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10 pm

The changes come into effect from 23 June 2010, which, as the right hon. Member for East Ham (Stephen Timms) astutely notes, is part way through the tax year 2010-11. Gains chargeable in the earlier part of that year are still liable to CGT at the old 18% rate. As he pointed out, we did that to avoid forestalling and transactions being brought forward before the end of the tax year in such a way as to distort activity. We saw that after the announcement in October 2007 of a reform in the way capital gains tax worked. The disruption within the economy and distortive effect result in the economy becoming less efficient as a consequence of the tax system. We did not go down the routes that were advocated for taper relief or indexation, which would have been difficult to implement immediately. We believe that the simple approach we adopted was the right one.

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The right hon. Member for East Ham raised the concerns of some professional groups that the transitional provisions are not fully adequate. We do not accept that. A number of capital gains tax rules do not specify the exact time at which a gain arises, but they do not create difficulties in relation to the change of rate in June 2010. In such cases the facts will determine whether the gain arose before or after 23 June 2010. Exactly the same question could arise in determining whether a gain arises in one tax year or the next. That question normally causes no difficulty, and there is no justification for special provisions for 2010-11.

The right hon. Gentleman and my hon. Friend the Member for St Ives (Andrew George), whom I thank for his kind remarks, raised the key issue of why a rate of 28% was chosen. As the right hon. Gentleman suggested, the answer is that it is close to the revenue-maximising point, as several of my right hon. and hon. Friends have said in recent weeks. There was some discussion about the methodology and how we worked that out, and the right hon. Gentleman requested that we put a copy in the Library. At the time of the Budget, we produced policy costings, which set out in greater detail than ever before how these matters are worked out. I advise him to look at pages 26 and 27 of the document in particular. For the benefit of the House, however, I will comment briefly on the thinking involved.

We start with a static costing for the additional tax that would be raised as a consequence of raising the CGT rate. Two post-behavioural factors then need to be taken into account. The first is the increase in the lock-in effect. As was suggested by my hon. Friend the Member for Wolverhampton South West (Paul Uppal), fewer gains will be realised if a CGT rate goes up. That finding is based on extensive research, including research in the United States. According to the Treasury's assessment-based on the evidence of a considerable number of studies-

of £925 million-

The second behavioural impact involves the movement from income to capital. That was raised by several Members. It was also very much behind the thinking in the Liberal Democrat manifesto, which raised the perfectly fair point that the size of the differential was such that it would result in a behavioural change, whether it be tax avoidance or tax planning. The Treasury has concluded that for every 1% reduction in the gap between the CGT rate and the higher rate of income tax, there is an increase in income tax yield of about £60 million. That increases the 2011-12 income tax yield by £600 million. I think that that answers explicitly one of the questions asked by the shadow Minister. The ultimate Exchequer impact of those two changes is that £725 million will be raised in 2011-12.

I know that the Members are anxious to hear me produce the same analysis of the figures for 2012-13, 2013-14 and 2014-15, but I am afraid that they will just have to have a look at the costings, which are available.

Stephen Timms: Why is no yield specified for the current year?

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Mr Gauke: I believe that the overall effects for this period balance out, but I shall write to the right hon. Gentleman to confirm that.

The right hon. Gentleman asked about the self-assessment return and guidance notes to help people to work out their final liability. For the tax year 2010-11, HMRC has worked to automate more of the online self-assessment processes in order to help customers with the changes. The software will be available for customers to use from 6 April 2011. The improvements will be conveyed to third-party software developers at the usual time, enabling them to modify their products in good time. Full guidance will be available in the self-assessment notes on HMRC's website and through its helplines.

Andrew George: May I return the Exchequer Secretary to the subject of the "composition of income" behavioural impact that he described earlier? He referred to the tax yield in forthcoming years. Is the tax yield for every reduction of one percentage point assumed as a continuing line beyond the 28%? What happens to the behavioural change after that?

Mr Gauke: The assumption is that there is an ongoing gain-that we will gain more in income tax as a consequence of the rise in the CGT rate.

The reason why there is no yield this year has suddenly dawned on me. We do not get the receipts for capital gains tax through self-assessment immediately; it is only in future that CGT will be paid through the self-assessment process.

