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Lord Clement-Jones moved Amendment No. 25:
The noble Lord said: My Lords, perhaps I may remind your Lordships of the definition in the Bill of health care:
In Committee the Minister's case was that the existing definition was wide enough and would cover many of the points on general clinical care raised in our amendment. In Committee the noble Baroness said:
The second respect in which it is faulty is that it refers to the prevention of illness. Surely that is not the same as the promotion of health. The prevention of illness is much narrower in scope. The promotion of health is, as the Minister said, very much something for which the PCTs will be responsible in their new incarnations. Having wrestled with this point since the Committee stage, I believe that there is a case for the department to consider the definition and come back with something rather wider. Otherwise, the duty of quality will not carry the weight that is being placed on it in the Bill. I beg to move.
Earl Howe: My Lords, I support this amendment. It is phrased in a different way from the similar amendment that was moved in Committee. The Minister argued in Committee that it was unnecessary to expand the definition of health care in the way proposed. I, too, have re-read her remarks. I confess that I am still uncertain about the matter. In particular, like the noble Lord, Lord Clement-Jones, I wonder whether the prevention of illness is the same as the promotion of health. It does not seem to me to be the same. Nor am I certain whether the treatment of illness includes the kinds of nursing activity referred to so powerfully by Christine Hancock at last week's RCN congress: an end to mixed sex wards; the privacy and dignity of the patient; emotional support; the absence of noise on a ward, and so on.
If a nurse is instrumental in planning the discharge of a patient successfully from hospital and providing information to the patient, is that really part of the patient's treatment? Similarly, if a nurse with expertise in pain control alleviates a patient's physical distress, is that necessarily part of the treatment of an illness, or is it rather an example of a much broader type of care? I do not know the answer to that. But if there is any doubt about it, some words, such as those in the amendment, should be included in the Bill. General clinical care is too important a part of the quality agenda to be left to argument in court as to what is meant by treatment of an illness.
Baroness Hayman: My Lords, I do not have any quarrel whatsoever with the general thrust of argument used in support of this amendment. I hope that I signalled that when we had a similar debate in Committee. However, we return to matters of drafting. Perhaps I may try to clarify further why we believe that these amendments are not necessary to encompass exactly the kinds of activity mentioned.
We define "health care" in the duty in Clause 13(4)as,
"Illness" as defined at Section 128(1) of the 1977 Act explicitly includes,
It is our belief and intention that the duty covers all those basic aspects of patient care which impact in one way or another on an individual's health and recovery. So far as a hospital is concerned, I see those as including cleanliness and hygiene, nutrition, and so forth. The HAS 2000 Report highlighted concerns that elderly patients in particular should be confident of basic care and nutrition as part of their hospital treatment and care. I am sure that none of us would dissent from that.
I do not believe that the addition of "general clinical care" on the face of the Bill would add to what is already there. One would then have to define that in a more precise way, and I cannot immediately think how that might be done in a way that addresses areas not already covered by the existing definition of health care.
I suggest that we also need to think very carefully about what would in practice be added to the duty if we were to add "promotion of health" to "prevention of illness". It is important to remember that we are dealing with a duty of quality related to the role of NHS trusts and primary care trusts in providing services. I can see that one might argue for a broader view of health-promoting activity in connection with the role of health authorities and primary care trusts in working with local government to promote the health of local communities in a wider sense. But I suggest that that is the territory of the duty of partnership. So far as the provision of health care by NHS bodies to individuals is concerned--that is what the duty of quality is all about--activities related to the prevention of illness will surely also have a health promoting effect and vice versa. One can think of examples of activities such as immunisation, smoking cessation support, healthy eating advice, and all kinds of things that noble Lords were stretching to ensure would be covered in the definition. They all relate to both the promotion of good health and the prevention of illness and are therefore encompassed by the duty as currently drafted. Indeed, the very act of providing high quality treatment and care plays its part, one might argue, in promoting better health.
I certainly share the view that the NHS should be just that: a health service, not merely a sickness service. But I believe that, for the purposes of the duty of quality, "prevention of illness" is a broad enough term to cover all that is intended. However, in the spirit of reading through the entrails after our previous debate, as noble Lords have done, I shall be happy, in the light of the specific points that have been raised in the debate, to check once again that nothing which has been pinpointed as essential in the contributions that noble Lords have made tonight is beyond the scope of the present definition. I hope that, with that assurance, the noble Lord will feel able to withdraw the amendment.
Lord Clement-Jones: I thank the noble Baroness for that response, particularly the latter part of it. I was becoming worried towards the end that pride of
Amendment, by leave, withdrawn.
