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I also want to discuss the concept of “widely known”. It is quite easy for us in Grand Committee, in your Lordships’ House and in the system to understand constitutions and handbooks. For the ordinary punter out there, however, it is a completely new concept.
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Lord Darzi of Denham: Amendment 27, tabled by the noble Baronesses, Lady Barker and Lady Tonge, proposes that the same list of persons and bodies that are required to be consulted on the 10-year review of the constitution, with the addition of carers, should also be consulted on the regular reviews of the handbook. Amendment 29, tabled by the noble Earl, Lord Howe, addresses a similar point, but suggests that the Secretary of State shall consult,
on any revision of the handbook.
I understand that the amendments seek to ensure that any reviews of the handbook to the constitution cannot be made without consulting those persons or bodies that might be affected by them. I have already set out my concerns about Amendments 26 and 28, so I will move on to the other amendments in the group. First, I would like to reassure noble Lords by restating our intentions behind the review of the handbook.
As I mentioned previously, the handbook is the explanatory guide to the NHS Constitution, to be used by patients, public and staff. The Secretary of State may make minor technical and legal changes to the handbook at any time, to reflect current departmental policy or changes in the law. We do not think that it would be proportionate to have to consult on such changes, and I think that most noble Lords agree. However, any significant changes to policy or law that affect the handbook are in themselves likely to trigger consultation requirements. We should bear in mind that if there is a policy change, that change itself will be consulted on. This debate is about the idea that there should be consultation on the policy change and then another consultation on the change to the handbook. I hope I have clarified that whatever change is to occur, there will be consultation on it. Requiring a second consultation on putting the change into the handbook would be a further burden and more bureaucracy. I reassure noble Lords that the Secretary of State is obliged to consult on any change in policy. The intention behind the regular reviews of the handbook is to assess whether the handbook continues to be fit for purpose for patients, public and staff. While the constitution is a formal document with formal consultation requirements, the handbook, as I said, acts more as an explanatory guide.
I hope that I have reassured noble Lords on these amendments. If there is still fairly strong feeling about it, I would be more than happy to look at the wording. Although I completely agree with the intention here, it is very important that, whatever we do, we do not increase the burden of consultation by requiring two consultations on a policy change that has exactly the same purpose.
Baroness Barker: I thank all noble Lords who contributed to this short debate. I say to the noble Baroness, Lady Young of Old Scone, that although
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I take entirely the Minister’s point about the burden of consultation. In the NHS and in social care we tend to swim in a sea of consultation, and, frankly, there are only so many sandwiches that can be eaten in the course of developing good policy. If he is suggesting that there should be only one opportunity to be involved in consultation then, on balance, my guess would be that most people would want to be consulted on the handbook, not the constitution. Not only is that when the detail of how the principle is to be implemented in the NHS is established, it is also the point at which people reading the documents get the sense of which principles are the really important ones and how all the different principles will interact in practice.
I have not spoken to anyone about this, but I know that many external organisations are very interested, and I would like to consult them on it. But that is my initial reaction to the Minister’s comments. I am very pleased that he has agreed that there is a degree of feeling about the issue. I am happy to look further at it and perhaps come back to it at a later stage.
I thank the noble Earl, Lord Howe, for his support. I do not want a never-ending list of people to be involved, but I do think that there is a case for this list, and possibly only this list, of people to be involved. I think it brings some welcome clarity. So, with the Minister’s assurances that he will not knock it out of court completely, I am very happy to beg leave to withdraw the amendment.
Amendments 28 and 29 not moved.
Clause 5: Report on effect of NHS Constitution
Amendments 30 to 32 not moved.
Clause 6: Duty of providers to publish information
Earl Howe: In moving this amendment I shall speak also to Amendment 36, and in doing so bring us to a subject that is particularly close to the Minister’s heart, namely quality accounts. I should say immediately to him that I see considerable potential in the idea of quality accounts. Nothing that I say when speaking to these or the next few amendments is in any way meant to be critical of the concept. There are, however, a number of aspects of the practical implementation of the policy that we need to explore.
