda, I hope that we will see an improvement in
the quality of what we, as taxpayers and patients, get from the
NHS.
Therefore,
the issue of core accounts is at the centre of that vision for the
future of the NHS and the next stage in improving it. I appreciate that
the Opposition amendments are primarily probing amendments, and I hope
that we will be able to acknowledge the importance of quality accounts
and understand what they propose to do. I therefore hope that
Opposition Members will not press their
amendments. Mr.
John Horam (Orpington) (Con): May I probe the Minister a
little further on how he will organise this? I understand that the
thinking might not have got down to this level yet, but as I understand
it, he is trying to elevate quality accounts to the same level as
financial accounts. There would be financial accounts and equality
accounts at an equal level, just as many organisations have elevated
environmental accounts to the same level as financial accounts,
and report on them in the same way.
In the
case of financial accounts, there is a clear historic structure. There
is a finance director to whom people report, and there is a clear,
understandable procedure
that is followed every year and is understood by everybody. In this
case, we are in relatively untrodden territory, as the Minister has
admitted to some extent. We are even dealing with questions that are
not simply about target setting, check lists and waiting times, but
that concern rather more intangible things such as the nature of care
and the compassion that is shown, which are much more difficult to
measure. Who will be responsible for that in any organisation, whether
it is a primary care trust or hospital trust? Will that responsibility
be put specifically on the clinical director’s shoulders, or
will it lie with the operations director or the chief executive? In my
experience, organisations and institutions do not work well unless
there are specific, clear responsibilities. Obviously, quality goes
right across the board. Everyone is concerned about quality in a
hospital or primary care trust, but, none the less, someone will be
collecting the information and pushing the agenda along. Has there been
any thinking on
that? 10
am
Mr.
O'Brien: I agree with the key thrust of the hon.
Gentleman’s points. We do not aim to create a new bureaucracy or
a pile of information that needs to be collected to ensure that we can
provide quality accounts. Much of the data that will be in quality
accounts are available now. Currently, trusts provide the CQC with data
about what they are doing, so that the CQC can look at the overall
quality of what they are doing and can do its regular
reports.
So, the data
are provided to the CQC, rather than the public, and the CQC will
periodically do a report based on some of those data. We want to make
sure that those data are more readily accessible and available, as far
as the core national data on quality are concerned, in a readable form
for the public. Then, local NHS organisations will have particular data
available to them, which they can measure themselves and can choose to
put out there too. We hope that will lead to a focus on what they want
to specialise in and where they can make a particular contribution to
the
NHS. The
hon. Gentleman asked who will be responsible, and that will vary
through the NHS. In a hospital, the trust board will be responsible for
the data that are out there. If they are medical data, the board will
want to, and will be obliged to, consult the clinical director to make
sure that the quality of those data are appropriate. In the end, the
buck will stop with the board and with those who are legally
responsible for the information that the trust puts out. That
information will not just be out there unchecked. The CQC, which has
much of that information anyway, will be able to say that some of it is
not accurate. With local data, the CQC may say, “Let’s
have a look at these data, because we want to find out the basis on
which you have claimed that you’re producing at this level of
quality.” If it found that the quality levels and the data
backing them up were not sound enough, the trust or other organisation
could be required to change
them.
Mr.
Horam: So, it will be up to the trust in question to
decide which member of staff is responsible for collecting and
monitoring that information and presenting it to the board. I agree
that the board is ultimately responsible, but there must be someone
inside the organisation, below the board, who collates all the
information and presents it to the board, just as a finance director
collects all the accounts and presents them to the
board.
Mr.
O'Brien: Clinical data are currently collected in any
event, and I do not envisage that someone will get a new job on quality
accounts. There will already be people who provide that information,
and it will probably vary between the trusts who they decide should be
responsible for delivering the text of a quality account. I am less
concerned about that, and more concerned that, however they do it, we
need to have quality accounts that the public can read and understand,
and that are not too cumbersome or indigestible. They should be
reliable and verifiable by outside organisations and they should give a
clear picture of the quality of what is being
delivered. In
the end, the people on the trust board, in the case of a hospital, for
example, will be responsible. They will have procedures for making
particular individuals responsible for particular aspects of the
quality account. That will be a decision for them—we are not
trying to top-down manage this. They will appoint clinical directors,
there are good governance procedures which trusts are well aware
of—some more than others. The governance procedures are out
there and they are well known. So there will be ways in which the data
will be collected and the appropriate people will be held
responsible.