Stephen Timms: The Minister has made the point, however, that most of the gain is in fact income tax, which surely would score in the coming year?

Mr Gauke: I think we will see more of that behavioural effect as time goes by, but I am not sure that that will come through immediately. In some cases, it will depend on when the additional income will be crystallised or realised. I think that is the explanation, but if I have anything to add I will write to the right hon. Gentleman.

Mr David Ward (Bradford East) (LD): There is a time lag, which is why the receipts are not shown for this year. There is also a bringing forward of benefit because, as opposed to the lock-in, there is an advance disposal of the assets which would not otherwise have taken place. Also, of course, there will be a release of income tax, rather than a waiting for a capital tax and putting off the delay that would come from the capital gain.

Mr Gauke: I will write to my hon. Friend to explain further why there is no yield in the current year, but I am very grateful for his expertise in this matter.

Questions were also asked about serial entrepreneurs who cannot claim entrepreneur's relief and defer gains under the enterprise investment scheme. People can now choose between claiming entrepreneur's relief and paying capital gains tax at 10% or deferring a tax charge by reinvesting under the EIS and paying 18% or 28% when the postponed gain comes into charge. If they claim entrepreneur's relief they can still invest in EIS companies. The CGT deferral relief will not be available, but income tax relief under the EIS could still be available if the
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conditions are met. Serial entrepreneurs who have used up their lifetime limit of entrepreneur's relief will be able to claim the EIS deferral relief on gains above the limit. Allowing individuals to claim both entrepreneur's relief and deferred gains will be highly complex and is inconsistent with the aim of simplifying the tax system.

The right hon. Member for East Ham also asked whether Her Majesty's Revenue and Customs is planning any extra education about the changes for customers and their advisers. HMRC will talk to representative bodies about what extra guidance is required. It will see what practical help it can give to agents generally through the "working together" agent network, and it will look at working with the media and interest groups to raise awareness among individuals who may be affected by the changes.

This is a reform that protects the Exchequer while ensuring that those on lower incomes are protected and the recovery is safeguarded. We have acted in a way that is in the spirit of the coalition agreement. I do not think any Member on the Government Benches would want to raise taxes beyond a level that would maximise revenue-revenue that is, after all, used to fund a substantial increase in the income tax threshold, taking 880,000 people out of income tax. If we had raised the level further, or if we had raised it by less, we would not have been able to do so much in that particular area. Consequently, we believe that 28% is the right level. We do not intend to return to this matter, and I ask that schedule 1 be agreed.

Stephen Timms: I do not propose to press this to a vote. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 1 agreed to.

To report progress and ask leave to sit again.- (Mr Newmark.)

The Deputy Speaker resumed the Chair.

Progress reported; Committee to sit again tomorrow.

Business without Debate

Delegated Legislation

Social Security

Motion made, and Question put forthwith (Standing Order No. 118(6)),

Question agreed to.


Political and Constitutional reform


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Mr Deputy Speaker (Mr Nigel Evans): With the leave of the House, we will take motions 4 to 22 together.


Business, Innovation and Skills

Communities and Local Government

Culture, Media and Sport



Energy and Climate Change

Environment, Food and Rural Affairs

Foreign Affairs


Home Affairs

International Development

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Public Accounts

Public Administration

Scottish Affairs

Statutory Instruments (Joint Committee)


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Welsh Affairs

Work and Pensions



Science and Technology


Business of the House

Motion made,

Hon. Members: Object.

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NHS (Cornwall)

Motion made, and Question proposed, That this House do now adjourn. -(Mr Newmark.)

10.17 pm

Sarah Newton (Truro and Falmouth) (Con): I am delighted to have this opportunity of welcoming the publication today of the coalition Government's health White Paper, "Liberating the NHS". It received a warm welcome in Cornwall this evening during the evening news on the BBC, with support from patient groups and GPs. I believe that making the NHS more accountable to patients and freeing staff from excessive bureaucracy and top-down control will drive up quality of care and outcomes for patients. I also welcome the measured pace of change and the Government's desire to engage in a wide range of consultations to get the detail of the proposals working for the benefit of patients.