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The first question to be asked, as a number of noble Lords did at Second Reading, is what quality accounts are for. What audience are they to be aimed at? The answer is that they are for several different audiences. They are perhaps first and foremost tools for doctors and other clinical staff which, if used properly, will enable them to drive up the quality of their own performance. I buy into that concept completely. Any professional worth his salt is driven by a desire to do his job supremely well. That is what motivates him and gets him out of bed in the morning. Any benchmarking tool that helps him to do that, especially a tool which he himself has helped to devise, will be good news to him. So far, so good. Quality accounts are also for trust boards, as a means whereby directors can hold clinical staff to account for the quality of their performance. Again, I am supportive of that idea.
However, it seems to me that the data that will be of practical use to doctors are not necessarily the same data that a board of directors will find most informative; or if they are, the data may well need to be presented and explained in a slightly different way. Who will be responsible for ensuring that that process of presentation and interpretation is done properly and fairly?
The real question-mark arises over the data presented for public consumption. The public do not need and do not want to have the same quality data as clinicians. The information that they get needs to be simple, easily understood and, above all, meaningful to enable them to make balanced and informed choices. In some areas they need access to the detail; in other areas, they do not.
There are several issues here. One is who will be responsible for packaging the data for public consumption. Another is who will decide what data are released into the public domain and what data are not. We know from what Ministers have told us, and from this clause, that some information in a set of quality accounts will be proscribed by government. However, a large part will not be. How are we to ensure that data published by different trusts are directly comparable? In various meetings, the Minister has spoken of the role of SHAs in acting as “quality observatories”. I would be interested to hear a little more from him about how these observatories will function. Equally, how are we to avoid the tendency, which a number of noble Lords referred to at Second Reading, for organisations to puff-up their successes but draw a discreet veil over their failures? In general, how are we to ensure that the information that is published does not mislead the innocent reader, however unintentionally?
One of the central features of any trust that claims to be a beacon of quality has to be that it is a safe place to be and to be treated in. The noble Lord, Lord Patel, will be speaking on this subject in a much more authoritative way than I can, and I will not steal his thunder. All I wish to say is that any areas of a trust’s performance where patient safety is decidedly lacking—and this could be in a whole range of areas, not just the ones that we immediately think of, like hospital-acquired infections—are not going to be things that a trust will naturally wish to advertise. Who will make them do so? There does not seem to
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2.45 pm
The RCN has spoken very cogently about quality in nursing and made the important point that quality of care extends well beyond the success of this or that medical intervention; it is also about things like avoiding pressure sores and reducing patient trips and falls. One thinks also of good nutritional care and the efficiency with which drugs are dispensed on the ward. There are aspects of care to do with patient dignity that are of huge importance. One can think of a whole host of indicators in this general area. At the same time, it is not feasible to collect and publish more than a certain amount of data without it becoming unacceptably onerous. How is the right balance going to be struck?
I should like to ask the Minister to elaborate a little more than he did at Second Reading on innovation as a feature of quality. He said that there were all kinds of incentives for innovation already in the system, as well as innovation metrics which strategic health authorities will monitor. I hope that he can go a bit further than that because it seems to me that, when it comes to quality accounts, the public have an interest in identifying those providers where innovation and progress are high on the agenda. I do not know what metrics have been devised in this area. One could think of two or three reasonably good proxy measures, such as the number of clinical trials being conducted in a trust or the percentage of NICE-recommended therapies which the trust has actively adopted. I was particularly impressed with the Second Reading speech of the noble Lord, Lord Turnberg, who highlighted the importance of fostering teaching and research within the NHS and the need for patients to be aware that research is going on which they can take part in.
My main worry with quality accounts is the quantity of data needed to feed them month after month if they are to be of real use to the different audiences. As I mentioned a minute ago, the information appropriate to each of those audiences will be subtly different, which makes the task more challenging. At the same time, there is a distinct risk that if we start expecting too much from quality accounts and pile more and more information into them, we will dilute their effectiveness. It would be very helpful to hear something from the Minister on that aspect of the matter, which I am sure will not have eluded him. I beg to move.
