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Baroness Noakes: Is the Minister saying that rehabilitation services within NHS bodies, such as those referred to by my noble friend Lady Byford and the noble Baroness, Lady Finlay, would be inspected by CSCI rather than CHAI? That was not my understanding.

Lord Warner: When the noble Baroness reads Hansard, she will see that I said that under the definition of "health care", one could include rehabilitation and work towards independent living, but I said that the bulk of that work was undertaken in a social care world. We have already discussed whether there would be protocols between CHAI and CSCI or joint working. There may well be reviews in which both inspections are involved. Noble Lords are attributing to my words—though I am pleased that they are listening to them—much more importance than is required. I have said merely that rehabilitation and independent living are primarily social care areas which are likely to be the responsibility of CSCI, but I have not said that they will be the responsibility only of CSCI. Healthcare includes those elements and, where it does, CHAI will have an involvement.

Baroness Noakes: In that case, where in subsection (2) of Clause 44 would one fit rehabilitation?

Lord Warner: "Treatment".

Earl Russell: As the Minister has now returned to the point twice, I shall touch on a point that I was

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going to refrain from making. He has slightly misunderstood the grammar of my noble friend's Amendment No. 254. I do not think that it was the purpose of that amendment to suggest that the NHS should be in charge of independent living. The word which governs that amendment is "promotion"—promotion of health and of independent living. In neither respect does the amendment suggest that the NHS should be in charge of all health. As I understand them, the words of the amendment are teleological. They describe a purpose to which "health care" should be addressed, not a continuing condition for which the NHS should be responsible. That makes a number of the Minister's criticisms a little wide of the point.

Lord Warner: In order for us to move on, I shall take away the amendment and have a look at its wording. I would be surprised if we were to shift our position, but I am happy to review the matter in light of possible confusion about our position. Before Report, I shall write to all noble Lords about the issue.

Baroness Barker: I thank all noble Lords who took part in that discussion. It perfectly encapsulated some of the worst things that are happening in hospital discharge. The debate perfectly encapsulated the gap between discharge from acute hospitals and community care.

I imagine the Minister is relieved that he did not sit through the many hours of the Community Care (Delayed Discharges) Bill when we discussed those matters at considerable length. It was feared then, as it is now, that continuing healthcare in the community had been inappropriately considered. My fear, and it has perhaps grown in the past half-hour, is that the inspection regime has not been fully thought out or joined up.

I thank all noble Lords. I will await with eager anticipation the noble Lord's letter to me, but I hope that he is not defensive of his position and takes on board the intent behind the amendment, which was precisely to see joined-up services in rehabilitation. On that note, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 255 not moved.]

Clause 44 agreed to.

Earl Howe moved Amendment No. 256:

    After Clause 44, insert the following new clause—

(1) The CHAI shall be the principal guardian of standards in the NHS and shall prepare and publish standards in relation to the provision of health care by and for English NHS bodies, Welsh NHS bodies and cross-border SHAs.
(2) The CHAI must keep the standards under review and shall publish amended statements whenever it considers it appropriate.
(3) The CHAI must consult the Secretary of State, the Assembly and such other persons as it considers appropriate before publishing a statement or amended statement under this section.

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(4) The standards set out in statements under this section are to be taken into account by every English NHS body, every Welsh NHS body and every cross-border SHA in discharging its duty under section 44."

The noble Earl said: In moving Amendment No. 256, I shall speak also to Amendments Nos. 336, 344 and 345. Amendment No. 256 precedes Clause 45 for a very good reason. It both anticipates and diametrically opposes the provisions of the clause. That provides us with a classic illustration, if ever there were one, of why the amendment tabled by my noble friend Lady Cumberlege at the start of the Committee proceedings was so apposite.

Clause 45 is a mark of the Government's obsession with political control of the health service and it is profoundly misconceived. It states that the standards to which healthcare is provided in the NHS are for the Secretary of State to determine. The principle underlying my amendment is simple. It is to state that the standards which are promulgated in the NHS and the equivalent standards adopted in social care should be those for which CHAI and CSCI respectively can claim full responsibility as independent bodies.