This evening, I would like to describe the current situation and direction of travel of the NHS in Cornwall, and to raise one important aspect outlined in "Liberating the NHS" today: assuring the continued improvement in quality of care in Cornwall. In addition to the ambulance service, we have three organisations that commission or provide care for people in Cornwall: the Royal Cornwall Hospitals NHS Trust, the Cornwall Partnership NHS Foundation Trust, and the Cornwall and Isles of Scilly primary care trust. There have been significant problems with some aspects of the quality of care provided by those organisations, but over the past three to four years improvements have been made. Significant challenges remain, and it is essential that momentum be maintained in the further improvement from ratings of "adequate" and "fair" to "good", and then sustained at that level.

The Royal Cornwall Hospitals NHS Trust annual health check ratings demonstrate some steady improvement. Areas that needed work were governance, financial management, infection control and elderly care. The quality of service was rated "weak", and remained weak until 2008-09. However, more recently the trust has demonstrated overall improvement through the interim core standards declaration in October 2009. The trust was registered under the Health and Social Care Act 2008 in April 2010 without conditions and with only minor concerns. The overall annual health check ratings of the Cornwall Partnership NHS Foundation Trust demonstrate improvement in performance, particularly since the high-profile investigation of services for people with a learning disability. In 2005-06, the trust's quality of service was rated weak, improving to good in 2007-08, and that improvement was sustained into 2008-09. Its quality of financial management similarly improved. The trust was registered without conditions under the 2008 Act in April 2010, and achieved foundation status on 1 March 2010.

The Cornwall and Isles of Scilly PCT has also seen some improvement in performance. In 2006-07, its quality of commissioning was rated fair, improving to good in 2007-08 and then returning to fair in 2008-09, and its quality of financial management is improving to good. The trust was also registered without condition, however this was with a moderate level of concern.

Also of relevance to all three Cornwall NHS trusts is the report on the inspection of safeguarding and looked-after children's services published by Ofsted on 23 October
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2009. Out of 16 outcomes, Cornwall council was awarded only one score of "good"-there were six of "adequate" and nine of "inadequate". Although most issues for action are for the local authority, there were also issues for the health community to address, which involve all three NHS trusts to a greater or lesser degree. Action plans are in place, and oversight and scrutiny of the health element is provided by the South West Strategic Health Authority. It is performance-managing progress on delivery of the action plan weekly and bi-monthly, alongside an improvement board, which has been established.

At such an important time, when Cornwall's NHS trusts are working hard to improve the quality of care, which they need to deliver for Cornwall, it is essential that momentum is not lost. The regulation of the quality of care is vital to patient confidence. The ability of patients and clinicians to access information about the quality of services provided, as well as their being able to feed in information to the inspection and regulation regime, is very important. With the abolition of many centrally imposed targets and more devolved target setting and commissioning, the regulation and inspection of the quality of commissioning will need to adapt to this new environment. Many local factors are important to health outcomes in Cornwall, such as access to services, and those will be able to be taken into consideration. There is also an opportunity to invite the greater involvement of patient and clinical experience of services into the regulation and inspection regime.

The information provided to patients must embrace all that goes on to make up quality, including access, waiting times, cleanliness, infection rates, quality of clinical care, results for patients, access to same-sex accommodation and single rooms, cancelled operations, emergency readmissions, discharge arrangements, numbers of complaints, patient experience and patient-reported outcomes. Most of those data already exist, but they are difficult to access for many people. An open attitude to acknowledging and acting upon criticism is also needed to drive up the quality of care. If we had an open information culture, the scandalous failings that took place in Maidstone and Tunbridge Wells and then at Stafford hospital would not have gone unchallenged.

I am concerned by the number of clinicians in the NHS in Cornwall who tell me that when they challenge their manager and try to improve a service for patients they are told, "Nothing can be done", "There's no point saying anything as nothing will change" and, "Don't ask, don't tell, don't complain". At Mid Staffs there was clearly a sense among some of the professionals, and indeed the public, that the hospital had problems, but that was just the way things were done. That is just not good enough. We should never allow that sort of thing to happen again.

Andrew George (St Ives) (LD): My hon. Friend is making a good point, particularly about whistleblowers in the NHS. It is vital that they are treated seriously and not threatened or bullied as a result of their whistleblowing.

