Mike
Penning: Perhaps I could clarify a point that I raised in
my earlier remarks. I indicated that the four points were from the
King’s Fund. I misread it, they actually came from the impact
assessment. Even though the Minister seems to disagree with his own
impact assessment, I should clarify that point. The King’s Fund
was concerned about the passive and limited method for increasing
public accountability within the publication. I have listened to what
the Minister has said and with that in mind I beg to ask leave to
withdraw the
amendment. Amendment,
by leave,
withdrawn.
Mr.
Stephen O'Brien: I beg to move amendment 119, in
clause 9, page 6, line 10, at
end insert— ‘(aa) as to the
information technology that trusts will require to measure and report
on quality in the quality
accounts;’. We
all know that the Government’s national programme for IT is now
four years behind schedule and there is little to show for its
£12 billion budget. The Lorenzo patient administration system is
in use by only three trusts and the Cerner Millennium system is live in
four trusts, three of which are using only the first phase of the
software. If 96 per cent. of acute trusts are without
a patient administration system, arguably the most fundamental of the
national programme for IT projects, one questions how many trusts
possess the IT capacity to provide an accurate portrait of the quality
of their services. Without the ability to track a patient’s
progress through various NHS services and record the outcome of their
treatment, trusts will not be able to present accurate information on
the overall quality of the services that they
provide. The impact
assessment for quality accounts stated that
“any data
mandated for inclusion in the accounts is likely already to be
collected for other purposes, so no further data collection costs are
anticipated.” However,
given the woeful inadequacy of IT provision in the NHS and the recent
report from the Audit Commission on the lack of quality in NHS data
sets—the report noted an error rate in NHS data of up to 52 per
cent.—I wonder if the Government are overestimating the capacity
for trusts to measure quality from existing data systems. I am also
concerned that the Government’s estimate that there will be no
extra costs is, frankly, a little optimistic. Either the integrity of
the quality accounts will
be—
Sandra
Gidley: The hon. Gentleman makes an interesting point and
I share his concern. In some fields, it is being made fairly clear that
a lack of a consistent data sets means that it becomes almost
impossible to compare trusts. Although we had reassurances earlier from
the Minister that there will be some flexibility about the way that
trusts collate data, any comparison will be meaningless if the data
sets are not similar. So there is a bit of a conflict here with what we
are doing, which the hon. Gentleman has rightly
highlighted.
Mr.
O'Brien: I am grateful to the hon. Lady, because she
raises the horizontal comparison, which is very important. To some
degree, what I am about to say slightly goes against my own instinct to
have a top-down approach and I dare say that the Minister was revving
up to make that rather easy point. However, regarding the horizontal
comparison there is a question, as is the case with all IT
implementation, notwithstanding our criticism of the current Government
project on IT and indeed our own views on how that project can be
improved, which will be made public later in the year. One must
recognise that there are great advantages in having some standard
setting and some protocols, because it is too easy to argue that it is
purely a case of rubbish in, rubbish out. That is the vertical
comparison.
However, with
the horizontal comparison, we are going to need really useful data sets
that will drive this process. The Government use the words about this
issue occasionally, but I regard it as being fundamentally more central
to improving patient healthcare outcomes. That is to use much more of
an upward-spiralling motivating benchmark process, which is owned by
the internal clinicians. That would be very helpful, but it absolutely
requires a fundamentally well-applied, locally-owned IT approach, while
at the same time having protocols across certain standards, so that we
can get the horizontal data. So the hon. Lady makes a valid point in
complimenting the approach that I was trying to raise with the
Government.
As I was
saying, either the integrity of the quality accounts will be undermined
by a lack of reliable data, or the cost of the accounts will far exceed
the cost that is outlined in the impact assessment. Hopefully the
Minister will take the opportunity to clarify which one of those rather
tense scenarios is closest to the truth.
I shall move
on to outcomes, which, as I indicated, are surely the most objective
indicator of quality. Again, we return to the issue of costs. In March,
I asked the Secretary of State for information on the outcomes that are
being measured for surgical operations. The Secretary of State for
Culture, Media and Sport, who was then a Health Minister, replied that
the clinical audit outcomes data for surgery was
“limited” and was collected for only six types of cancer
surgery and for heart disease. When information on outcomes is so
sparse and the technology to collect it is barely present, I fail to
see how quality accounts can play a role in improving the quality of
NHS patient care without there being further investment in systems to
measure outcomes.
The
Government have failed to create a framework of technology and data
collection that will support trusts in the measurement of quality.
Trusts are expected to produce annual quality accounts without having
been given the technological and statistical toolkit to do so. It is
important that it is a toolkit; it is not an imposition, but a question
of making available the right tools to be able to deliver on the job.