I have used the words "principal guardian" in the amendments and I hope that these convey the right connotation of ownership that is predominant but not exclusive. It is to be hoped that when standards are set in the NHS everyone will feel ownership of them, but CHAI will be their chief defender and promoter. The Government say that CHAI is there to assess whether the standards set by the Government have been reached and that it would be quite wrong for the body responsible for setting standards to be promoting them. This amounts to saying that CHAI cannot be judge and jury in its own cause.

I believe that that is exactly what CHAI ought to be. The standards by which the quality of healthcare is to be measured should not be for politicians to determine. As the noble Earl, Lord Russell, pointed out last week in a characteristically acute intervention—and I am sorry he is not in his place now—benchmarks that are set for the NHS by politicians contain hidden clinical judgments.

The present Government came to office in 1997 proclaiming a healthcare standard: it was that fewer people should be kept waiting for treatment. To the voter, that standard seemed sensible. But arising from it, targets were set which meant that the NHS, instead of being in the business of treating the sickest patients first, was all of a sudden in a numbers game. The standard and the targets worked directly contrary to the interests of patients because they distorted clinical judgments.

The Government have now moved away from a pure numbers game by focusing on waiting times, but they are in exactly the same trap. While it can matter very much how long a patient has to wait for in-patient treatment, what really matters is that the sickest and most urgent cases are treated before less serious ones. These are prime examples of how political interference in setting standards can damage patients—and I could name others.

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To me, this issue is the crux of Part 2 of the Bill. The Secretary of State can try to influence CHAI insidiously through the purse strings that he holds and the appointments that he makes. Each of these is wrong. But if CHAI is not to be fully responsible for the standards that it upholds and cannot defend those standards to the hilt as clinically and ethically well-founded, its credibility will be non-existent.

Nor is there any sense in proposing, as the Bill effectively does, that the standards of quality that are observed in England should be different from those that are observed in Wales. It is a nonsense to think of a different and parallel set of standards operating in Wales, yet Clause 46 explicitly provides for different standards to be in force in Wales, set by the Assembly.

We all know about devolution—like it or dislike it—but to say that there should not be a uniform set of standards recognised on both sides of the Border is carrying devolution to excess. We will have an opportunity to debate Clause 46 a little later.

What I passionately want to see emerging from the Bill are two organisations—CHAI and CSCI—which command the confidence of patients, of hospitals, of PCTs, local government, care homes and the general public. They should bestride the NHS and social care and they should bestride politicians.

If need be, CHAI should be in a position to say to the government of the day and to the Assembly that this or that is what should happen for the good of NHS patients and these are the standards that we should use for measuring the delivery of the service. The second-guessing of standards by Ministers is, in my view, no way to proceed.

Therefore, I make no apology for the amendments. They go to the heart of the difference of approach between the Government and ourselves towards professional autonomy in the health service and beyond. The Government should be letting go of the reins. I beg to move.

5.30 p.m.

Baroness Barker: I shall speak to Amendments Nos. 259, 261, 262, 263, 265 and 267, which are grouped with those of the noble Earl, Lord Howe. These amendments follow very much in the same vein as those outlined by the noble Earl. In order to have the confidence of the public, the process of setting standards should involve the key stakeholders—particularly patients.

I return to the matter of national service frameworks. One reason that the national service frameworks are so good and effective is that they are the product of collaboration between researchers and clinicians and, in particular, they involve patients in the process. One of the greatest things about national service frameworks is that they counteract the often episodic view of illness which can come across from a strictly clinical point of view.

We believe that, taken together with the approach of the noble Earl, Lord Howe, the amendments that we have tabled provide the way to achieve a set of

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standards in which confidence can be sustained. Therefore, it is my pleasure to support the noble Earl, Lord Howe.

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