Lord Patel: With the clarity with which the noble Earl speaks, I would always be glad if he were to speak on my behalf. As he has forgone that privilege on this occasion, I will do my best. I am very much attracted to many of the noble Earl’s comments and hope the Minister will come back to them. My amendments would ensure that improving patient safety is given equal importance to the pursuit of quality in the NHS and seek to ensure that the potential of quality accounts to drive safety improvements is fully realised.
I should declare an interest as chairman of the National Patient Safety Agency, which has a central role in increasing the safety of healthcare. Improving
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Over the past few years, much effort has gone into raising the profile of patient safety: establishing the national reporting and learning system, providing guidance and support to healthcare providers, putting patient safety systems into place and developing interventions to reduce the risks of known sources of harm. In the report by the noble Lord, Lord Darzi, High Quality Care for All, quality is defined as a combination of clinical effectiveness, safety, and patient experience. It seems to be taken as a matter of faith that that definition will become universally adopted. The difficulty with that assumption is that definitions of quality are notoriously variable and imprecise.
Within the report itself quality is sometimes paired with safety, and at other times it is mentioned alone or with clinical effectiveness and so on. I was interested to see that the Care Quality Commission used a different definition of high quality care in its recent manifesto. While I am pleased that safety is included in the definition, it highlights the risk that a lack of clarity in definitions will result in patient safety being sidelined as different bodies pursue their own ideas about quality.
“Quality” is currently left undefined in the Bill and the Explanatory Notes, and that, together with the fact that safety is not mentioned in the legislation, sends a message that patient safety is not important. Specific reference to safety in the legislation would send a powerful message to the contrary and help to mitigate the risks that I have highlighted. Failing to define quality adequately could lead to differences in interpretation of what should be included in quality accounts and to the exclusion of information related to patient safety. That would be a shame, because quality accounts have the potential to become powerful levers for the improvement of healthcare in the NHS.
I want to give some examples of how quality accounts could be harnessed to improve patient safety. “Never events” are serious, largely preventable patient safety incidents that should not occur if the available preventive measures have been implemented. Next year, PCTs will require healthcare providers to put in place preventive guidance in relation to a core list of never events; report the occurrence of events on the core list of never events to them; and, if events occur, put in place action plans to prevent recurrence. Requiring providers to report publicly the occurrence of never events would act as further encouragement to prevent them occurring in the first place.
Another example is safer surgery checklists. Earlier this year the National Patient Safety Agency issued an alert requiring healthcare organisations in England and Wales to implement World Health Organisation surgical safety checklists for every patient undergoing a surgical procedure. That was based on the results of a pilot which included the department of the noble Lord, Lord Darzi. The checklist is intended to strengthen
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The next example is Matching Michigan, a two-year initiative which will reduce the number of central venous catheter-associated bloodstream infections in intensive care units in England. It draws on lessons learnt from the successful Michigan initiative, called the Michigan study, on the same topic. If providers with intensive care units were required to report their rates of central venous catheter-associated bloodstream infections, I am sure that that would add to the success of the initiative.
Patient safety is a fundamental aspect of high quality care for patients. It is essential that healthcare organisations put in place all that is required to improve the safety of patients—such as local systems to record, investigate and respond to patient safety incidents; systems to report patient safety incidents nationally; and systems to implement national patient safety initiatives and interventions. They should also implement all national guidance and initiatives related to safety improvement. Making providers report on whether they are doing these things as part of quality accounts is a powerful lever in ensuring that they do. I hope the Minister agrees that patient safety is of paramount importance in modern healthcare and that we must not risk it being cast aside as we seek to improve the quality of healthcare in general.
Lord Walton of Detchant: My comments will be relatively brief, as the noble Earl and my noble friend Lord Patel have already expressed very clearly most of what I would wish to say.
The noble Earl highlighted the crucial importance of the education of staff in the NHS and research. I draw attention to principle 3 of the NHS constitution, which states:
“The NHS aspires to the highest standards of excellence and professionalism—in the provision of high-quality care that is safe, effective and focused on patient experience; in the planning and delivery of the clinical and other services it provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population”.