That situation will lead only to what the impact assessment calls
“perverse incentives” to publish an unreliable or
misleading document to meet the annual
deadline. I
noted in an earlier intervention that the publication date of the
quality accounts of April next year raises questions about the
trusts’ preparedness for the initiative, not least because they
should already be collecting data from 1 April this year, before the
Bill has been considered fully and before trusts can assume that they
have to. The Minister said on the last amendment group that people tend
engage once they know that the law is coming into effect, so they may
not be engaging and therefore not preparing for what is already the
year of account. I am concerned that this measure is jumping the gun,
which the Minister accused me of on Tuesday on the NHS boards. There is
a certain reciprocity of argument.
I hope that
the Secretary of State will clarify the baseline data from which trusts
are expected to analyse the quality of their services for the first
year of the scheme. For instance, if trusts are using mortality as an
indicator of quality, they will need to compare the mortality rates
this year with those of another, as yet unspecified, period. It is
unclear how trusts will go about benchmarking services in terms of
quality in 2010 when the terms by which the Government define quality
were not available to trusts in previous years to benchmark against. It
makes sense to delay the publication date of the first round of quality
accounts until 2011 when the trusts can compare data from two
successive
years. I
hope that those points have been heard and that there is recognition
that the Government are behind the curve in making the means by which
they want to achieve their aspirations come
about.
Mr.
Mike O’Brien: Let us be clear about what is being
proposed: regulations should be made to make
provision “as
to the information technology that trusts will require to measure and
report on quality in the quality accounts”.
If that is not top-down
micro-management, I do not know what is. The Opposition have constantly
said that they want to give trusts and NHS organisations greater
freedom. They are not even in Government yet—if they ever will
be—so should not try to get Whitehall and this House to dictate
the information technology that trusts require to report quality
accounts. They will use various kinds of information
technology. We
need to ensure the good quality of the data provided. I agree with some
points made by hon. Member for Eddisbury. The CQC will need to ensure
that it can use its data for assessing the quality of what particular
trusts provide. The hon. Gentleman says that some trusts are not
providing the data now, but we have clearly said that we will use the
data that are already provided by trusts to the CQC. Trusts are
preparing for quality accounts, as they are already providing data to
CQC, which is of precisely the kind that we envisage being used for the
first set of quality
accounts. In
a sense, we are not behind the curve, but well ahead of it. Therefore,
there does not need to be any delay in the way in which quality
accounts will develop in the course of the coming year. The data are
broadly available. We know what we want to do, but we want to consult
on the detail of how we will present it, how we will set out the
regulations and the extent to which we want core data to be provided to
the CQC and in quality accounts. That core data is one of the key
issues—how much is core and how much is local? It is important
that we get the balance right. I hope that the hon. Gentleman will
accept that there is no need for that level of top-down
micro-management, as proposed by the Conservative party. I am somewhat
surprised that it has gone down that route. I did not expect it to, and
I very much hope that, on reflection, it can think again about its
top-down
micro-management. 2.30
pm
Mr.
Stephen O'Brien: As I anticipated, when we reached the
substance of the Minister’s remarks, putting to one side the
well-rehearsed attempt at a little political banter, he said that he
broadly agreed with what I was seeking to do, and I am grateful to him
for that. Even the Bill
states: “Regulations
under subsection (1) or (3) of section 8
may”— not
“must”— “in
particular make
provision”. The
Government have a fundamental misunderstanding of how IT projects work.
Simply stating an aspiration and then seeking to impose it in a
“one size fits all”, does not make happen, as the NHS IT
programme has demonstrated. Far from our seeking to dictate anything,
as the Minister said, somewhat pejoratively, on the contrary we
recognise that IT is a tool that helps to facilitate and enable
processes that improve patient health care and social care
outcomes. Indeed,
as highlighted by the hon. Member for Romsey, part of what is required,
even when going down the quality route of IT applications, is to make
available the information and the expectation required so that people
can procure the right type of IT to make sure that it is interoperable
with all the other aspects of communication channels necessary to build
data sets to interrogate and collate and, thus, be useful in policy
and, above all, quality audit. There is also the motivational and
quality
enhancement process that comes through sensibly applied benchmarking,
the horizontal reference to which hon. Lady referred. I saw that
work extraordinarily well in my pre-political career in the
manufacturing industry for more than a decade. Through good
benchmarking techniques and the provision of sensible IT
standardisation without imposing from the top down, quality can really
be spiralled up and people engaged in such a process can be motivated
rather than achieving that result by means of imposition, in my case
from head office, or in this case from Government. I strongly urge them
to consider matters with genuine seriousness and make little less of an
attempt to deal with such matters on a political point scoring
basis.
The matter
will be more broadly in context with a number of things. I shall not
press the amendment to a Division. That would just be a gesture. More
importantly, I have put my argument and I hope that the Government will
think more about it. If they really want to make sure that we get some
quality accounts, our point must be taken somewhat seriously. I hope
that we can revisit the matter, but now I beg to ask leave to withdraw
the
amendment. Amendment,
by leave,
withdrawn. Question
proposed, That the clause stand part of the
Bill.
