The
Chairman: With this it will be convenient to discuss the
following: amendment 120, in clause 9,page 5,
line 41, after ‘Authority’, insert
‘or a Local Involvement
Network’. Amendment
121, in
clause 9, page 6, line 6, at
end insert— ‘(4A) If a
patient or member of the public notifies the provider of an error or
omission in a document published under that section, the Secretary of
State must within 21 days make an amended document available to the
public.’.
Mike
Penning: With your indulgence, Mr.
O’Hara, I will deal with amendment 99, and my hon. Friend the
Member for Eddisbury will deal with amendments 120 and 121.
Amendment 99
deals with the whole issue of what exactly the Care Quality Commission
is to look at within quality accounts. In the other place, Earl Howe
addressed that with amendment 38. I want to press the Minister a little
more on what part of the accounts will be validated when they are
published. I like referring to the health impact assessment because it
is the Government’s document and gives their concerns about the
legislation. It says that the public can hold providers to account for
the quality of NHS care services and demand action from them when
they “believe
that providers are falling short on
quality”. We
must therefore have confidence that the accounts are audited by people
who have the clout and powers to deal with
them. The
Government’s inquiry into the terrible situation in the Mid
Staffordshire trust set out the intention to stipulate a legal
requirement for the commissioners to validate providers’ quality
accounts before they are published. I am sure that the Minister will
correct me if I am wrong, but to my knowledge, nothing in the Bill
addresses the recommendations of that inquiry. Why is that, given that
the Government accepted the inquiry’s
findings? Mr.
Stephen O'Brien (Eddisbury) (Con): The aim of amendments
120 and 121 is to give patients a role in scrutinising quality
accounts, by giving first local involvement networks and then the
public at large the opportunity to review the information in a
trust’s quality account, along with the CQC and SHA. The driving
force behind quality accounts should not be limited to the enhancement
of performance monitoring by clinical teams and commissioners. The
principal motive behind the introduction of the accounts should to
improve patient access to information on care.
If patients
were given a stake in the information in quality accounts, trusts would
have to ensure that the accounts could be understood by the wider
audience of patients under their care, not just by commissioners, the
Department of Health and clinicians. The Bill should not only enable
the Secretary of State to monitor quality, but allow patients to hold
the trust to account for the care it provides. In “High Quality
Care For All”, Lord Darzi
stated: “We
should be seeking to create a more transparent NHS. It may be a complex
task, but we should develop acceptable methodologies and then collect
and publish information so that patients and their carers can make
better informed choices, clinical teams can benchmark, compare and
improve their performance and commissioners and providers can agree
priorities for
improvement.” If
I understand that correctly, one purpose of quality accounts in Lord
Darzi’s eyes is to inform the choices of patients. They will
facilitate patient choice only if they can be clearly understood by
patients. By giving patient representatives early sight of the document
and powers to point out errors in the account, trusts will have an
incentive to ensure that the accounts can be understood by a non-NHS
and non-clinical
audience. In
June 2008, the then Secretary of State for Health pledged that
easy-to-understand comparative information would be made available
online through quality accounts. Surely, if ease of understanding is
one of the key characteristics intended for quality accounts, that
should be enshrined in primary legislation, with mechanisms to ensure
that patients are consulted on the contents of the
accounts. I
was struck that the Minister’s response to the first group of
amendments on clause 8 invoked the fact that LINks can have an input
into what trusts include in quality accounts, because that is not in
the Bill either, nor in the explanatory notes. That is the
rationale for pushing amendments 120 and 121. They relate to
clause 9, but they have been selected in this group for the
convenience of the
Committee.
Mr.
Mike O'Brien: I want to clarify exactly what the hon.
Gentleman proposes the role of LINks should be. It is clear that
quality accounts will have to contain data, which will be provided by
the NHS. Those who have data, are able to deal with them and, in
effect, own them will be able to intervene to say that the quality
accounts are right or wrong. He is proposing a role, as I understand
it, for LINks, which do not own data, somehow to intervene. Will they
provide data? I am not clear what role he is proposing. For
clarification, our proposed role for LINks is to suggest to the NHS
organisation what ought to be included in the local quality accounts.
That is
different.
Mr.
O'Brien: I am grateful to the Minister for that
intervention because, as I hasten to explain, the amendments actually
relate to clause 9, and we are taking them now for convenience. It
might have been clearer if they had been set in the context of clause
9.