Within the coalition agreement, to return to the role of patients and the local community, there was a commitment to a strong voice for patients locally through directly elected individuals on the boards of local primary care trusts, with the other members being representatives from the local authorities. However, those PCTs will be
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abolished. Does my hon. Friend agree that in Cornwall we need to ensure that there is some democratic accountability and community representation in the overview, scrutiny and management of the local NHS?

Sarah Newton: I thank my hon. Friend for that comment and I am sure that when the Minister replies he will describe some of the proposals in the White Paper to give local authorities and representatives far greater involvement in the overview and scrutiny of health services.

Instead of whistleblowing being seen as going outside the organisation, we should see such challenges as integral to safety and improvement within the organisation. In April 2009, John Watkinson was dismissed from his role as chief executive of the Royal Cornwall Hospitals NHS Trust. He took his case to an employment tribunal, which has published its judgment that he was unfairly dismissed. In the opinion of the tribunal, he was unfairly dismissed because he made a "protected disclosure" covered by the Public Interest Disclosure Act 1998. The disclosure was linked to the reconfiguration of upper gastro-intestinal services in Cornwall. The tribunal also found that the trust acted as it did as a result of pressure from the South West strategic health authority. Verita, a specialist company that conducts independent investigations, reviews and inquiries, has been commissioned to undertake a review and will report later this year. With a different culture in the NHS, this difficult situation might well have been avoided.

In the same way, instead of seeing complaints as a burden, distraction or something to be dealt with outside mainstream service provision, we must see them as integral to the improvement of the service that we provide. Learning from our mistakes, listening to complaints, comparing what we do, evaluating our performance and constantly seeking to improve quality are the features of the best performing organisations in every sector, and they can be already found in the best performing NHS trusts.

Listening to patients-asking, reporting and learning from patient experience-will be of great importance in designing and improving services, including achieving greater efficiency. However, the NHS too often asks insufficiently penetrating questions, insufficiently frequently, of too few patients. The NHS patient survey, which asks whether patients are satisfied with the care they received, is too much like asking patients if they are grateful.

I have read with interest the section in the White Paper entitled, "Autonomy, accountability and democratic legitimacy". It sets out the outline of the proposed registration, evaluation and inspection regime. The Care Quality Commission process is new and generally thought to have made a good start in Cornwall, and I am pleased to see that it has an extended role in regulating quality of care.

Given the important stage that the NHS trusts have reached in Cornwall, assistance from those aiding the improvements that have already been identified in action plans needs to continue. As a result, I want to understand what plans the Minister has to develop the regulation and inspection of care providers and commissioners to ensure that standards of health care and the confidence
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of clinicians and patients in that care are improved. What is the time frame for migrating from the current regime to the new one and who will be involved in the consultation process for the creation of the new regime?

10.29 pm

The Minister of State, Department of Health (Mr Simon Burns): May I say, Mr Deputy Speaker, what a particular pleasure it is to have you in the Chair this evening for this important and interesting debate on the NHS in Cornwall? I pay tribute to my hon. Friend the Member for Truro and Falmouth (Sarah Newton) for securing her first Adjournment debate on this subject, which is important not only to her constituents but to the constituents of all other hon. Members and hon. Friends from Cornwall. I know from an earlier debate in Westminster Hall with my colleague the hon. Member for St Ives (Andrew George) that he has long-term concerns about funding for the NHS in Cornwall.

The comments of my hon. Friend the Member for Truro and Falmouth about my right hon. Friend the Secretary of State's announcement on the White Paper, "Liberating the NHS", and the way it has found approval in her county are replicated throughout the country. That is, as she rightly said, because of the freedoms and liberation that the Government are giving to the NHS, not only in Cornwall but throughout England, so that we do not have an NHS that is distorted by targets and in which clinical decisions are taken not on clinical grounds but to meet deadlines. We will not have politicians and civil servants in Whitehall seeking to micro-manage the NHS throughout the country.

Next to reducing the deficit, the NHS is the Government's top priority. That is why we have decided that, despite the dire state of the public finances, the sick should not have to foot the bill for years of living beyond our means. We will increase NHS spending in real terms for each year of this Parliament. As today's White Paper sets out, that money will be accompanied by a radical shift of power away from the centre and down to the front line. For the first time, NHS staff will have the responsibility and the resources to improve outcomes for patients, free from the shackles of central Government, and patients will be given more power over their care and treatment than ever before.