The
Chairman: With this it will be convenient to discuss the
following: new clause 2— Report to parliament on impact of
quality
accounts— ‘(1)
The Secretary of State shall report to Parliament no later than 4 years
after the coming into force of Part 1 on the impact of quality
accounts. (2) The report shall
examine the methods and technologies employed by trusts to measure the
quality of services and collect data for inclusion in their quality
accounts.’. New
clause 5—Notification to Parliament of the impact of quality
accounts— ‘(1)
The Secretary of State shall make a statement to Parliament no later
than 3 years after the coming into force of this Part regarding the
impact of quality accounts. (2)
This statement shall address the demand for quality accounts from
patients and members of the public, the improvements that quality
accounts have brought about as provider organisations focus on quality
improvement, and the way that quality accounts reflect the healthcare
needs of patients served by the bodies listed in Clause 8, subsections
(2) and
(3).’. New
clause 7—Evaluation of quality
accounts— ‘(1)
The Secretary of State shall make a statement to Parliament no later
than 4 years after the coming into force of this Part regarding the
impact of quality accounts. (2)
This statement shall examine the way quality accounts reflect the
demographic, social, economic and geographical areas served by the
bodies listed in Clause 8, subsections (2) and
(3).’.
Mr.
Stephen O'Brien: I shall deal with new clause 2, and my
hon. Friend the Member for Hemel Hempstead will deal with the other two
new clauses. New clause 2 would make the Secretary of State accountable
for the consequences of quality accounts four years after their
introduction. At present, there is no mechanism for accountability to
Parliament under the Bill, which means that the Government could launch
a significant initiative on trusts without any intention of reviewing
its impact on Parliament later down the line. If quality accounts
descend into the realm of bureaucracy, trusts need to have an assurance
from the Government that they will intervene to tackle the problem.
However, if, as the Minister is promising, they will have a substantial
effect on raising the quality of services, I am sure that the
Government would welcome the opportunity to report on that success to
the
House. The
second part of the new clause would ensure that the Government’s
report to Parliament would examine the information technology needs of
trusts producing quality accounts, which is very much linked the point
that we discovered in respect of the forgoing amendment. My concern
lies once again with the capacity for acute trusts to measure outcomes
when they do not yet have a patient administration system to allow them
to track the progress of each patient through different NHS
services. The
Government have produced a prototype for quality accounts as a template
on which trusts can base their quality accounts. As we all know, it is
rather charmingly called, “The Sunnyview University Hospital
Trust quality report 2008-09”. Unfortunately, I fear that if
trusts were to follow this document as an example of measuring quality
with any kind of sincerity, their hopes of driving up quality would be
as utopian and unrealistic as the name
“Sunnyview”. If
we turn to priority 1 in the document—I am sure that other
members of the Committee have seen it, as it is part of the
documentation behind the Bill—which deals with the reduction of
stroke mortality rates, we begin to see some of the problems posed by
the measurement of quality. Mortality is not a nuanced measure of
quality if the circumstances leading up to the death of each patient
are not examined. Strokes are caused by a variety of circumstances and
conditions, and each stroke patient’s medical history will
differ. By setting clinicians a target of reducing stroke mortality
without examination of the care pathway of each patient, the trust will
not obtain an accurate indication of
quality. I
realise that the Sunnyview document is not intended to be replicated to
the last word by trusts, and that trusts are expected to ascertain
their own priorities for measurement. However, I can easily envisage a
tired and stressed chief executive cutting and pasting information into
a document in order hastily to meet the annual quality accounts
deadline. What precautions has the Minister taken to ensure that that
does not become a prevalent practice among
trusts? My
worry is that quality accounts will descend into a rebranded version of
targets and will detract from the care of individual patients. If
trusts were given the IT capacity to measure patient care from start to
finish and to record the circumstances surrounding their condition, and
if quality were deduced from that and not from amorphous mortality or
infection rates, real progress could be
made. Somewhat
harking back to the amendment that we have just discussed, which I
tabled, if the Government’s national programme for IT had
delivered the systems it promised, acute trusts would already have
significant capacity to track electronically a patient’s pathway
through services and to measure the outcome of their treatment right
the way from their first GP consultation to their
final discharge from hospital. However, the programme is four years
overdue, and the information and data that trusts possess on outcomes
is patchy and limited to individual specialisms or
procedures. We
support a strengthened emphasis on quality in the NHS, but we also
recognise that trusts will not be able to measure quality accurately if
they cannot track the care of patients along the care pathway.
Information systems are a key facilitator—that is an important
word—in this, which is why I propose to place a duty on the
Government to review IT capacity in trusts after four
years. I
hope that the Minister listened carefully to the previous conversation.
The fact is that this is not intended to impose IT, which he sought as
a defence for not accepting the previous amendment, but to recognise
that for any kind of information system that is supported by IT, there
needs to be analysis of the standardisation. The intention is not to
limit the offering of products, but to ensure that there is at least a
quality assurance within the IT systems and an interoperability
analysis so that the data classes and the measures which will enable
these things to happen will be in
place. With
that, I beg leave to move new clause
2.
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