Mike
Penning: I want to clarify a couple of points before the
Minister comes to his conclusion. The Government already have powers
under section 8 of the National Health Service Act 2006 to ask NHS
bodies for quality accounts. As they already have such powers, will
this legislation bring in other bodies, perhaps those supplying
services to the NHS? If there are already powers, I cannot understand
why we need the clause, unless we are bringing in other
bodies. If
we are asking the public, understandably, to have confidence in the
accounts, the accounts must be like for like. Two trusts next to each
other must be offering similar things, and we must have a level playing
field. We do not want a postcode
lottery. So
who will audit the accounts? The British Medical Association is
concerned about that, and I share its concerns. As this is prescribed
information on the quality of the services, the manner in which they
are published should, as I just said, be equal—in other words,
there should be a level playing field. Who will audit the accounts, or
will there not be an audit at all? If there is no form of audit, what
is the logic of introducing the
measure?
Mr.
O'Brien: On bringing in other bodies, the hon. Gentleman
is right. Quality accounts will apply not just to hospitals. They will
apply to other NHS organisations and providers of NHS services. Even
those in the private sector who provide NHS services will be required
to look at the quality of what they do and report on it, and that
information should be available to the public so that taxpayers are
able to see the quality of what they
get. It
is important that the quality accounts are verifiable. I have already
indicated that CQC will be able to examine and check them. There will
not be an outside
auditor such as Ernst and Young brought in. That is not the approach
that we are taking. We are saying that the trust or other organisation
board, the partners in a practice and so on will be responsible for
writing a basic quality account. There will be core national things
that they must include and other things that they may choose to
include. They will be responsible for ensuring the quality of the
quality account. There will be a failsafe—a check—to
ensure that what they have done is not in any way unsound. The CQC will
be there to do that, but I suspect that once these things are made
public, others who work in the NHS will start looking at them and
asking questions about them. If people are making claims that cannot be
substantiated, I suspect that they will be caught out fairly
quickly. Mike
Penning: As I said at the outset, we are broadly in
support, but there is very little detail in the Bill. I hope that the
Minister will understand why we have introduced these probing
amendments and discussions. With that in mind, I do not wish to press
amendments 87 and
156. Dr.
John Pugh (Southport) (LD): I want to make a few comments
on amendment 169. I believe the Minister alluded to the fact that, in
the past, targets have been slightly distorting, and that assessing
quality from time to time can become distorting. I wonder to what
extent assessment by the public of quality accounts will differ from
internal assessment by professionals. In the case of education
assessments and establishments, people inside the education world and
the general public often have different readings of information that is
made public. However, I accept that assessing quality, albeit at a
subtle distance, may at the end of the day improve the quality of
services. The
Minister mentioned that the clause draws a distinction between quantity
and quality. The amendment is about quantity, while the particular
clause is about quality, though I accept that quantity and statistics
are often a good indication of the quality of a service being
delivered. The amendment makes an important point about the necessity
of collecting injury statistics and presenting them in ways that would
lead people to consider what the causes and the preventions are of such
injuries. I want to put on the record that my hon. Friend the Member
for Romsey has gone to the Health Committee and has not abnegated her
duties here.
Mike
Penning: I beg to ask leave to withdraw the
amendment. Amendment,
by leave, withdrawn.
Mike
Penning: I beg to move amendment 159, in
clause 8, page 5, line 24, leave
out paragraph
(c). The
amendment would leave out the paragraph that stipulates that anyone
who “makes
arrangements...for another person to provide NHS
services”— those
who are pursuing a contract or making an
arrangement “for
another person to provide or assist in providing”
such
services—will need to publish a document. Even though the noble
Lord Darzi attempted to address the situation in the other place, there
is still a lack of clarity in the Bill regarding which organisations
that supplies services to the NHS will be required to provide. A few
moments ago, the Minister listed some. It would be useful, at least in
correspondence, if the Minister could indicate exactly which bodies
that supply services to the NHS will be required. That is important, as
so much of the detail required will be left to the Minister or the
Secretary of State to decide under secondary
legislation. The
concern is that not everyone is going to be caught up in the quality
accounts. The consultation that took place regarding which bodies
should be there was—I am sorry to say—slightly flawed.
Out of the whole of the NHS, only 299 people responded, of which 11
were GPs. That is not a real barometer on the field of the
wonderful service the NHS provides to the nation. Further consultation
took place between the Department, the donation trusts and other NHS
organisations. Some 15 NHS trusts responded—not a huge
amount—so did nine primary care trusts, one strategic health
authority and the Foundation Trust Network. That is not a definitive
list of respondents as to who will be caught up in the
legislation. The
other thing, which I alluded to earlier, is the role of the CQC. The
Minister responded that it will be the CQC’s responsibility to
look at the accounts. When and how often are the obvious questions.
What is the role of Monitor in routinely examining information for
presenting the quality accounts for the foundation trusts? That could
lead to quite a punitive effect if we are not careful. The
Government’s assessments indicate that the accounts will be
quite challenging for trusts. They may have to take on new and
temporary staff. Exactly which organisations will be required to
produce quality accounts must be definitive in the Bill, and it is
disappointing that it is
not. 10.15
am
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