Yet on those particular aspects of the constitution, the handbook is almost completely silent. Bearing in mind that quality accounts must take account of the standard of service provided to patients, and of course to staff, I believe that these issues of education, research and innovation must in some way be mentioned and referred to. As the noble Earl said, my noble friend Lord Patel tabled a Question earlier today on clinical trials. The establishment of high quality in an era of evidence-based medicine is often based on the outcome of such clinical trials. I must say that I would wish to have specifically
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I do not speak particularly to this amendment, but I believe that the issue is crucial to quality accounts as a whole. I am very firmly in favour of quality accounts being provided, if, as I said at Second Reading—the noble Earl highlighted this—the collection of the information will not be too burdensome on the staff who are required to provide them. For that reason, certain principles relating to the nature of the information to be included in these quality accounts is something to which the Government should pay very close attention, while bearing in mind throughout that the outcome of clinical trials and the importance of evidence-based medicine is highlighted.
Baroness Tonge: Briefly, I once again express my anxieties about quality accounts. The concept of quality in the NHS goes without saying. Everyone wants quality healthcare; we would all accept that. What I find so difficult with Clause 6 is that without the regulations we have no idea what we are legislating for. We have no idea what we are creating here. We like the idea of quality accounts but we do not know what they are. This frequently happens in government legislation as Bills are going through both Houses. In this case, it really is crucial, as the noble Earl, Lord Howe, said, to know what we are going to measure. Patient dignity is probably one of the most important things of all. How do you measure patient dignity? It is going to take an awful lot of work to do that.
Safety, as the noble Lord, Lord Patel, said, is crucial. My concept of quality in the NHS has always been, as the noble Lord, Lord Darzi, said at Second Reading, the concept of clinical teams getting together on a regular basis to assess their progress, where they are going and how they could improve their performance. That has always been my idea, and I think that goes on all over the health service now, as I think the noble Lord said at Second Reading. We really do not know what these quality accounts are going to be. How can we insist on setting something up when we do not know how big it is going to be, what data we are going to collect, or what sort of organisation will be required?
3 pm
I know that I am always beefing on about NHS bureaucracy, but we have an awful lot of it. Maybe the noble Lord cannot see this, but I can see a department of quality accounts and a director of quality in the next couple of years being embraced with delight by health service management. The fights will go on about offices and filing cabinets and who is going to be shifted where, and the whole concept will be absorbed into the health service as another branch of its bureaucracy. Who will collect the data? The data will be collected by the clinical staff when they should be attending to their patients. That is my anxiety. I am sure that the Minister is going to reassure me that this will not happen, that there will not be such a department and that clinicians will be left to treat patients; but frankly I do not believe it.
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Finally, I do not want to labour the point, but I am not clear how quality accounts are going to be used. Are they going to be used internally? Apparently not, because they are going to be published. Are they going to form league tables? Are patients going to choose where they go based on the number of percentage points that a certain establishment gets for safety, or are we going to go more for dignity or for what percentage of patients live through a procedure? Has this been properly thought through? I hope that I am going to be reassured, but I had to reiterate my anxieties on the whole question.
Baroness Murphy: I shall speak to the amendment tabled by the noble Baroness, Lady Greengross, which is grouped with this amendment. Although I am not particularly wedded to her wording about the domains, it is important that we have an understanding of what quality is and that we should make clear what areas we are looking to express data about.
Unusually, I profoundly disagree with the noble Baroness, Lady Tonge. I think that this is an extraordinarily welcome innovation, and I shall wax even more lyrical when I get to the next group of amendments—
Baroness Tonge: Will the noble Baroness allow me to intervene? I do not think that I said that. I said that I would welcome the concept of quality accounts if I knew what they were.
Baroness Murphy: I accept that, and I will be pressing those questions on the next group of amendments. There is a real risk that quality accounts will, as the noble Earl, Lord Howe, said, turn into what I call PR guff. The NHS is getting better and better. If you visit an American hospital as a manager, as soon as you walk through the door you will be handed its PR guff. It usually starts with the heart transplant programme and goes on from there. It talks about all the great things that the hospital does and tells you absolutely nothing about what really goes on in the hospital. I worry that there is a potential problem there.
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