The White Paper shows that the NHS can become a truly world-class service that is easy to access, that treats people as individuals and that offers care that is safe and of the highest quality. We have published a revised operating framework for the NHS as a first step in delivering those priorities. The framework is putting in place a zero-tolerance approach to infections, setting out how we can move from process targets to evidence-based measures of quality, developing payments for performance geared to results and moving towards a service that empowers clinicians and makes them more accountable for achieving the best outcomes for their patients.

The NHS in Cornwall has made important strides in the past 12 months and I pay tribute to NHS staff across the whole county, who are already improving the care given to my hon. Friend's constituents. For example, in 2008-09, the Care Quality Commission's annual health check gave the Royal Cornwall Hospitals NHS trust a "weak" designation for quality of services, but with the hard work and dedication of staff, it obtained registration
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without conditions with the CQC for 2010-11. On 1 March, the Cornwall Partnership NHS trust became Cornwall's first foundation trust. It has consistently achieved good ratings from regulators and I know that its services are well regarded by patients and commissioners.

The PCT is working hard to move services closer to home for patients, with several services being brought back into the county, including those on surgery to widen blocked or narrowed coronary arteries, breast reconstruction, treatment for wet, age-related macular degeneration and services for weight management. In the past two years, the PCT has moved care closer to home for more than 19,000 people and it is committed to moving a further 10% of services out of district general hospitals and into the community. It will also work with the local authority to improve patient transport services in order to improve access for the constituents of my hon. Friend and of other hon. Members who are present.

The NHS in Cornwall is involved in some innovative pilot schemes. The whole systems demonstrator pilot is enabling more than 1,000 people to be cared for while remaining independent and in their own homes. That is the biggest pilot of its kind in the UK. The Newquay integrated care pilot is changing the way that people with dementia are cared for. A new purpose-built health centre has just opened in Truro alongside the two existing GP practices. It provides a wide range of services, including family planning, podiatry, physiotherapy, speech and language therapy and social care. The scheme is the result of collaboration between local GPs, members of the public, the local council and other stakeholders.

My hon. Friend mentioned the situation at the Royal Cornwall Hospitals NHS Trust. Although it received a "weak" designation in 2008-09, the CQC annual health check showed that significant improvements have enabled it to obtain registration without conditions with the CQC for 2010-11. After an independent review of management and governance, and recommendations reported in 2009, the strategic health authority carried out a six-month review of the trust's progress, followed by monthly follow-ups until the end of the last financial year.

At that point, the trust was able to confirm that it had achieved all the recommendations. The PCT and the SHA are arranging a formal meeting with the Royal Cornwall Hospitals NHS Trust further to review the trust's performance against the recommendations. At its board meeting on the 30 June, the trust agreed the updated chairman's progress review action plan, which continues to be monitored through the trust's monthly chairman's meeting. Progress reports have been shared with the PCT, and clear progress is being made.

My colleague the hon. Member for St Ives (Andrew George) discussed the election of members to PCT boards-a proposal which, as he now knows, is somewhat past its sell-by date. As a result of discussions with the coalition, we have determined the right way forward. In addition to abolishing strategic health authorities-that was in his manifesto-the whole reform package in the White Paper on PCTs and the transfer of commissioning to GP practices makes his proposal redundant. The idea of locally elected PCT members will therefore not be pursued.

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Andrew George: I am grateful to the Minister for his response. As he says, things have moved on in a few weeks on the commitment directly to elect PCT boards, but a vacuum has been left, and not just in Cornwall, because we must make sure that finances are adequate for future need and because the local community cannot be represented through the GP commissioning boards. It needs a role in the shaping of services.

Mr Burns: I am extremely grateful to my hon. colleague. As he reads the White Paper in conjunction with other documents that will flow from it in the next few weeks, he will come to understand that all the pieces are in place to deal with the concerns that he has expressed. We as a Government are committed to providing a strong local voice for patients through democratic participation. As he and my hon. Friends will appreciate, the nub of the White Paper announced today for Cornwall and for the rest of England is about putting patients at the heart of our reforms, so that their desires and health care needs drive the reformed NHS. No longer will the NHS be told from the top what has to be done throughout our local communities, both in Cornwall and elsewhere. It will be driven by a bottom-up, rather than a top-down, process. To meet that objective, PCT commissioning functions will be phased out and transferred to the NHS commissioning board.