The important
point about giving a role to a patient representative organisation,
such as LINks—where there may be errors or in any form of
communication—is that the input test for information is to give
the earnest to what Lord Darzi has said about making it
patient-friendly. That means data can be readily understood by
patients. There is a danger, which I am sure that he accepts, that if a
lot of data—which he claims are sourced in terms of
ownership—are put in by people who are highly qualified
clinically and used to NHS-speak, they could be very alienating and
difficult for lay people to understand. We need to ensure that the
information is written and input in such a way as to ensure the ability
to communicate at a lay level. That is as important as the raw data
that go in, which may be heavily clinically biased. The essence
of the proposal is to get that sense of ownership of the communication
standard, as much as the raw data. I hope that that interaction helps
to clarify the thrust behind the proposal, which is important because
in “High Quality Care for All”, the Government
stated: “For
the first time, all organisations will account publicly for the quality
of care they
provide”. It
is the word publicly that I want to pick up on. Surely, if the aim of
quality accounts is to create a public document that conveys the
quality of the trust’s services, the public should be involved
in reviewing the contents of the document each year—hence my
point about the input rather than just the output. The public are the
service users; they are most heavily impacted on by the services that a
trust provides. I will not rehearse further, as we had a long outing
during discussion of the NHS constitution, the role and merit of LINks
and the need to enshrine them more explicitly. That was covered in our
earlier
interactions.
Mr.
Mike O'Brien: So the hon. Gentleman is suggesting that
LINks’ role—in addition to suggesting what might be in
the quality accounts—would be to have an input into how the
accounts are presented, so that they can be clearly presented in a way
that the public would understand. That is what he is looking for,
rather than that LINks would be able to challenge the validity of the
data with alternative data that they would provide themselves. Am I
correct?
Mr.
O'Brien: I am grateful to the Minister for trying to
understand this carefully. He comes from the right point of view. The
previous Secretary of State—and, I believe, the new Secretary of
State—mentioned a more patient-centred and delivered NHS. Part
of the patient experience will involve not just the objective
data—although we would argue that data on improving health care
and social care outcomes should always be included—but the
subjective data that patients provide about the journey that they have
had. It has always been admitted across the House that the patient
journey, measured properly and particularly when allied to outcomes,
will be both subjective and objective. The danger has been that it will
be ridiculous that we could be only subjective—we could not have
just what the patient believes; we must have the objective clinical
data to make sure. That is the thrust of his proposal.
There should
be not only an input to ensure that things are readily understood by
those who are not expert data managers, controllers and inputters, but
a readily available communication. That would also carry over time the
message—to whatever degree is decided—that subjective
patient journey and experience data are also important. The account is
therefore intended to drive and demonstrate and to be a forcer and an
audit. As I
understand it, that would tie in the subjective patients’
experience with the more important thing, which is the ability of
patients to understand and accept it. Therefore, there will be a degree
of ownership, to take the analogy on face value. I hope that that makes
it clear. I will not rehearse the conclusions, and I look forward to
see whether the Minister finds some merit in the
proposal. Mr.
John Horam (Orpington) (Con): I am delighted that my hon.
Friend the Member for Eddisbury mentioned local involvement networks,
which are in danger of being downplayed or overlooked in the context of
quality care—even though I fully accept and support what the
Government are trying to do. None the less, there is a danger that the
local element, which is represented by the local involvement network,
is somehow neglected or downplayed, and that would be a great
mistake. For
example, in my own area of Bromley, the Minister will know that we have
just had the merger of three big hospital trusts, in Bromley, Bexley
and Greenwich. That has inevitably meant a lot of centralisation. It is
a huge trust, with 4,000, perhaps even 6,000 employees, that extends
over a wide area of south London. Inevitably, therefore, the intimate
relationship that used to exist between the LINk and its predecessors,
Bromley council and the trust—they were all within one
borough—was broken and the local element was in danger of being
devalued. It is important that we maintain that, and I seek a
reassurance from the Minister that that is the intention.
To return to
the point made by my hon. Friend, as the Minister said, not only should
LINks be involved in looking at what input they make into the
information that is provided, but, as my hon. Friend said, the input
should be clear. We are all familiar with jargon. Every profession has
jargon—Parliament has jargon to the nth degree, so we are all
guilty in that respect—but NHS jargon is particularly obscure
sometimes, and it takes a long time for people to understand what is
being said. Clarity, which is my hon. Friend’s second point,
should also be there.