Clause 14 [The Commission for Health Improvement]:
Lord Clement-Jones moved Amendment No. 26:
The noble Lord said: My Lords, the hour is late and I think that it would probably be more suitable to have a debate on this important aspect at a later stage of the Bill. We had some debate on the matter in Committee. It relates to the important area of postcode prescribing and the way in which many groups feel that there is no rhyme or reason for the way in which certain health authorities allow prescribing of certain drugs. I have particularly in mind beta-interferon for MS sufferers and Aricept for those who suffer from Alzheimer's disease, but I could cite many other examples. The concern is that the commission, which is a potentially powerful new body, should be guided by national standards in order to ensure that there is not a continuation of that postcode prescribing.
At Committee stage the Minister rather chided me for proposing too limited an amendment in that the only national standards and guidelines referred to were those produced by NICE. Of course, there were national service frameworks. I have attempted to cure that in this amendment by including the important national service frameworks. The Minister said in Committee:
The noble Baroness said that the Government would be concerned if there were an unacceptable delay in the implementation of guidance. She acknowledged that the Secretary of State for Health had the power to enforce compliance with NICE guidance under the terms of the National Health Service Act 1977. But she gave no commitment that the Government would use those powers to enforce the guidance. For instance, if CHIMP spotted in its reviews that a particular trust was not
All in all, it is extremely important that the standards of NICE and those of the national service framework are enforced by the commission. There is a suspicion among many of the bodies that have promoted the amendment that the reason for not making NICE or national framework standards enforceable is cost--that automatically central funding will be required to ensure that local health authorities and trusts act on the recommendation, for example, to introduce a new drug. When the noble Baroness, Lady Jay, was Minister of State, she told an all-party group on MS in April 1998 that the Treasury was resistant to making NICE guidance mandatory for precisely that reason. If that is the case, it is worrying.
It is notable that in the case of the notorious 1995 beta-interferon circular to which I referred in Committee, the department did not provide extra money to assist the introduction of the new drug, even though that was national policy. There are issues here. The amendment is based on somewhat unhappy experience as a result of that circular and continuing forms of postcode prescribing. I hope that the Minister will be able to give extra comfort in that respect.
Of course one does not want national standards to be enforced in an over-prescriptive way. We had that debate in Committee. Nobody believes that is the best way forward. There has to be flexibility and understanding of the fact that different trusts operate in different ways. The broad principle that the national standards should be enforceable is one that a great many people support. I commend the amendment to the House. I beg to move.
Page 11, line 17, at end insert ("including, without prejudice to the generality of this section, general clinical care as well as medical treatment, and the promotion of health,").
"'health care' means services for or in connection with the prevention, diagnosis or treatment of illness".
Amendment No. 25 is designed to ensure that the definition is rather wider. It seeks to add the words,
"including, without prejudice to the generality of this section, general clinical care as well as medical treatment, and the promotion of health".
That is similar to, but significantly different in one respect from the amendment which we put forward from these Benches in Committee. The difference is that we seek to include the words "and the promotion of health".
"The duty, we believe, is broad enough to cover not only medical interventions but certainly nursing care".--[Official Report, 1/3/99; col. 1384.]
At face value, that is a perfectly fair statement. But the more one looks at that definition, the more one sees that it does not cover all the cases it should cover if the duty of quality is to mean anything. In particular, let us consider the reception of pregnant women or the position of women immediately after childbirth. That surely is not covered by "illness". I cannot believe that that is the case. The termination of pregnancy is not "illness". I could cite a number of other aspects; for example, the carrying out of surgical procedures under anaesthesia. That is not always a question of illness. They are procedures often carried out on perfectly well people. This means that the definition is certainly faulty in that respect.
"services for or in connection with the prevention, diagnosis or treatment of illness".
I draw the attention of the House to the words, "or in connection with", which significantly broaden the scope of the definition.
"any injury or disability requiring medical or dental treatment or nursing".
15 Mar 1999 : Column 581
Again, I draw the attention of the House explicitly to the inclusion of nursing care. It is clear, when one examines the Bill carefully--although I am the first to concede that one needs to look below the surface--that there is no question of the definition of health care equating solely with medical care.
Page 11, line 20, at end insert--
("( ) The Commission for Health Improvement shall, except in exceptional circumstances, be guided by the relevant national service frameworks, the standards set by the National Institute for Clinical Excellence and other relevant national standards as regards best practice in clinical care and treatment.").
"As I say, I think it important that the commission is guided not only by NICE but that it considers best practice in clinical care and treatment, and particularly national service frameworks. I do not wish to specify only NICE guidance as that which the commission should take on board and which it should ensure is being implemented".--[Official Report, 1/3/99; col. 1389.]
Neither do I. I am perfectly happy to bring in the national standards. There were other national standards, and the noble Earl introduced an interesting amendment on those in Committee. It is, however, extremely important that NICE's standards are enforced by CHIMP. If that is not the case, what is NICE there for? Is everything purely voluntary within the health service?
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