My hon. Friend the Member for Truro and Falmouth asked about the time scale for these reforms. The time scale for phasing is between now and 2013. We propose to replace PCTs with an enhanced role for elected councillors and local authorities to boost local democratic engagement in the NHS. Given the way in which the whole system is to be held accountable, they will increase their responsibilities from their existing role in the public health sphere.

I now turn to my hon. Friend's point about information. If we are going to create a national health service that is driven by patients, for patients, they must have the information that qualifies them to make the decisions and the choices that are all part of our vision for a patient-led NHS. I can give her this commitment: information across the whole of the health sector will be made available to all patients and members of the public so that they will be able to access it and then make a judgment based on their health requirements as to their choices of consultants and hospitals. That informed decision making can be provided only by enhanced information for those people. I can assure her that that information will be made available so that they can make those decisions and choices.

My hon. Friend mentioned whistleblowing. As she will know, my right hon. Friend the Secretary of State is a strong supporter of holding the NHS to account when it fails or could do better to ensure that we have the finest health service that does not concentrate on processes, as it has for too long, but is driven by outcomes, which is the important thing that matters the most to our constituents. My right hon. Friend has already stated that he is going to strengthen and protect the position of whistleblowers, to use the old-fashioned phrase-I am not convinced it is the best one, but it is certainly the most obvious-so that people who see things that are wrong or things being done that should not be done have the protection and the confidence to be able to draw them to the attention of the authorities
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so that we can right the wrongs and make the improvements without those individuals fearing for their jobs, future careers and commitment to the NHS. I hope that my hon. Friend is reassured by that.

My hon. Friend mentioned the inspection and regulation regime and the Care Quality Commission. Let me tell her, although she will certainly know the basic principles, that the role of the CQC as the regulator of all health care providers will be strengthened by a clear focus on essential levels of safety and quality. All providers of regulated health care and adult social care will be registered against essential levels of safety and quality, and the CQC has the power to take action against providers that do not meet these standards. The CQC will carry out targeted inspections of providers against the essential standards.

As my hon. Friend will be aware from the White Paper, GP consortiums will commission the majority of health services in place of PCTs, and the NHS commissioning board will authorise consortiums and hold them to account for their performance. The CQC will no longer have a role in assessing commissioning. On the involvement of patient and clinical experience of services in the regulation and inspection regime, instead of focusing on the measurement of processes or targets, the CQC now places the experiences of the people who use health and social care services at the very heart of its work.

The CQC actively seeks the views of people who use health and social care services when making assessments of the quality and safety of that care. When inspecting a care provider, it asks to see evidence of outcomes and evidence that patients experience effective, safe and
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appropriate care. Rather than looking at policies, it speaks to people experiencing care, to their families and to staff to find out what the quality of care is like in practice. The CQC also actively seeks the views of clinicians, who play a crucial role in improving the quality of care. When there is a problem, it works with them to work out the best way to solve it and to improve care. Clinicians' expertise in service delivery and design is invaluable, as I am sure my hon. Friend will agree.

In addition, the CQC works in partnership with a range of professional regulators, such as the General Medical Council and the Nursing and Midwifery Council, to ensure that its assessments of a provider are informed by their views on clinical best practice. Integration with HealthWatch, as announced in today's White Paper, will give patients in Cornwall and throughout the country a greater public voice, providing a greater connection between their views and the actions of the regulator.

I reassure my hon. Friend, my colleague the hon. Member for St Ives and all other hon. Members from the great county of Cornwall that we are determined to improve and enhance the quality of care in the county and throughout the whole country. We want to ensure that the improvements are experienced by patients, because patients are at the heart of the new NHS that we envisage. Only by taking into account what they want and their patient experience within the NHS can we make the improvements necessary to ensure that we have a great NHS not just for the next five years but thereafter.

Question put and agreed to.

10.46 pm

House adjourned.

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