The Minister
said that my hon. Friend was suggesting that the validity of data might
be challenged by a LINk—yes. Because we are talking about a
rather impressionistic course of things, local people may well have a
different take on whether a particular indicator is the right one for
that profession or speciality, and their view should be taken into
account. I agree with the Minister that they will not necessarily have
other sources of data, but they may well be able to challenge, out of
their personal experience, whether the trust is producing the data in a
right way or the right data. Those are the three
elements—clarity, being asked to say what people want and
looking at whether the data provided by the trust can be challenged. I
think that there is a large role for LINks to play, and I hope that the
Minister will take that into account and push it down the line, as
something that should and will continue to be
valuable. 1.30
pm
Mr.
Mike O'Brien: Amendment 99 would give the CQC a formal
role in auditing a provider’s quality account. Amendment 120
seeks to extend to local involvement networks the role in correcting
quality accounts. Similarly, amendment 121 would give a role
to patients and the public to correct those accounts. The function is
currently limited to the CQC and strategic health
authorities.
Two reasons
underlie the original choice. The first is affordability and the second
is achievability. We limited the number of correcting agencies to the
CQC and SHAs, because the information in question is reported to them
for regulatory, registration and contracting reasons. Contractual
information is, of course, primarily reported to PCTs, but many
providers will have multiple contracts, and we do not want to
complicate the relationships. Thus the two agencies—the CQC,
which oversees quality standards, and the strategic health authorities,
which oversee commissioning and contracting—can cover the whole
spectrum of correctable information without overburdening any part of
the NHS system. That is our proposed affordable
solution. Those
agencies are in a good position to do that, because they have a better
overview of the local health care system, which makes the correcting
function more achievable. By way of contrast, there is some concern
that patients and members of the public do not “own” any
of the data involved in producing quality accounts. They are therefore
not in a position to fulfil the role envisaged for them in amendment
121, but LINks will have a role in setting out what local people want
to see in quality
accounts. The
hon. Member for Orpington made the point that people will want to have
some ownership of the information that they receive in order to know
whether their part of the community is getting a service. They might go
to the NHS organisation, such as a local hospital, and say,
“What are you doing for this part of Orpington? We would like
you to state that in your quality accounts. Remember we are focusing on
the issue of quality. How are you seeking to improve the quality of a
particular service?” That is the sort of role that LINks can
play. Before a quality account is published, and indeed afterwards,
people can go to the organisation and say, “It would be better
if you had done it this way. Next time, can we make sure that you do?
And by the way, you have got a website. Can you not update
it?” So
there are ways in which LINks, and indeed other patients’
organisations, could be involved. The other way is the one suggested by
the hon. Member for Eddisbury, who said that they could ensure that the
presentation of the data is done in a way that is easily accessible for
members of the public to use and that allows them to bring forward
their views about how presentation could be
improved. I
part company with the hon. Member for Eddisbury on the introduction of
subjective data from members of the public. There are ways of ensuring
that the patient journey, and the quality of that journey, are included
in quality data. Indeed, part of the assessment of the quality of a
service is how good that patient journey is. My noble Friend Lord Darzi
has made it clear that that is part of the assessment. But the way to
do that is to ensure that appropriate surveys are carried out and that
there is an assessment of the level of complaints and the response to
them. There
is a range of ways in which the quality of the patient journey can be
examined. There can be evaluations of the quality of cleanliness and
the way in which the
organisations have responded to public concerns about that. The public
can have an input in ways that do not rely on people saying what their
subjective feeling is, or what their personal experience is, and being
able to go to the organisation and say, “You have to put in a
paragraph now about how I feel about my treatment on x ward on this
date.” That is not the way in which we envisage quality accounts
proceeding. Mr.
Stephen O'Brien: Clause 8(5) gave rise to the thinking on
the
amendments: “The
Secretary of State may by regulations provide that subsection (1) or
(3) does not apply to prescribed bodies, persons or services, or to
bodies, persons or services of a prescribed
description.” To
include or not include who is consulted is obviously a wide power for
the Secretary of State, and there is a danger. Patients will be given a
sense of shared ownership, with the ability to understand and
scrutinise the data. A full quality account, as the Minister rightly
says, must include, crucially, patients’ sense of the quality of
care that they receive. Despite the Minister’s very reasonable
approach in his answer so far, that, coupled with the Secretary of
State’s power, seems to carry with it the possibility of a more
whimsical choice of who might or might not appear. For instance, a
Secretary of State might say, “I really don’t think we
want to hear from homeopathic medicine,” despite the fact that
some in the medical profession think it important, and that could
become an excluded item. That is what gave rise to the
amendments.
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